[Federal Register Volume 73, Number 84 (Wednesday, April 30, 2008)]
[Proposed Rules]
[Pages 23528-23938]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 08-1135]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid



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42 CFR Parts 411, 412, 413 et al.



Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed 
Changes to Disclosure of Physician Ownership in Hospitals and Physician 
Self-Referral Rules; Proposed Collection of Information Regarding 
Financial Relationships Between Hospitals and Physicians; Proposed Rule

Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / 
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 411, 412, 413, 422, and 489

[CMS-1390-P]
RIN 0938-AP15


Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed 
Changes to Disclosure of Physician Ownership in Hospitals and Physician 
Self-Referral Rules; Proposed Collection of Information Regarding 
Financial Relationships Between Hospitals and Physicians

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

ACTION: Proposed rule.

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SUMMARY: We are proposing to revise the Medicare hospital inpatient 
prospective payment systems (IPPS) for operating and capital-related 
costs to implement changes arising from our continuing experience with 
these systems, and to implement certain provisions made by the Deficit 
Reduction Act of 2005, the Medicare Improvements and Extension Act, 
Division B, Title I of the Tax Relief and Health Care Act of 2006, and 
the TMA, Abstinence Education, and QI Programs Extension Act of 2007. 
In addition, in the Addendum to this proposed rule, we describe the 
proposed changes to the amounts and factors used to determine the rates 
for Medicare hospital inpatient services for operating costs and 
capital-related costs. These proposed changes would be applicable to 
discharges occurring on or after October 1, 2008. We also are setting 
forth the proposed update to the rate-of-increase limits for certain 
hospitals and hospital units excluded from the IPPS that are paid on a 
reasonable cost basis subject to these limits. The proposed updated 
rate-of-increase limits would be effective for cost reporting periods 
beginning on or after October 1, 2008.
    Among the other policy decisions and changes that we are proposing 
to make are changes related to: Limited proposed revisions of the 
classification of cases to Medicare severity diagnosis-related groups 
(MS-DRGs), proposals to address charge compression issues in the 
calculation of MS-DRG relative weights, the proposed revisions to the 
classifications and relative weights for the Medicare severity long-
term care diagnosis-related groups (MS-LTC-DRGs); applications for new 
medical services and technologies add-on payments; wage index reform 
changes and the wage data, including the occupational mix data, used to 
compute the proposed FY 2009 wage indices; submission of hospital 
quality data; proposed changes to the postacute care transfer policy 
relating to transfers to home for the furnishing of home health 
services; and proposed policy changes relating to the requirements for 
furnishing hospital emergency services under the Emergency Medical 
Treatment and Labor Act of 1986 (EMTALA).
    In addition, we are proposing policy changes relating to disclosure 
to patients of physician ownership or investment interests in hospitals 
and soliciting public comments on a proposed collection of information 
regarding financial relationships between hospitals and physicians. We 
are also proposing changes or soliciting comments on issues relating to 
policies on physician self-referrals.

DATES: To be assured consideration, comments must be received at one of 
the addresses provide below, no later than 5 p.m. E.S.T. on June 13, 
2008.

ADDRESSES: When commenting on issues presented in this proposed rule, 
please refer to filecode CMS-1390-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 to http://www.regulations.gov. Follow the instructions for 
``Comment or Submission'' and enter the file code CMS-1390-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-1390-P, P.O. Box 8011, Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address ONLY: Centers for 
Medicare & Medicaid Services, Department of Health and Human Services, 
Attention: CMS-1390-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.)
    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.
    Submission of comments on paperwork requirements. You may submit 
comments on this document's paperwork requirements by following the 
instructions at the end of the ``Collection of Information 
Requirements'' section in this document.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION, CONTACT: 
    Michele Hudson, (410) 786-4487, Operating Prospective Payment, MS-
DRGs, Wage Index, New Medical Service and Technology Add-On Payments, 
Hospital Geographic Reclassifications, and Postacute Care Transfer 
Issues.
    Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded 
Hospitals, Direct and Indirect Graduate Medical Education, MS-LTC-DRGs, 
EMTALA, Hospital Emergency Services, and Hospital-within-Hospital 
Issues.
    Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital 
Demonstration Program Issues.
    Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment 
Update Issues.
    Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing and 
Readmissions to Hospital Issues.
    Anne Hornsby, (410) 786-1181, Collection of Managed Care Encounter 
Data Issues.
    Jacqueline Proctor, (410) 786-8852, Disclosure of Physician 
Ownership in

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Hospitals and Financial Relationships between Hospitals and Physicians 
Issues.
    Lisa Ohrin, (410) 786-4565, and Don Romano, (410) 786-1404, 
Physician Self-Referral 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 as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on 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 p.m. To schedule 
an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. Free public access is available on a Wide 
Area Information Server (WAIS) through the Internet and via 
asynchronous dial-in. Internet users can access the database by using 
the World Wide Web (the Superintendent of Documents' home page address 
is http://www.gpoaccess.gov/), by using local WAIS client software, or 
by telnet to swais.access.gpo.gov, then login as guest (no password 
required). Dial-in users should use communications software and modem 
to call (202) 512-1661; type swais, then login as guest (no password 
required).

Acronyms

AARP American Association of Retired Persons
AAHKS American Association of Hip and Knee Surgeons
AAMC Association of American Medical Colleges
ACGME Accreditation Council for Graduate Medical Education
AF Artrial fibrillation
AHA American Hospital Association
AICD Automatic implantable cardioverter defibrillator
AHIMA American Health Information Management Association
AHIC American Health Information Community
AHRQ Agency for Healthcare Research and Quality
AMA American Medical Association
AMGA American Medical Group Association
AMI Acute myocardial infarction
AOA American Osteopathic Association
APR DRG All Patient Refined Diagnosis Related Group System
ASC Ambulatory surgical center
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
BIPA Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Benefits Improvement and Protection Act of 2000, 
Pub. L. 106-554
BLS Bureau of Labor Statistics
CAH Critical access hospital
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
CoP [Hospital] condition of participation
CPI Consumer price index
CY Calendar year
DFRR Disclosure of financial relationship report
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DRG Diagnosis-related group
DSH Disproportionate share hospital
DVT Deep vein thrombosis
ECI Employment cost index
EMR Electronic medical record
EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 
99-272
FAH Federation of Hospitals
FDA Food and Drug Administration
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
HCRIS Hospital Cost Report Information System
HHA Home health agency
HHS Department of Health and Human Services
HIC Health insurance card
HIPAA Health Insurance Portability and Accountability Act of 1996, 
Pub. L. 104-191
HIPC Health Information Policy Council
HIS Health information system
HIT Health information technology
HMO Health maintenance organization
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-PCS International Classification of Diseases, Tenth Edition, 
Procedure Coding System
ICR Information collection requirement
IHS Indian Health Service
IME Indirect medical education
IOM Institute of Medicine
IPF Inpatient psychiatric facility
IPPS [Acute care hospital] inpatient prospective payment system
IRF Inpatient rehabilitation facility
LAMCs Large area metropolitan counties
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
MIEA-TRHCA Medicare Improvements and Extension Act, Division B of 
the Tax Relief and Health Care Act of 2006, Pub. L. 109-432
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, Pub. L. 108-173
MPN Medicare provider number
MRHFP Medicare Rural Hospital Flexibility Program
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
NCD National coverage determination

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NCHS National Center for Health Statistics
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
NECMA New England County Metropolitan Areas
NQF National Quality Forum
NTIS National Technical Information Service
NVHRI National Voluntary Hospital Reporting Initiative
OES Occupational employment statistics
OIG Office of the Inspector General
OMB Executive Office of Management and Budget
O.R. Operating room
OSCAR Online Survey Certification and Reporting [System]
PE Pulmonary embolism
PMSAs Primary metropolitan statistical areas
POA Present on admission
PPI Producer price index
PPS Prospective payment system
PRM Provider Reimbursement Manual
ProPAC Prospective Payment Assessment Commission
PRRB Provider Reimbursement Review Board
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
RRC Rural referral center
RUCAs Rural-urban commuting area codes
RY Rate year
SAF Standard Analytic File
SCH Sole community hospital
SFY State fiscal year
SIC Standard Industrial Classification
SNF Skilled nursing facility
SOCs Standard occupational classifications
SOM State Operations Manual
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-
248
TMA TMA [Transitional Medical Assistance], Abstinence Education, and 
QI [Qualifying Individuals] Programs Extension Act of 2007, Pub. L. 
110-09
TJA Total joint arthroplasty
UHDDS Uniform hospital discharge data set
VAP Ventilator-associated pneumonia
VBP Value-based purchasing

Table of Contents

I. Background
    A. Summary
    1. Acute Care Hospital Inpatient Prospective Payment System 
(IPPS)
    2. Hospitals and Hospital Units Excluded From the IPPS
    a. Inpatient Rehabilitation Facilities (IRFs)
    b. Long-Term Care Hospitals (LTCHs)
    c. Inpatient Psychiatric Facilities (IPFs)
    3. Critical Access Hospitals (CAHs)
    4. Payments for Graduate Medical Education (GME)
    B. Provisions of the Deficit Reduction Act of 2005 (DRA)
    C. Provisions of the Medicare Improvements and Extension Act 
under Division B, Title I of the Tax Relief and Health Care Act of 
2006 (MIEA-TRHCA)
    D. Provision of the TMA, Abstinence Education, and QI Programs 
Extension Act of 2007
    E. Major Contents of this Proposed Rule
    1. Proposed Changes to MS-DRG Classifications and Recalibrations 
of Relative Weights
    2. Proposed Changes to the Hospital Wage Index
    3. Other Decisions and Proposed Changes to the IPPS for 
Operating Costs and GME Costs
    4. Proposed Changes to the IPPS for Capital-Related Costs
    5. Proposed Changes to the Payment Rates for Excluded Hospitals 
and Hospital Units: Rate-of-Increase Percentages
    6. Proposed Changes Relating to Disclosure of Physician 
Ownership in Hospitals
    7. Proposed Changes and Solicitation of Comments on Physician 
Self-Referral Provisions
    8. Proposed Collection of Information Regarding Financial 
Relationships between Hospitals and Physicians
    9. Determining Proposed Prospective Payment Operating and 
Capital Rates and Rate-of-Increase Limits
    10. Impact Analysis
    11. Recommendation of Update Factors for Operating Cost Rates of 
Payment for Inpatient Hospital Services
    12. Disclosure of Financial Relationships Report (DFRR) Form
    13. Discussion of Medicare Payment Advisory Commission 
Recommendations
    F. Public Comments Received on Issues in Related Rules
    1. Comments on Phase-Out of the Capital Teaching Adjustment 
under the IPPS Included in the FY 2008 IPPS Final Rule with Comment 
Period
    2. Policy Revisions Related to Medicare GME Group Affiliations 
for Hospitals in Certain Declared Emergency Areas
II. Proposed Changes to Medicare Severity DRG (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. MS-DRG Documentation and Coding Adjustment, Including the 
Applicability to the Hospital-Specific Rates and the Puerto Rico-
Specific Standardized Amount
    1. MS-DRG Documentation and Coding Adjustment
    2. Application of the Documentation and Coding Adjustment to the 
Hospital-Specific Rates
    3. Application of the Documentation and Coding Adjustment to 
Puerto Rico-Specific Standardized Amount
    4. Potential Additional Payment Adjustments in FYs 2010 through 
2012
    E. Refinement of the MS-DRG Relative Weight Calculation
    1. Background
    2. Refining the Medicare Cost Report
    3. Timeline for Revising the Medicare Cost Report
    4. Revenue Codes used in the MedPAR File
    F. Preventable Hospital-Acquired Conditions (HACs), Including 
Infections
    1. General
    2. Statutory Authority
    3. Public Input
    4. Collaborative Process
    5. Selection Criteria for HACs
    6. HACs Selected in FY 2008 and Proposed Changes to Certain 
Codes
    a. Foreign Object Retained After Surgery: Proposed Inclusion of 
ICD-9-CM Code 998.7 (CC)
    b. Pressure Ulcers: Proposed Changes in Code Assignments
    7. HACs Under Consideration as Additional Candidates
    a. Surgical Site Infections Following Elective Surgeries
    b. Legionnaires' Disease
    c. Glycemic Control
    d. Iatrogenic Pneumothorax
    e. Delirium
    f. Ventilator-Associated Pneumonia (VAP)
    g. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
    h. Staphylococcus aureus Septicemia
    i. Clostridium Difficile-Associated Disease (CDAD)
    j. Methicillin-Resistant Staphylococcus aureus (MRSA)
    8. Present on Admission (POA) Indicator Reporting
    9. Enhancement and Future Issues
    a. Risk Adjustment
    b. Rates of HACs
    c. Use of POA Information
    d. Transition to ICD-10-PCS
    e. Application of Nonpayment for HACs to Other Settings
    f. Relationship to NQF's Serious Reportable Adverse Events
    G. Proposed Changes to Specific MS-DRG Classifications
    1. Pre-MDCs: Artificial Heart Devices
    2. MDC 1 (Diseases and Disorders of the Nervous System)
    a. Transferred Stroke Patients Receiving Tissue Plasminogen 
Activator (tPA)
    b. Intractable Epilepsy with Video Electroencephalogram (EEG)
    3. MDC 5 (Diseases and Disorders of the Circulatory System)
    a. Automatic Implantable Cardioverter-Defibrillators (AICD) Lead 
and Generator Procedures
    b. Left Atrial Appendage Device
    4. MDC 8 (Diseases and Disorders of the Musculoskeletal System 
and Connective Tissue): Hip and Knee Replacements and Revisions
    a. Brief History of Development of Hip and Knee Replacement 
Codes
    b. Prior Recommendations of the AAHKS
    c. Adoption of MS-DRGs for Hip and Knee Replacements for FY 2008 
and AAHKS' Recommendations
    d. AAHKS' Recommendations for FY 2009
    e. CMS' Response to AAHKS' Recommendations
    f. Conclusion
    5. MDC 18 (Infections and Parasitic Diseases Systemic or 
Unspecified Sites): Severe Sepsis

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    6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): 
Traumatic Compartment Syndrome
    7. Medicare Code Editor (MCE) Changes
    a. List of Unacceptable Principal Diagnoses in MCE
    b. Diagnoses Allowed for Male Only Edit c. Limited Coverage Edit
    8. Surgical Hierarchies
    9. CC Exclusions List
     a. Background
    b. CC Exclusions List for FY 2009
    10. Review of Procedure Codes in MS-DRGs 981, 982, and 983; 984, 
985, and 986; and 987, 988, and 989
    a. Moving Procedure Codes from MS-DRG 981 through 983 or MS-DRG 
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
    H. Recalibration of MS-DRG Weights
    I. Proposed Medicare Severity Long-Term Care Diagnosis-Related 
Group (MS-LTC-DRG) Reclassifications and Relative Weights for LTCHs 
for FY 2009
    1. Background
    2. Proposed Changes in the MS-LTC-DRG Classifications
    a. Background
    b. Patient Classifications into MS-LTC-DRGs
    3. Development of the Proposed FY 2009 MS-LTC-DRG Relative 
Weights
    a. General Overview of Development of the MS-LTC-DRG Relative 
Weights
    b. Data
    c. Hospital-Specific Relative Value (HSRV) Methodology
    d. Treatment of Severity Levels in Developing Proposed Relative 
Weights
    e. Proposed Low-Volume MS-LTC-DRGs
    4. Steps for Determining the Proposed FY 2009 MS-LTC-DRG 
Relative Weights
    J. Proposed Add-On Payments for New Services and Technologies
    1. Background
    2. Public Input Before Publication of a Notice of Proposed 
Rulemaking on Add-On Payments
    3. FY 2009 Status of Technologies Approved for FY 2008 Add-On 
Payments
    4. FY 2009 Applications for New Technology Add-On Payments
    a. CardioWest<SUP>TM</SUP> Temporary Total Artificial Heart 
System (CardioWest<SUP>TM</SUP> TAH-t)
    b. Emphasys Medical Zephyr[supreg] Endobronchial Valve 
(Zephyr[supreg] EBV)
    c. Oxiplex[supreg]
    d. TherOx Downstream[supreg] System
    5. Proposed Regulatory Change
III. Proposed Changes to the Hospital Wage Index
    A. Background
    B. Requirements of Section 106 of the MIEA-TRHCA
    1. Wage Index Study Required Under the MIEA-TRHCA
    2. CMS Proposals in Response to Requirements Under Section 
106(b) of the MIEA-TRHCA
    a. Proposed Revision of the Reclassification Average Hourly Wage 
Comparison Criteria
    b. Within-State Budget Neutrality Adjustment for the Rural and 
Imputed Floors
    c. Within-State Budget Neutrality Adjustment for Geographic 
Reclassification
    C. Core-Based Statistical Areas for the Hospital Wage Index
    D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 
Wage Index
    1. Development of Data for the Proposed FY 2009 Occupational Mix 
Adjustment
    2. Calculation of the Proposed Occupational Mix Adjustment for 
FY 2009
    3. 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index
    E. Worksheet S-3 Wage Data for the Proposed FY 2009 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
    1. Wage Data for Multicampus Hospitals
    2. New Orleans' Post-Katrina Wage Index
    G. Method for Computing the Proposed FY 2009 Unadjusted Wage 
Index
    H. Analysis and Implementation of the Proposed Occupational Mix 
Adjustment and the Proposed FY 2009 Occupational Mix Adjustment Wage 
Index
    I. Proposed Revisions to the Wage Index Based on Hospital 
Redesignations
    1. General
    2. Effects of Reclassification/Redesignation
    3. FY 2009 MGCRB Reclassifications
    4. FY 2008 Policy Clarifications and Revisions
    5. Redesignations of Hospitals under Section 1886(d)(8)(B) of 
the Act
    6. Reclassifications under Section 1886(d)(8)(B) of the Act
    J. Proposed FY 2009 Wage Index Adjustment Based on Commuting 
Patterns of Hospital Employees
    K. Process for Requests for Wage Index Data Corrections
    L. Labor-Related Share for the Proposed Wage Index for FY 2009
IV. Other Decisions and Proposed Changes to the IPPS for Operating 
Costs and GME Costs
    A. Proposed Changes to the Postacute Care Transfer Policy
    1. Background
    2. Proposed Policy Change Relating to Transfers to Home with a 
Written Plan for the Provision of Home Health Services
    3. Evaluation of MS-DRGs under Postacute Care Transfer Policy 
for FY 2009
    B. Reporting of Hospital Quality Data for Annual Hospital 
Payment Update
    1. Background
    a. Overview
    b. Voluntary Hospital Quality Data Reporting
    c. Hospital Quality Data Reporting under Section 501(b) of Pub. 
L. 108-173
    d. Hospital Quality Data Reporting under Section 5001(a) of Pub. 
L. 109-171
    2. Proposed Quality Measures for FY 2010 and Subsequent Years
    a. Proposed Quality Measures for FY 2010
    b. Possible New Quality Measures, Measure Sets, and Program 
Requirements for FY 2011 and Subsequent Years
    c. Considerations in Expanding and Updating Quality Measures 
Under the RHQDAPU Program
    3. Form and Manner and Timing of Quality Data Submission
    4. Current and Proposed RHQDAPU Program Procedures
    a. RHQDAPU Program Procedures for FY 2009
    b. Proposed RHQDAPU Program Procedures for FY 2010
    5. Current and Proposed HCAHPS Requirements
    a. FY 2009 HCAHPS Requirements
    b. Proposed FY 2010 HCAHPS Requirements
    6. Current and Proposed Chart Validation Requirements
    a. Chart Validation Requirements for FY 2009
    b. Proposed Chart Validation Requirements for FY 2010
    c. Chart Validation Methods and Requirements Under Consideration 
for FY 2011 and Subsequent Years
    7. Data Attestation Requirements
    a. Proposed Change to Requirements for FY 2009
    b. Proposed Requirements for FY 2010
    8. Public Display Requirements
    9. Proposed Reconsideration and Appeal Procedures
    10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 
and 2010
    11. Requirements for New Hospitals
    12. Electronic Medical Records
    C. Medicare Hospital Value-Based Purchasing (VBP)
    1. Medicare Hospital VBP Plan Report to Congress
    2. Testing and Further Development of the Medicare Hospital VBP 
Plan
    D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small 
Rural Hospitals (MDHs): Volume Decrease Adjustment
    1. Background
    2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources 
for Determining Core Staff Values
    a. Occupational Mix Survey
    b. AHA Annual Survey
    E. Rural Referral Centers (RRCs)
    1. Case-Mix Index
    2. Discharges
    F. Indirect Medical Education (IME) Adjustment
    1. Background
    2. IME Adjustment Factor for FY 2009
    G. Medicare GME Affiliation Provisions for Teaching Hospitals in 
Certain Emergency Situations; Technical Correction
    1. Background
    2. Technical Correction
    H. Payments to Medicare Advantage Organizations: Collection of 
Risk Adjustment Data
    I. Hospital Emergency Services under EMTALA

[[Page 23532]]

    1. Background
    2. EMTALA Technical Advisory Group (TAG): Recommendations
    3. Proposed Changes Relating to Applicability of EMTALA 
Requirements to Hospital Inpatients
    4. Proposed Changes to the EMTALA Physician On-Call Requirements
    a. Relocation of Regulatory Provisions
    b. Shared/Community Call
    5. Proposed Technical Change to Regulations
    J. Application of Incentives To Reduce Avoidable Readmissions to 
Hospitals
    1. Introduction
    2. Measurement
    3. Accountability
    4. Interventions
    5. Financial Incentive: Direct Payment Adjustment
    6. Financial Incentive: Performance-Based Payment Adjustment
    7. Nonfinancial Incentive: Public Reporting
    8. Conclusion
    K. Rural Community Hospital Demonstration Program
V. Proposed Changes to the IPPS for Capital-Related Costs
    A. Background
    1. Exception Payments
    2. New Hospitals
    3. Hospitals Located in Puerto Rico
    B. Revisions to the Capital IPPS Based on Data on Hospitals 
Medicare Capital Margins
    1. Elimination of the Large Add-On Payment Adjustment
    2. Changes to the Capital IME Adjustment
    a. Background and Changes Made for FY 2008
    b. Public Comments Received on Phase Out of Capital IPPS 
Teaching Adjustment Provisions Included in the FY 2008 Final Rule 
With Comment Period and Further Solicitation of Public Comments
VI. Proposed Changes for Hospitals and Hospital Units Excluded From 
the IPPS
    A. Proposed Payments to Excluded Hospitals and Hospital Units
    B. IRF PPS
    C. LTCH PPS
    D. IPF PPS
    E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) under 
the LTCH PPS
    F. Proposed Change to the Regulations Governing Hospitals-
Within-Hospitals
VII. Disclosure Required of Certain Hospitals and Critical Access 
Hospitals Regarding Physician Ownership
VIII. Physician Self-Referrals Provisions
    A. Stand in the Shoes Provisions
    1. Physician ``Stand in the Shoes'' Provisions
    a. Background
    b. Proposals
    2. DHS Entity ``Stand in the Shoes'' Provisions
    3. Application of the Physician ``Stand in the Shoes'' and the 
Entity ``Stand in the Shoes'' Provisions
    4. Definitions: ``Physician'' and ``Physician Organization''
    B. Period of Disallowance
    C. Gainsharing Arrangements
    1. Background
    2. Statutory Impediments to Gainsharing Arrangements
    3. Office of Inspector General (OIG) Approach Towards 
Gainsharing Arrangements
    4. MedPAC Recommendation
    5. Demonstration Programs
    6. Solicitation of Comments
    D. Physician-Owned Implant and Other Medical Device Companies
    1. Background
    2. Solicitation of Comments
IX. Financial Relationships between Hospitals and Physicians
    A. Background
    B. Section 5006 of the Deficit Reduction Act (DRA) of 2005
    C. Disclosure of Financial Relationships Report (DFRR)
    D. Civil Monetary Penalties
    E. Uses of Information Captured by the DFRR
    F. Solicitation of Comments
X. MedPAC Recommendations
XI. Other Required Information
    A. Requests for Data from the Public
    B. Collection of Information Requirements
    1. Legislative Requirement for Solicitation of Comments
    2. Solicitation of Comments on Proposed Requirements in 
Regulatory Text
    a. ICRs Regarding Physician Reporting Requirements
    b. ICRs Regarding Risk Adjustment Data
    c. ICRs Regarding Basic Commitments of Providers
    3. Associated Information Collections Not Specified in 
Regulatory Text
    a. Present on Admission (POA) Indicator Reporting
    b. Proposed 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 2009 Index (Hospital 
Wage Index Occupational Mix Survey)
    4. Addresses for Submittal of Comments on Information Collection 
Requirements
    C. Response to Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, 
and Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2008

I. Summary and Background
II. Proposed Changes to the Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2009
    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 of Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2009
    A. Determination of Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update
    B. Calculation of the Proposed Inpatient Capital-Related 
Prospective Payments for FY 2009
    C. Capital Input Price Index
IV. Proposed Changes to Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
V. Tables
    Table 1A.--National Adjusted Operating Standardized Amounts, 
Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share 
If Wage Index Is Greater Than 1)
    Table 1B.--National Adjusted Operating Standardized Amounts, 
Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If 
Wage Index Is Less Than or Equal to 1)
    Table 1C.--Adjusted Operating Standardized Amounts for Puerto 
Rico, Labor/Nonlabor
    Table 1D.--Capital Standard Federal Payment Rate
    Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal 
Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 
2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage 
Data); and 3-Year Average of Hospital Average Hourly Wages
    Table 3A.--FY 2009 and 3-Year Average Hourly Wage for Urban 
Areas by CBSA
    Table 3B.--FY 2009 and 3-Year Average Hourly Wage for Rural 
Areas by CBSA
    Table 4A.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Urban Areas by CBSA and by State--FY 2009
    Table 4B.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Rural Areas by CBSA and by State--FY 2009
    Table 4C.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Hospitals That Are Reclassified by CBSA and by State--FY 
2009
    Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009
    Table 4D-2.--Urban Areas with Hospitals Receiving the Statewide 
Rural Floor or Imputed Floor Wage Index--FY 2009
    Table 4E.--Urban CBSAs and Constituent Counties--FY 2009
    Table 4F.--Puerto Rico Wage Index and Capital Geographic 
Adjustment Factor (GAF) by CBSA--FY 2009
    Table 4J.--Out-Migration Wage Adjustment--FY 2009
    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 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

[[Page 23533]]

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 2007 MedPAR Update--December 2007 
GROUPER V25.0 MS-DRGs
    Table 7B.--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007 
GROUPER V26.0 MS-DRGs
    Table 8A.--Proposed Statewide Average Operating Cost-to-Charge 
Ratios--March 2008
    Table 8B.--Proposed Statewide Average Capital Cost-to-Charge 
Ratios--March 2008
    Table 8C.--Proposed Statewide Average Total Cost-to-Charge 
Ratios for LTCHs--March 2008
    Table 9A.--Hospital Reclassifications and Redesignations--FY 
2009
    Table 9B.--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2009
    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 2008
    Table 11.--Proposed FY 2009 MS-LTC-DRGs, Proposed Relative 
Weights, Proposed Geometric Average Length of Stay, and Proposed 
Short-Stay Outlier Threshold

Appendix A--Regulatory Impact Analysis

I. Overall Impact
II. Objectives
III. Limitations on Our Analysis
IV. Hospitals Included in and Excluded From the IPPS
V. Effects on Excluded Hospitals and Hospital Units
VI. Quantitative Effects of the Proposed Policy Changes Under the 
IPPS for Operating Costs
    A. Basis and Methodology of Estimates
    B. Analysis of Table I
    C. Effects of the Proposed Changes to the MS-DRG 
Reclassifications and Relative Cost-Based Weights (Column 2)
    D. Effects of Proposed Wage Index Changes (Column 3)
    E. Combined Effects of Proposed MS-DRG and Wage Index Changes 
(Column 4)
    F. Effects of MGCRB Reclassifications (Column 5)
    G. Effects of the Proposed Rural Floor and Imputed Rural Floor, 
Including the Proposed Application of Budget Neutrality at the State 
Level (Column 6)
    H. Effects of the Proposed Wage Index Adjustment for Out-
Migration (Column 7)
    I. Effects of All Proposed Changes with CMI Adjustment Prior to 
Estimated Growth (Column 8)
    J. Effects of All Proposed Changes with CMI Adjustment and 
Estimated Growth (Column 9)
    K. Effects of Policy on Payment Adjustment for Low-Volume 
Hospitals
    L. Impact Analysis of Table II
VII. Effects of Other Proposed Policy Changes
    A. Effects of Proposed Policy on HACs, Including Infections
    B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative 
Weights for LTCHs
    C. Effects of Proposed Policy Change Relating to New Medical 
Service and Technology Add-On Payments
    D. Effects of Proposed Policy Change Regarding Postacute Care 
Transfers to Home Health Services
    E. Effects of Proposed Requirements for Hospital Reporting of 
Quality Data for Annual Hospital Payment Update
    F. Effects of Proposed Policy Change to Methodology for 
Computing Core Staffing Factors for Volume Decrease Adjustment for 
SCHs and MDHs
    G. Effects of Proposed Clarification of Policy for Collection of 
Risk Adjustment Data From MA Organizations
    H. Effects of Proposed Policy Changes Relating to Hospital 
Emergency Services under EMTALA
    I. Effects of Implementation of Rural Community Hospital 
Demonstration Program
    J. Effects of Proposed Policy Changes Relating to Payments to 
Hospitals-Within-Hospitals
    K. Effects of Proposed Policy Changes Relating to Requirements 
for Disclosure of Physician Ownership in Hospitals
    L. Effects of Proposed Changes Relating to Physician Self-
Referral Provisions
    M. Effects of Proposed Changes Relating to Reporting of 
Financial Relationships Between Hospitals and Physicians
VIII. Effects of Proposed Changes in the Capital IPPS
    A. General Considerations
    B. Results
IX. Alternatives Considered
X. Overall Conclusion
XI. Accounting Statement
XII. Executive Order 12866

Appendix B--Recommendation of Update Factors for Operating Cost Rates 
of Payment for Inpatient Hospital Services

I. Background
II. Inpatient Hospital Update for FY 2009
III. Secretary's Recommendation
IV. MedPAC Recommendation for Assessing Payment Adequacy and 
Updating Payments in Traditional Medicare

Appendix C--Disclosure of Financial Relationships Report (DFRR) Form

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)
    Section 1886(d) of the Social Security Act (the Act) sets forth a 
system of payment for the operating costs of acute care hospital 
inpatient stays under Medicare Part A (Hospital Insurance) based on 
prospectively set rates. Section 1886(g) of the Act requires the 
Secretary to pay for the capital-related costs of hospital inpatient 
stays under a prospective payment system (PPS). Under these PPSs, 
Medicare payment for hospital inpatient operating and capital-related 
costs is made at predetermined, specific rates for each hospital 
discharge. Discharges are classified according to a list of diagnosis-
related groups (DRGs).
    The base payment rate is comprised of a standardized amount that is 
divided into a labor-related share and a nonlabor-related share. The 
labor-related share is adjusted by the wage index applicable to the 
area where the hospital is located. 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

[[Page 23534]]

payment, it would be inadequately paid under the regular DRG payment.
    The costs incurred by the hospital for a case are evaluated to 
determine whether the hospital is eligible for an additional payment as 
an outlier case. This additional payment is designed to protect the 
hospital from large financial losses due to unusually expensive cases. 
Any outlier payment due is added to the DRG-adjusted base payment rate, 
plus any DSH, IME, and new technology or medical service add-on 
adjustments.
    Although payments to most hospitals under the IPPS are made on the 
basis of the standardized amounts, some categories of hospitals are 
paid 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 higher of FY 1982, FY 1987, or FY 1996) or 
the IPPS rate based on the standardized amount. Until FY 2007, a 
Medicare-dependent, small rural hospital (MDH) has received the IPPS 
rate plus 50 percent of the difference between the IPPS rate and its 
hospital-specific rate if the hospital-specific rate based on their 
costs in a base year (the higher of FY 1982, FY 1987, or FY 2002) is 
higher than the IPPS rate. As discussed below, for discharges occurring 
on or after October 1, 2007, but before October 1, 2011, an MDH will 
receive the IPPS rate plus 75 percent of the difference between the 
IPPS rate and its hospital-specific rate, if the hospital-specific rate 
is higher than the IPPS rate. SCHs are the sole source of care in their 
areas, and MDHs are a major source of care for Medicare beneficiaries 
in their areas. Both of these categories of hospitals are afforded this 
special payment protection in order to maintain access to services for 
beneficiaries.
    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. However, as discussed in section V.B.2. of this 
preamble, we are phasing out the IME adjustment beginning with FY 2008. 
In addition, hospitals may receive outlier payments for those cases 
that have unusually high costs.
    The existing regulations governing payments to hospitals under the 
IPPS are located in 42 CFR Part 412, Subparts A through M.
2. Hospitals and Hospital Units Excluded From the IPPS
    Under section 1886(d)(1)(B) of the Act, as amended, certain 
specialty hospitals and hospital units are excluded from the IPPS. 
These hospitals and units are: Rehabilitation hospitals and units; 
long-term care hospitals (LTCHs); psychiatric hospitals and units; 
children's hospitals; and cancer hospitals. Religious nonmedical health 
care institutions (RNHCIs) are also excluded from the IPPS. Various 
sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the 
Medicare, Medicaid and SCHIP [State Children's Health Insurance 
Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and 
the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000 (Pub. L. 106-554) provide for the implementation of PPSs 
for rehabilitation hospitals and units (referred to as inpatient 
rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and 
units (referred to as inpatient psychiatric facilities (IPFs)), as 
discussed below. Children's hospitals, cancer hospitals, and RNHCIs 
continue to be paid solely under a reasonable cost-based system.
    The existing regulations governing payments to excluded hospitals 
and hospital units are located in 42 CFR Parts 412 and 413.
a. Inpatient Rehabilitation Facilities (IRFs)
    Under section 1886(j) of the Act, as amended, rehabilitation 
hospitals and units (IRFs) have been transitioned from payment based on 
a blend of reasonable cost reimbursement subject to a hospital-specific 
annual limit under section 1886(b) of the Act and the adjusted facility 
Federal prospective payment rate for cost reporting periods beginning 
on or after January 1, 2002 through September 30, 2002, to payment at 
100 percent of the Federal rate effective for cost reporting periods 
beginning on or after October 1, 2002. IRFs subject to the blend were 
also permitted to elect payment based on 100 percent of the Federal 
rate. The existing regulations governing payments under the IRF PPS are 
located in 42 CFR Part 412, Subpart P.
b. Long-Term Care Hospitals (LTCHs)
    Under the authority of sections 123(a) and (c) of Pub. L. 106-113 
and section 307(b)(1) of Pub. L. 106-554, the LTCH PPS was effective 
for a LTCH's first cost reporting period beginning on or after October 
1, 2002. LTCHs that do not meet the definition of ``new'' under Sec.  
412.23(e)(4) are paid, during a 5-year transition period, a LTCH 
prospective payment that is comprised of an increasing proportion of 
the LTCH Federal rate and a decreasing proportion based on reasonable 
cost principles. Those LTCHs that did not meet the definition of 
``new'' under Sec.  412.23(e)(4) could elect to be paid based on 100 
percent of the Federal prospective payment rate instead of a blended 
payment in any year during the 5-year transition. For cost reporting 
periods beginning on or after October 1, 2006, all LTCHs are paid 100 
percent of the Federal rate. The existing regulations governing payment 
under the LTCH PPS are located in 42 CFR Part 412, Subpart O.
c. Inpatient Psychiatric Facilities (IPFs)
    Under the authority of sections 124(a) and (c) of Pub. L. 106-113, 
inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals 
and psychiatric units of acute care hospitals) are paid under the IPF 
PPS. For cost reporting periods beginning on or after January 1, 2008, 
all IPFs are paid 100 percent of the Federal per diem payment amount 
established under the IPF PPS. (For cost reporting periods beginning on 
or after January 1, 2005, and ending on or before December 31, 2007, 
some IPFs received transitioned payments for inpatient hospital 
services based on a blend of reasonable cost-based payment and a 
Federal per diem payment rate.) The existing regulations governing 
payment under the IPF PPS are located in 42 CFR part 412, Subpart N.
3. Critical Access Hospitals (CAHs)
    Under sections 1814, 1820, and 1834(g) of the Act, payments are 
made to critical access hospitals (CAHs) (that is, rural hospitals or 
facilities that meet certain statutory requirements) for inpatient and 
outpatient services are based on 101 percent of reasonable cost. 
Reasonable cost is determined under the provisions of section 
1861(v)(1)(A) of the Act and existing regulations under 42 CFR Parts 
413 and 415.
4. Payments for Graduate Medical Education (GME)
    Under section 1886(a)(4) of the Act, costs of approved educational 
activities are excluded from the operating costs of inpatient hospital 
services. Hospitals with approved graduate medical education (GME) 
programs are paid for the direct costs of GME in accordance with 
section 1886(h) of the Act. The amount of payment for direct GME costs

[[Page 23535]]

for a cost reporting period is based on the hospital's number of 
residents in that period and the hospital's costs per resident in a 
base year. The existing regulations governing payments to the various 
types of hospitals are located in 42 CFR Part 413.

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

    Section 5001(b) of the Deficit Reduction Act of 2005 (DRA), Pub. L. 
109-171, requires the Secretary to develop a plan to implement, 
beginning with FY 2009, a value-based purchasing plan for section 
1886(d) hospitals defined in the Act. In section IV.C. of the preamble 
of this proposed rule, we discuss the report to Congress on the 
Medicare value-based purchasing plan and the current testing of the 
plan.

C. Provisions of the Medicare Improvements and Extension Act Under 
Division B, Title I of the Tax Relief and Health Care Act of 2006 
(MIEA-TRHCA)

    Section 106(b)(2) of the MIEA-TRHCA instructs the Secretary of 
Health and Human Services 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 instructed to consider MedPAC's recommendations on 
the Medicare wage index classification system in developing these 
proposals. In section III. of the preamble of this proposed rule, we 
discuss MedPAC's recommendations in a report to Congress and present 
our proposed changes to the FY 2009 wage index in response to those 
recommendations.

D. Provision of the TMA, Abstinence Education, and QI Programs 
Extension Act of 2007

    Section 7 of the TMA [Transitional Medical Assistance], Abstinence 
Education, and QI [Qualifying Individuals] Programs Extension Act of 
2007 (Pub. L. 110-90) provides for a 0.9 percent prospective 
documentation and coding adjustment in the determination of 
standardized amounts under the IPPS (except for MDHs and SCHs) for 
discharges occurring during FY 2009. The prospective documentation and 
coding adjustment was established in FY 2008 in response to the 
implementation of an MS-DRG system under the IPPS that resulted in 
changes in coding and classification that did not reflect real changes 
in case-mix under section 1886(d) of the Act. We discuss our proposed 
implementation of this provision in section II.D. of the preamble of 
this proposed rule and in the Addendum and in Appendix A to this 
proposed rule.

E. Major Contents of This Proposed Rule

    In this proposed rule, we are setting forth proposed changes to the 
Medicare IPPS for operating costs and for capital-related costs in FY 
2009. 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, we are presenting proposed changes relating to disclosure to 
patients of physician ownership and investment interests in hospitals, 
proposed changes to our physician self-referral regulations, and a 
solicitation of public comments on a proposed collection of information 
regarding financial relationships between hospitals and physicians.
    The following 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 to this proposed rule, we are 
including--
    <bullet> Proposed changes to MS-DRG reclassifications based on our 
yearly review.
    <bullet> Proposed application of the documentation and coding 
adjustment to hospital-specific rates resulting from implementation of 
the MS-DRG system.
    <bullet> Proposed changes to address the RTI reporting 
recommendations on charge compression.
    <bullet> Proposed recalibrations of the MS-DRG relative weights.
    We also are proposing to refine the hospital cost reports so that 
charges for relatively inexpensive medical supplies are reported 
separately from the costs and charges for more expensive medical 
devices. This proposal would be applied to the determination of both 
the IPPS and the OPPS relative weights as well as the calculation of 
the ambulatory surgical center payment rates.
    We are presenting a listing and discussion of additional hospital-
acquired conditions (HACs), including infections, that are being 
proposed to be subject to the statutorily required quality adjustment 
in MS-DRG payments for FY 2009.
    We are presenting our evaluation and analysis of the FY 2009 
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).
    We are proposing the annual update of the MS-LTC-DRG 
classifications and relative weights for use under the LTCH PPS for FY 
2009.
2. Proposed Changes to the Hospital Wage Index
    In section III. of the preamble to this proposed rule, we are 
proposing revisions to the wage index and the annual update of the wage 
data. Specific issues addressed include the following:
    <bullet> Proposed wage index reform changes in response to 
recommendations made to Congress as a result of the wage index study 
required under Pub. L. 109-432. We discuss changes related to 
reclassifications criteria, application of budget neutrality in 
reclassifications, and the rural floor and imputed floor budget 
neutrality at the State level.
    <bullet> Changes to the CBSA designations.
    <bullet> The methodology for computing the proposed FY 2009 wage 
index.
    <bullet> The proposed FY 2009 wage index update, using wage data 
from cost reporting periods that began during FY 2006.
    <bullet> Analysis and implementation of the proposed FY 2009 
occupational mix adjustment to the wage index.
    <bullet> Proposed revisions to the wage index based on hospital 
redesignations and reclassifications.
    <bullet> The proposed adjustment to the wage index for FY 2009 
based on commuting patterns of hospital employees who reside in a 
county and work in a different area with a higher wage index.
    <bullet> The timetable for reviewing and verifying the wage data 
used to compute the proposed FY 2009 wage index.
    <bullet> The proposed labor-related share for the FY 2009 wage 
index, including the labor-related share for Puerto Rico.
3. Other Decisions and Proposed Changes to the IPPS for Operating Costs 
and GME Costs
    In section IV. of the preamble to this proposed rule, we discuss a 
number of the provisions of the regulations in 42 CFR Parts 412, 413, 
and 489, including the following:
    <bullet> Proposed changes to the postacute care transfer policy as 
it relates to transfers to home with the provision of home health 
services.
    <bullet> The reporting of hospital quality data as a condition for 
receiving the full annual payment update increase.
    <bullet> Proposed changes in the collection of Medicare Advantage 
(MA) encounter data that are used for computing the risk payment 
adjustment made to MA organizations.
    <bullet> Discussion of the report to Congress on the Medicare 
value-based purchasing

[[Page 23536]]

plan and current testing and further development of the plan.
    <bullet> Proposed changes to the methodology for determining core 
staff values for the volume decrease payment adjustment for SCHs and 
MDHs.
    <bullet> The proposed updated national and regional case-mix values 
and discharges for purposes of determining RRC status.
    <bullet> The statutorily-required IME adjustment factor for FY 2009 
and technical changes to the GME payment policies.
    <bullet> Proposed changes to policies on hospital emergency 
services under EMTALA to address EMTALA Technical Advisory Group (TAG) 
recommendations.
    <bullet> Solicitation of public comments on Medicare policies 
relating to incentives for avoidable readmissions to hospitals.
    <bullet> Discussion of the fifth year of implementation of the 
Rural Community Hospital Demonstration Program.
4. Proposed Changes to the IPPS for Capital-Related Costs
    In section V. of the preamble to this proposed rule, we discuss the 
payment policy requirements for capital-related costs and capital 
payments to hospitals. We acknowledge the public comments that we 
received on the phase-out of the capital teaching adjustment included 
in the FY 2008 IPPS final rule with comment period, and again are 
soliciting public comments on this phase-out in this proposed rule.
5. Proposed Changes to the Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
    In section VI. of the preamble to this proposed rule, we discuss 
proposed changes to payments to excluded hospitals and hospital units, 
proposed changes for determining LTCH CCRs under the LTCH PPS, 
including a discussion regarding changing the annual payment rate 
update schedule for the LTCH PPS, and proposed changes to the 
regulations on hospitals-within-hospitals.
6. Proposed Changes Relating to Disclosure of Physician Ownership in 
Hospitals
    In section VII. of the preamble of this proposed rule, we present 
proposed changes to the regulations relating to the disclosure to 
patients of physician ownership or investment interests in hospitals.
7. Proposed Changes and Solicitation of Comments on Physician Self-
Referrals Provisions
    In section VIII. of the preamble of this proposed rule, we present 
proposed changes to the policies on physician self-referrals relating 
to the ``Stand in Shoes'' provision, In addition, we solicit public 
comments regarding physician-owned implant companies and gainsharing 
arrangements.
8. Proposed Collection of Information Regarding Financial Relationships 
Between Hospitals and Physicians
    In section IX. of the preamble of this proposed rule, we solicit 
public comments on our proposed collection of information regarding 
financial relationships between hospitals and physicians.
9. Determining Proposed Prospective Payment Operating and Capital Rates 
and Rate-of-Increase Limits
    In the Addendum to this proposed rule, we set forth proposed 
changes to the amounts and factors for determining the FY 2009 
prospective payment rates for operating costs and capital-related 
costs. We also establish the proposed threshold amounts for outlier 
cases. In addition, we address the proposed update factors for 
determining the rate-of-increase limits for cost reporting periods 
beginning in FY 2009 for hospitals and hospital units excluded from the 
PPS.
10. Impact Analysis
    In Appendix A of this proposed rule, we set forth an analysis of 
the impact that the proposed changes would have on affected hospitals.
11. Recommendation of Update Factors for Operating Cost Rates of 
Payment for Inpatient Hospital Services
    In Appendix B of this proposed rule, as required by sections 
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of 
the appropriate percentage changes for FY 2009 for the following:
    <bullet> A single average standardized amount for all areas for 
hospital inpatient services paid under the IPPS for operating costs 
(and hospital-specific rates applicable to SCHs and MDHs).
    <bullet> Target rate-of-increase limits to the allowable operating 
costs of hospital inpatient services furnished by hospitals and 
hospital units excluded from the IPPS.
12. Disclosure of Financial Relationships Report (DFRR) Form
    In Appendix C of this proposed rule, we present the reporting form 
that we are proposing to use for the proposed collection of information 
on financial relationships between hospitals and physicians discussed 
in section IX, of the preamble of this proposed rule.
13. 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 2008 recommendations concerning hospital inpatient 
payment policies address the update factor for inpatient hospital 
operating costs and capital-related costs under the IPPS and for 
hospitals and distinct part hospital units excluded from the IPPS. We 
address these recommendations in Appendix B of this proposed rule. For 
further information relating specifically to the MedPAC March 2008 
reports or to obtain a copy of the reports, contact MedPAC at (202) 
220-3700 or visit MedPAC's Web site at: www.medpac.gov.

F. Public Comments Received on Issues in Related Rules

1. Comments on Phase-Out of the Capital Teaching Adjustment Under the 
IPPS Included in the FY 2008 IPPS Final Rule With Comment Period
    In the FY 2008 IPPS final rule with comment period, we solicited 
public comments on our policy changes related to phase-out of the 
capital teaching adjustment to the capital payment update under the 
IPPS (72 FR 47401). We received approximately 90 timely pieces of 
correspondence in response to our solicitation. (These public comments 
may be viewed on the following Web site: http://www.cms.hhs.gov/eRulemaking/ECCMSR/list.asp under file code CMS-1533-FC.) In section V. 
of the preamble of this proposed rule, we acknowledge receipt of these 
public comments and again solicit public comments on the phase-out in 
this proposed rule. We will respond to the public comments received in 
response to both the FY 2008 IPPS final rule with comment period and 
this proposed rule in the FY 2009 IPPS final rule, which is scheduled 
to be published in August 2008.
2. Policy Revisions Related to Medicare GME Group Affiliations for 
Hospitals in Certain Declared Emergency Areas
    We have issued two interim final rules with comment periods in the 
Federal Register that modified the GME

[[Page 23537]]

regulations as they apply to Medicare GME affiliated groups to provide 
for greater flexibility in training residents in approved residency 
programs during times of disasters: on April 12, 2006 (71 FR 18654) and 
on November 27, 2007 (72 FR 66892). We received a number of timely 
pieces of correspondence in response to these interim final rules with 
comment period. (The public comments that we received may be viewed on 
the Web site at: http://www.cms.hhs.gov/eRulemaking/ECCMSR/list.asp 
under the file codes CMS-1531-IFC1 and CMS-1531-IFC2, respectively.) We 
will summarize and address these public comments in the FY 2009 IPPS 
final rule, which is scheduled to be published in August 2008.

II. Proposed Changes to Medicare Severity DRG (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.
    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 into account 
severity of illness and applying hospital-specific relative value 
(HSRV) weights to DRGs.\1\ We began this reform process by adopting 
cost-based weights over a 3-year transition period beginning in FY 2007 
and making interim changes to the DRG system for FY 2007 by creating 20 
new CMS DRGs and modifying 32 others across 13 different clinical areas 
involving nearly 1.7 million cases. As described below in more detail, 
these refinements were intermediate steps towards comprehensive reform 
of both the relative weights and the DRG system that is occurring as we 
undertook further study. For FY 2008, 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 was established based 
on severity levels of illness (72 FR 47141).
---------------------------------------------------------------------------

    \1\ Medicare Payment Advisory Commission: Report to the 
Congress, Physician-Owned Specialty Hospitals, March 25, page viii.
---------------------------------------------------------------------------

    Currently, cases are classified into MS-DRGs for payment under the 
IPPS based on the principal diagnosis, up to eight additional 
diagnoses, and up to six procedures performed during the stay. In a 
small number of 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).
    The process of forming 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 formed 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. Most MDCs are based on a particular organ 
system of the body. For example, MDC 6 is Diseases and Disorders of the 
Digestive System. This approach is used because clinical care is 
generally organized in accordance with the organ system affected. 
However, some MDCs are not constructed on this basis because they 
involve multiple organ systems (for example, MDC 22 (Burns)). For FY 
2008, cases are assigned to one of 745 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.
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 26.0), there are 9 
MS-DRGs to

[[Page 23538]]

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 for tracheostomies. Cases are 
assigned to these MS-DRGs before they are classified to an MDC. The 
table below lists the nine current pre-MDCs.

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

    Once the MDCs were defined, each MDC was evaluated to identify 
those additional patient characteristics that would have a consistent 
effect on the consumption of hospital resources. Because the presence 
of a surgical procedure that required the use of the operating room 
would have a significant effect on the type of hospital resources used 
by a patient, most MDCs were initially divided into surgical DRGs and 
medical DRGs. Surgical DRGs are based on a hierarchy that orders 
operating room (O.R.) procedures or groups of O.R. procedures by 
resource intensity. Medical DRGs generally are differentiated on the 
basis of diagnosis and age (0 to 17 years of age or greater than 17 
years of age). Some surgical and medical DRGs are further 
differentiated based on the presence or absence of a complication or 
comorbidity (CC) 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 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 the consumption of hospital 
resources. 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 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.
    As we indicated above, for FY 2008, we made significant improvement 
in the DRG system to recognize severity of illness and resource usage 
by adopting MS-DRGs. The changes we adopted were reflected in the FY 
2008 GROUPER, Version 25.0, and were effective for discharges occurring 
on or after October 1, 2007. Our DRG analysis for the FY 2008 final 
rule with comment period was based on data from the March 2007 update 
of the FY 2006 MedPAR file, which contained hospital bills received 
through March 31, 2007, for discharges occurring through September 30, 
2006. For this proposed rule, for FY 2009, our DRG analysis is based on 
data from the September 2007 update of the FY 2007 MedPAR file, which 
contains hospital bills received through September 30, 2007, for 
discharges through September 30, 2007.
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 concerns about MS-DRG 
classifications to bring those concerns to our attention in a timely 
manner so they can be carefully considered for possible inclusion in 
the annual proposed rule and, if included, may be subjected to public 
review and comment. Therefore, similar to the

[[Page 23539]]

timetable for interested parties to submit non-MedPAR data for 
consideration in the MS-DRG recalibration process, concerns about MS-
DRG classification issues should be brought to our attention no later 
than early December in order to be considered and possibly included in 
the next annual proposed rule updating the IPPS.
    The actual process of forming the 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 
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). However, based on public comments received on 
the FY 2007 IPPS proposed rule, we decided not to adopt the CS DRGs. 
Rather, we decided to make interim changes to the existing DRGs for FY 
2007 by creating 20 new DRGs involving 13 different clinical areas that 
would significantly improve the CMS DRG system's recognition of 
severity of illness. We also modified 32 DRGs to better capture 
differences in severity. The new and revised DRGs were selected from 40 
existing CMS DRGs that contained 1,666,476 cases and represent a number 
of body systems. In creating these 20 new DRGs, we deleted 8 and 
modified 32 existing DRGs. We indicated that these interim steps for FY 
2007 were being taken as a prelude to more comprehensive changes to 
better account for severity in the DRG system by FY 2008.
    In the FY 2007 IPPS final rule, we indicated our intent to pursue 
further DRG reform through two initiatives. First, we announced that we 
were in the process of engaging a contractor to assist us with 
evaluating alternative DRG systems that were raised as potential 
alternatives to the 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, our 
actions for FY 2008, and our proposals for FY 2009 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 2009 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 methodology. The cost-based weights are 
being adopted over a 3-year transition period in \1/3\ increments 
between FY 2007 and FY 2009. In addition, in the FY 2007 IPPS final 
rule, we indicated our intent to further study the 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 our proposals for addressing the 
issue of charge compression and the HSRV cost-weighting methodology for 
FY 2009.
    We believe that revisions to the DRG system to better recognize 
severity of

[[Page 23540]]

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 
in this proposed rule for FY 2009 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).

D. MS-DRG Documentation and Coding Adjustment, Including the 
Applicability to the Hospital-Specific Rates and the Puerto Rico-
Specific Standardized Amount

1. MS-DRG Documentation and Coding Adjustment
    As stated above, we adopted the new MS-DRG patient classification 
system for the IPPS, effective October 1, 2007, to better recognize 
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. By increasing the number of DRGs and more fully taking 
into account severity of illness in Medicare payment rates, the 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), which appeared in the Federal Register on 
August 22, 2007, 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 improved documentation and coding. In that 
final rule with comment period, using the Secretary's authority under 
section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by 
adjusting the standardized amount to eliminate the effect of changes in 
coding or classification 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.
    On September 29, 2007, the TMA, Abstinence Education, and QI 
Programs Extension Act of 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 
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 payment rates, factors, and thresholds accordingly, 
with these revisions effective October 1, 2007.
    For FY 2009, Pub. L. 110-90 requires 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 are applying 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 is in 
addition to the -0.6 percent adjustment in FY 2008, yielding a combined 
effect of -1.5 percent.
2. 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 national rate; the updated hospital-specific rate based on 
FY 1982 costs per discharge; the updated hospital-specific rate based 
on FY 1987 costs per discharge; or the updated hospital-specific rate 
based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of 
the Act, MDHs are paid based on the Federal national rate or, if 
higher, the Federal national rate plus 75 percent of the difference 
between the Federal national rate and the updated hospital-specific 
rate based on the greater of either the FY 1982, 1987, or 2002 costs 
per discharge. In the FY 2008 IPPS final rule with comment period, we 
established a policy of applying the documentation and coding 
adjustment to the hospital-specific rates. In that rule, 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 cited our 
authority under section 1886(d)(3)(A)(vi) of the Act, which provides 
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 a 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 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'' and does not 
mention adjusting the hospital-specific rates.
    We continue 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 coding improvements 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 rate should not have the potential 
to realize increased payments due to documentation and coding 
improvements 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 authority authorizes us 
to provide ``for such other exceptions and adjustments to [IPPS] 
payment amounts * * * as the Secretary deems appropriate.'' In light of 
this authority, for the FY 2010 rulemaking, we plan to

[[Page 23541]]

examine our FY 2008 claims data for hospitals paid based on the 
hospital-specific rate. If we find 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 hospital-specific rates under our authority in section 
1886(d)(5)(I)(i) of the Act. As noted previously, the documentation and 
coding adjustments established in the FY 2008 IPPS final rule with 
comment period are cumulative. For example, the -0.9 percent 
documentation and coding adjustment to the national standardized amount 
in FY 2009 is in addition to the -0.6 percent adjustment made in FY 
2008, yielding a combined effect of -1.5 percent in FY 2009. Given the 
cumulative nature of the documentation and coding adjustments, if we 
were to propose to apply the documentation and coding adjustment to the 
FY 2010 hospital-specific rates, it may involve applying the FY 2008 
and FY 2009 documentation and coding adjustments (-1.5 percent 
combined) plus the FY 2010 documentation and coding adjustment, 
discussed in the FY 2008 IPPS final rule with comment period, to the FY 
2010 hospital-specific rates.
3. 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) of the 
Act, which provides 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 change 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. We are currently in the process of 
developing a Federal Register notice to correct that error in the 
Puerto Rico-specific standardized amount for FY 2008 retroactive to 
October 1, 2007.
    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, discussed in section II.D.2. of this preamble, 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 improvements that do not 
reflect real increases in patients' severity of illness. Consistent 
with the approach described for SCHs and MDHs in section II.D.2. of the 
preamble of this proposed rule, for the FY 2010 rulemaking, we plan to 
examine our FY 2008 claims data for hospitals in Puerto Rico. If we 
find 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. As noted previously, the documentation and 
coding adjustments established in the FY 2008 IPPS final rule with 
comment period are cumulative. Given the cumulative nature of the 
documentation and coding adjustments, if we were to propose to apply 
the documentation and coding adjustment to the FY 2010 Puerto Rico-
specific standardized amount, it may involve applying the FY 2008 and 
FY 2009 documentation and coding adjustments (-1.5 percent combined) 
plus the FY 2010 documentation and coding adjustment, discussed in the 
FY 2008 IPPS final rule with comment period, to the FY 2010 Puerto 
Rico-specific standardized amount.
4. Potential Additional Payment Adjustments in FYs 2010 Through 2012
    Section 7 of Pub. L.110-90 also provides for payment adjustments in 
FYs 2010 through 2012 based upon a retrospective evaluation of claims 
data from the implementation of the MS-DRG system. If, based on this 
retrospective evaluation, the Secretary finds that in FY 2008 and FY 
2009, the actual amount of change in case-mix that does not reflect 
real change in underlying patient severity differs from the statutorily 
mandated documentation and coding adjustments implemented in those 
years, the law requires the Secretary to adjust payments for discharges 
occurring in FYs 2010 through 2012 to offset the estimated amount of 
increase or decrease in aggregate payments that occurred in FY 2008 and 
FY 2009 as a result of that difference, in addition to making an 
appropriate adjustment to the standardized amount under section 
1886(d)(3)(A)(vi) of the Act.
    In order to implement these requirements of section 7 of Pub. L. 
110-90, we are planning a thorough retrospective evaluation of our 
claims data. Results of this evaluation would be used by our actuaries 
to determine any necessary payment adjustments in FYs 2010 through 2012 
to ensure the budget neutrality of the MS-DRG implementation for FY 
2008 and FY 2009, as required by law. We are currently developing our 
analysis plans for this effort.
    We intend to measure and corroborate the extent of the overall 
national average changes in case-mix for FY 2008 and FY 2009. We expect 
part of this overall national average change would be attributable to 
underlying changes in actual patient severity and part would be 
attributable to documentation and coding improvements under the MS-DRG 
system. In order to separate the two effects, we plan 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 shifts among base DRGs are the 
result of changes in principal diagnoses while the shifts within base 
DRGs are the result of changes in secondary diagnoses. Because we 
expect most of the documentation and coding improvements under the MS-
DRG system will occur in the secondary diagnoses, the shifts among base 
DRGs are less likely to be the result of the MS-DRG system and the 
shifts within base DRGs are more likely to be the result of the MS-DRG 
system. We also anticipate evaluating data to identify the specific MS-
DRGs and diagnoses that contributed significantly to the improved 
documentation and coding payment effect and to quantify their impact. 
This step would entail analysis of the secondary diagnoses driving the 
shifts in severity within specific base DRGs.
    While we believe that the data analysis plan described previously 
will produce an appropriate estimate of the extent of case-mix changes 
resulting from documentation and coding improvements, we may also 
decide, if feasible, to use historical data from our Hospital Payment 
Monitoring Program

[[Page 23542]]

(HPMP) to corroborate the within base DRG shift analysis. The HPMP is 
supported by the Medicare Clinical Data Abstraction Center (CDAC). From 
1999 to 2007, the CDAC obtained medical records for a sample of 
discharges as part of our hospital monitoring activities. These data 
were collected on a random sample of between 30,000 to 50,000 hospital 
discharges per year. The historical CDAC data could be used to develop 
an upper bound estimate of the trend in real case-mix growth (that is, 
real change in underlying patient severity) prior to implementation of 
the MS-DRGs.
    We welcome public comments on our analysis plans, as well as 
suggestions on other possible approaches for conducting 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. Our analysis, findings, and any resulting 
proposals to adjust payments for discharges occurring in FYs 2010 
through 2012 to offset the estimated amount of increase or decrease in 
aggregate payments that occurred in FY 2008 and FY 2009 will be 
discussed in future years' rulemakings.

E. Refinement of the MS-DRG Relative Weight Calculation

1. Background
    In the FY 2008 IPPS final rule with comment period (72 FR 47188), 
we continued to implement significant revisions to Medicare's inpatient 
hospital rates by basing relative weights on hospitals' estimated costs 
rather than on charges. We continued 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 raised in the public comments, 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 
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. In FY 2008, we continued our transition by 
blending the relative weights with one-third charge-based weights and 
two-thirds cost-based weights.
    Also, 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. We refer readers to the FY 2007 IPPS final rule (71 FR 
47882) for more detail on 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.
    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 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 March 2007 which was 
posted on the CMS Web site with its findings on charge compression. In 
that report, RTI found that a number of factors contribute to charge 
compression and affect the accuracy of the relative weights. RTI found 
inconsistent matching of charges in the Medicare cost report and their 
corresponding charges in the MedPAR claims for certain cost centers. In 
addition, there was inconsistent reporting of costs and charges among 
hospitals. For example, some hospitals would report costs and charges 
for devices and medical supplies in the Medical Supplies Charged to 
Patients cost center, while other hospitals would report those costs 
and charges in their related ancillary departments such as Operating 
Room or Radiology. RTI also found evidence that certain revenue codes 
within the same cost center had significantly different markup rates. 
For example, within the Medicare Supplies Charged to Patients cost 
center, revenue codes for devices, implantables, and prosthetics had 
different markup rates than the other medical supplies in that cost 
center. RTI's findings demonstrated that charge compression exists in 
several CCRs, most notably in the Medical Supplies and Equipment CCR.
    RTI offered short-term, medium-term, and long-term recommendations 
to mitigate the effects of charge compression. RTI's short-term 
recommendations included expanding the distinct hospital CCRs to 19 by 
disaggregating the ``Emergency Room'' and ``Blood and Blood Products'' 
from the Other Services cost center and by estimating regression-based 
CCRs to disaggregate Medical Supplies, Drugs, and Radiology cost 
centers. RTI recommended, for the medium-term, to expand the MedPAR 
file to include separate fields that disaggregate several existing 
charge departments. In addition, RTI recommended improving hospital 
cost reporting instructions so that hospitals can properly report costs 
in the appropriate cost centers. RTI's long-term recommendations 
included 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''.
    Among RTI's short-term recommendations, for FY 2008, we expanded 
the number of distinct hospital department CCRs from 13 to 15 by 
disaggregating ``Emergency Room'' and ``Blood and Blood Products'' from 
the Other Services cost center as these lines already exist on the 
hospital cost report. Furthermore, in an effort to improve consistency 
between costs and their corresponding charges in the MedPAR file, we 
moved the costs for cases involving electroencephalography (EEG) from 
the Cardiology cost center to the Laboratory cost center group which 
corresponds with the EEG MedPAR claims categorized under the Laboratory 
charges. We also agreed with RTI's recommendations to revise the 
Medicare cost report and the MedPAR file as a long-term solution for 
charge compression. We stated that, in the upcoming year, we would 
consider additional lines to the cost report and additional revenue 
codes for the MedPAR file.
    We did not adopt RTI's short-term recommendation to create four

[[Page 23543]]

additional regression-based CCRs for several reasons, even though we 
had received 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 were 
concerned that RTI's analysis was limited to charges on hospital 
inpatient claims while typically hospital cost report CCRs combine both 
inpatient and outpatient services. Further, because both the IPPS and 
OPPS rely on cost-based weights, we preferred to introduce any 
methodological adjustments to both payment systems at the same time. We 
have since expanded RTI's analysis of charge compression to incorporate 
outpatient services. RTI has been evaluating the cost estimation 
process for the OPPS cost-based weights, including a reassessment of 
the regression-based CCR models using both outpatient and inpatient 
charge data. The RTI report was finalized at the conclusion of our 
proposed rule development process and is expected to be posted on the 
CMS Web site in the near future. We welcome comments on this report.
    A second reason 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. We stated that we would consider the 
results of the second phase of the RAND study as we prepared for the FY 
2009 IPPS rulemaking process. The purpose of the RAND study was to 
analyze how the relative weights would change if we were to adopt 
regression-based CCRs to address charge compression while 
simultaneously adopting an HSRV methodology using fully phased-in MS-
DRGs. We had intended to include a detailed discussion of RAND's study 
in this FY 2009 IPPS proposed rule. However, due to some delays in 
releasing identifiable data to the contractor under revised data 
security rules, the report on this second stage of RAND's analysis was 
not completed in time for the development of this proposed rule. 
Therefore, we continue to have the same concerns with respect to 
uncertainty about how regression-based CCRs would interact with the MS-
DRGs or an HSRV methodology. Therefore, we are not proposing to adopt 
the regression-based CCRs or an HSRV methodology in this FY 2009 IPPS 
proposed rule. Nevertheless, we welcome public comments on our 
proposals not to adopt regression-based CCRs or an HSRV methodology at 
this time or in the future. The RAND report on regression-based CCRs 
and the HSRV methodology was finalized at the conclusion of our 
proposed rule development process and is expected to be posted on the 
CMS Web site in the near future. Although we are unable to include a 
discussion of the results of the RAND study in this proposed rule, we 
welcome public comment on the report.
    Finally, we received public comments on the FY 2008 IPPS proposed 
rule raising concerns on the accuracy of using regression-based CCR 
estimates to determine the relative weights rather than the Medicare 
cost report. Commenters noted that regression-based CCRs would not fix 
the underlying mismatch of hospital reporting of costs and charges. 
Instead, the commenters suggested that the impact of charge compression 
might be mitigated through an educational initiative that would 
encourage hospitals to improve their cost reporting. Commenters 
recommended that hospitals be educated to report costs and charges in a 
way that is consistent with how charges are grouped in the MedPAR file. 
In an effort to achieve this goal, hospital associations have launched 
an educational campaign to encourage consistent reporting, which would 
result in consistent groupings of the cost centers used to establish 
the cost-based relative weights. The commenters requested that CMS 
communicate to the fiscal intermediaries/MACs that such action is 
appropriate. In the FY 2008 IPPS final rule with comment period, we 
stated that we were supportive of the educational initiative of the 
industry, and we encouraged hospitals to report costs and charges 
consistently with how the data are used to determine relative weights 
(72 FR 47196). We would also like to affirm that the longstanding 
Medicare principles of cost apportionment at 42 CFR 413.53 convey that, 
under the departmental method of apportionment, the cost of each 
ancillary department is to be apportioned separately rather than being 
combined with another ancillary department (for example, combining the 
cost of Medical Supplies Charged to Patients with the costs of 
Operating Room or any other ancillary cost center. (We note that, 
effective for cost reporting periods starting on or after January 1, 
1979, the departmental method of apportionment replaced the combination 
method of apportionment where all the ancillary departments were 
apportioned in the aggregate (Section 2200.3 of the Provider 
Reimbursement Manual (PRM), Part I).)
    Furthermore, longstanding Medicare cost reporting policy has been 
that hospitals must include the cost and charges of separately 
``chargeable medical supplies'' in the Medical Supplies Charged to 
Patients cost center (line 55 of Worksheet A), rather than in the 
Operating Room, Emergency Room, or other ancillary cost centers. 
Routine services, which can include ``minor medical and surgical 
supplies'' (Section 2202.6 of the PRM, Part 1), and items for which a 
separate charge is not customarily made, may be directly assigned 
through the hospital's accounting system to the department in which 
they were used, or they may be included in the Central Services and 
Supply cost center (line 15 of Worksheet A). Conversely, the separately 
chargeable medical supplies should be assigned to the Medical Supplies 
Charged to Patients cost center on line 55.
    We note that not only is accurate cost reporting important for IPPS 
hospitals to ensure that accurate relative weights are computed, but 
hospitals that are still paid on the basis of cost, such as CAHs and 
cancer hospitals, and SCHs and MDHs must adhere to Medicare cost 
reporting principles as well.
    The CY 2008 OPPS/ASC final rule with comment period (72 FR 66601) 
also discussed the issue of charge compression and regression-based 
CCRs, and noted that RTI is currently evaluating the cost estimation 
process underpinning the OPPS cost-based weights, including a 
reassessment of the regression models using both outpatient and 
inpatient charges, rather than inpatient charges only. In responding to 
comments in the CY 2008 OPPS/ASC final rule with comment period, we 
emphasized that we ``fully support'' the educational initiatives of the 
industry and that we would ``examine whether the educational activities 
being undertaken by the hospital community to improve cost reporting 
accuracy under the IPPS would help to mitigate charge compression under 
the OPPS, either as an adjunct to the application of regression-based 
CCRs or in lieu of such an adjustment'' (72 FR 66601). However, as we 
stated in the FY 2008 IPPS final rule with comment period that we would 
consider the results of the RAND study before considering whether to 
adopt regression-based CCRs, in the CY 2008 OPPS/ASC final rule with 
comment period, we stated that we would determine whether refinements 
should be proposed, after reviewing the results of the RTI study.
    On February 29, 2008, we issued Transmittal 321, Change Request 
5928, to inform the fiscal intermediaries/

[[Page 23544]]

MACs of the hospital associations' initiative to encourage hospitals to 
modify their cost reporting practices with respect to costs and charges 
in a manner that is consistent with how charges are grouped in the 
MedPAR file. We noted that the hospital cost reports submitted for FY 
2008 may have costs and charges grouped differently than in prior 
years, which is allowable as long as the costs and charges are properly 
matched and the Medicare cost reporting instructions are followed. 
Furthermore, we recommended that fiscal intermediaries/MACs remain 
vigilant to ensure that the costs of items and services are not moved 
from one cost center to another without moving their corresponding 
charges. Due to a time lag in submittal of cost reporting data, the 
impact of changes in providers' cost reporting practices occurring 
during FY 2008 would be reflected in the FY 2011 IPPS relative weights.
2. Refining the Medicare Cost Report
    In developing this FY 2009 proposed rule, we considered whether 
there were concrete steps we could take to mitigate the bias introduced 
by charge compression in both the IPPS and OPPS relative weights in a 
way that balance hospitals' desire to focus on improving the cost 
reporting process through educational initiatives with device industry 
interest in adopting regression-adjusted CCRs. Although RTI recommended 
adopting regression-based CCRs, particularly for medical supplies and 
devices, as a short-term solution to address charge compression, RTI 
also recommended refinements to the cost report as a long-term 
solution. RTI's draft interim March 2007 report discussed a number of 
options that could improve the accuracy and precision of the CCRs 
currently being derived from the Medicare cost report and also reduce 
the need for statistically-based adjustments. As mentioned in the FY 
2008 IPPS final rule with comment period (72 FR 47193), we believe that 
RTI and many of the public commenters on the FY 2008 IPPS proposed rule 
concluded that, ultimately, improved and more precise cost reporting is 
the best way to minimize charge compression and improve the accuracy of 
cost weights. Therefore, in this proposed rule, we are proposing to 
begin making cost report changes geared to improving the accuracy of 
the IPPS and OPPS relative weights. However, we also received comments 
last year asking that we proceed cautiously with changing the Medicare 
cost report to avoid unintended consequences for hospitals that are 
paid on a cost basis (such as CAHs and, to some extent, SCHs and MDHs), 
and to consider the administrative burden associated with adapting to 
new cost reporting forms and instructions. Accordingly, we are 
proposing to focus at this time on the CCR for Medical Supplies and 
Equipment because RTI found that the largest impact on the relative 
weights could result from correcting charge compression for devices and 
implants. When examining markup differences within the Medical Supplies 
Charged to Patients cost center, RTI found that its ``regression 
results provide solid evidence that if there were distinct cost centers 
for items, cost ratios for devices and implants would average about 17 
points higher than the ratios for other medical supplies'' (January 
2007 RTI report, page 59). This suggests that much of the charge 
compression within the Medical Supplies CCR results from inclusion of 
medical devices that have significantly different markups than the 
other supplies in that CCR. Furthermore, in the FY 2007 final rule and 
FY 2008 IPPS final rule with comment period, the Medical Supplies and 
Equipment CCR received significant attention by the public commenters.
    Although we are proposing to make improvements to lessen the 
effects of charge compression only on the Medical Supplies and 
Equipment CCR as a first step, we are inviting public comments as to 
whether to make other changes to the Medicare cost report to refine 
other CCRs. In addition, we are open to making further refinements to 
other CCRs in the future. Therefore, we are proposing at this time to 
add only one cost center to the cost report, such that, in general, the 
costs and charges for relatively inexpensive medical supplies would be 
reported separately from the costs and charges of more expensive 
devices (such as pacemakers and other implantable devices). We will 
consider public comments submitted on this proposed rule for purposes 
of both the IPPS and the OPPS relative weights and, by extension, the 
calculation of the ambulatory surgical center (ASC) payment rates.
    Under the IPPS for FY 2007 and FY 2008, the aggregate CCR for 
supplies and equipment was computed based on line 55 for Medical 
Supplies Charged to Patients and lines 66 and 67 for DME Rented and DME 
Sold, respectively. To compute the 15 national CCRs used in developing 
the cost-based weights under the IPPS (explained in more detail under 
section II.H. of the preamble of this proposed rule), we take the costs 
and charges for the 15 cost groups from Worksheet C, Part I of the 
Medicare cost report for all hospital patients and multiply each of 
these 15 CCRs by the Medicare charges on Worksheet D-4 for those same 
cost centers to impute the Medicare cost for each of the 15 cost 
groups. Under this proposal, the goal would be to split the current CCR 
for Medical Supplies and Equipment into one CCR for medical supplies, 
and another CCR for devices and DME Rented and DME Sold.
    In considering how to instruct hospitals on what to report in the 
cost center for supplies and the cost center for devices, we looked at 
the existing criteria for what type of device qualifies for payment as 
a transitional pass-through device category in the OPPS. (There are no 
such existing criteria for devices under the IPPS.) The provisions of 
the regulations under Sec.  419.66(b) state that for a medical device 
to be eligible for pass-through payment under the OPPS, the medical 
device must meet the following criteria:
    a. If required by the FDA, the device must have received FDA 
approval or clearance (except for a device that has received an FDA 
investigational device exemption (IDE) and has been classified as a 
Category B device by the FDA in accordance with Sec. Sec.  405.203 
through 405.207 and 405.211 through 405.215 of the regulations) or 
another appropriate FDA exemption.
    b. The device is determined to be reasonable and necessary for the 
diagnosis or treatment of an illness or injury or to improve the 
functioning of a malformed body part (as required by section 
1862(a)(1)(A) of the Act).
    c. The device is an integral and subordinate part of the service 
furnished, is used for one patient only, comes in contact with human 
tissues, and is surgically implanted or inserted whether or not it 
remains with the patient when the patient is released from the 
hospital.
    d. The device is not any of the following:
    <bullet> Equipment, an instrument, apparatus, implement, or item of 
this type for which depreciation and financing expenses are recovered 
as depreciable assets as defined in Chapter 1 of the Medicare Provider 
Reimbursement Manual (CMS Pub. 15-1).
    <bullet> A material or supply furnished incident to a service (for 
example, a suture, customized surgical kit, or clip, other than a 
radiological site marker).
    <bullet> Material that may be used to replace human skin (for 
example, a biological or synthetic material).
    These requirements are the OPPS criteria used to define a device 
for pass-through payment purposes and do not include additional 
criteria that are used

[[Page 23545]]

under the OPPS to determine if a candidate device is new and represents 
a substantial clinical improvement, two other requirements for 
qualifying for pass-through payment.
    For purposes of applying the eligibility criteria, we interpret 
``surgical insertion or implantation'' to include devices that are 
surgically inserted or implanted via a natural or surgically created 
orifice as well as those devices that are inserted or implanted via a 
surgically created incision (70 FR 68630).
    In proposing to modify the cost report to have one cost center for 
medical supplies and one cost center for devices, we are proposing that 
hospitals would determine what should be reported in the Medical 
Supplies cost center and what should be reported in the Medical Devices 
cost center using criteria consistent with those listed above that are 
included under Sec.  419.66(b), with some modification. Specifically, 
for purposes of the cost reporting instructions, we are proposing that 
an item would be reported in the device cost center if it meets the 
following criteria:
    a. If required by the FDA, the device must have received FDA 
approval or clearance (except for a device that has received an FDA 
investigational device exemption (IDE) and has been classified as a 
Category B device by the FDA in accordance with Sec. Sec.  405.203 
through 405.207 and 405.211 through 405.215 of the regulations) or 
another appropriate FDA exemption.
    b. The device is reasonable and necessary for the diagnosis or 
treatment of an illness or injury or to improve the functioning of a 
malformed body part (as required by section 1862(a)(1)(A) of the Act).
    c. The device is an integral and subordinate part of the service 
furnished, is used for one patient only, comes in contact with human 
tissue, is surgically implanted or inserted through a natural or 
surgically created orifice or surgical incision in the body, and 
remains in the patient when the patient is discharged from the 
hospital.
    d. The device is not any of the following:
    <bullet> Equipment, an instrument, apparatus, implement, or item of 
this type for which depreciation and financing expenses are recovered 
as depreciable assets as defined in Chapter 1 of the Medicare Provider 
Reimbursement Manual (CMS Pub. 15-1).
    <bullet> A material or supply furnished incident to a service (for 
example, a surgical staple, a suture, customized surgical kit, or clip, 
other than a radiological site marker).
    <bullet> Material that may be used to replace human skin (for 
example, a biological or synthetic material).
    <bullet> A medical device that is used during a procedure or 
service and does not remain in the patient when the patient is released 
from the hospital.
    We are proposing to select the existing criteria for what type of 
device qualifies for payment as a transitional pass-through device 
under the OPPS as a basis for instructing hospitals on what to report 
in the cost center for Medical Supplies Charged to Patients or the cost 
center for Medical Devices Charged to Patients because these criteria 
are concrete and already familiar to the hospital community. However, 
the key difference between the existing criteria for devices that are 
eligible for pass-through payment under the OPPS at Sec.  419.66(b) and 
our proposed criteria stated above to be used for cost reporting 
purposes is that the device that is implanted remains in the patient 
when the patient is discharged from the hospital. Essentially, we are 
proposing to instruct hospitals to report only implantable devices that 
remain in the patient at discharge in the cost center for devices. All 
other devices and non-routine supplies which are separately chargeable 
would be reported in the medical supplies cost center. We believe that 
defining a device for cost reporting purposes based on criteria that 
specify implantation and adding that the device must remain in the 
patient upon discharge would have the benefit of capturing virtually 
all costly implantable devices (for example, implantable cardioverter 
defibrillators (ICDs), pacemakers, and cochlear implants) for which 
charge compression is a significant concern.
    However, we acknowledge that a definition of device based on 
whether an item is implantable and remains in the patient could, in 
some cases, include items that are relatively inexpensive (for example, 
urinary catheters, fiducial markers, vascular catheters, and drainage 
tubes), and which many would consider to be supplies. Thus, some modest 
amount of charge compression could still be present in the cost center 
for devices if the hospital does not have a uniform markup policy. In 
addition, requiring as a cost reporting criterion that the device is to 
remain in the patient at discharge could exclude certain technologies 
that are moderately expensive (for example, cryoablation probes, 
angioplasty catheters, and cardiac echocardiography catheters, which do 
not remain in the patient upon discharge). Therefore, some charge 
compression could continue for these technologies. We believe this 
limited presence of charge compression is acceptable, given that the 
proposed definition of device for cost reporting purposes would isolate 
virtually all of the expensive items, allowing them to be separately 
reported from most inexpensive supplies.
    The criteria we are proposing above for instructing hospitals as to 
what to report in the device cost center specify that a device is not a 
material or supply furnished incident to a service (for example, a 
surgical staple, a suture, customized surgical kit, or clip, other than 
a radiological site marker) (emphasis added). We understand that 
hospitals may sometimes receive surgical kits from device manufacturers 
that consist of a high-cost primary implantable device, external 
supplies required for operation of the device, and other disposable 
surgical supplies required for successful device implantation. Often 
the device and the attending supplies are included on a single invoice 
from the manufacturer, making it difficult for the hospital to 
determine the cost of each item in the kit. In addition, manufacturers 
sometimes include with the primary device other free or ``bonus'' items 
or supplies that are not an integral and necessary part of the device 
(that is, not actually required for the safe surgical implantation and 
subsequent operation of that device). (We note that arrangements 
involving free or bonus items or supplies may implicate the Federal 
anti-kickback statue, depending on the circumstances.) One option is 
for the hospital to split the total combined charge on the invoice in a 
manner that the hospital believes best identifies the cost of the 
device alone. However, because it may be difficult for hospitals to 
determine the respective costs of the actual device and the attending 
supplies (whether they are required for the safe surgical implantation 
and subsequent operation of that device or not), we are soliciting 
comments with respect to how supplies, disposable or otherwise, that 
are part of surgical kits should be reported. We are distinguishing 
between such supplies that are an integral and necessary part of the 
primary device (that is, required for the safe surgical implantation 
and subsequent operation of that device) from other supplies that are 
not directly related to the implantation of that device, but may be 
included by the device manufacturer with or without charge as ``perks'' 
along with the kit. If it is difficult to break out the costs and 
charges of these lower cost items that are an integral and necessary

[[Page 23546]]

part of the primary device, we would consider allowing hospitals to 
report the costs and charges of these lower cost supplies along with 
the costs and charges of the more expensive primary device in the cost 
report cost center for implantable devices. However, to the extent that 
device manufacturers could be encouraged to refine their invoicing 
practices to break out the charges and costs for the lower cost 
supplies and the higher cost primary device separately, so that 
hospitals need not ``guesstimate'' the cost of the device, this would 
facilitate more accurate cost reporting and, therefore, the calculation 
of more accurate cost-based weights. Under either scenario, even for an 
aggregated invoice that contains an expensive device, we believe that 
RTI's findings of significant differences in supply CCRs for hospitals 
with a greater percentage of charges in device revenue codes 
demonstrate that breaking the Medical Supplies Charged to Patients cost 
center into two cost centers and using appropriate revenue codes for 
devices, and walking those costs to the new Implantable Devices Charged 
to Patients cost center, will result in an increase in estimated device 
costs.
    In summary, we are proposing to modify the cost report to have one 
cost center for Medical Supplies Charged to Patients and one cost 
center for Implantable Devices Charged to Patients. We are proposing to 
instruct hospitals to report only devices that meet the four criteria 
listed above (specifically including that the device is implantable and 
remains in the patient at discharge) in the cost center for Implantable 
Devices Charged to Patients. All other devices and nonchargeable 
supplies would be reported in the Medical Supplies cost center. This 
would allow for two distinct CCRs, one for medical supplies and one for 
implantable devices and DME rented and DME sold.
    However, we are also soliciting comments on alternative approaches 
that could be used in conjunction with or in lieu of the four proposed 
criteria for distinguishing between what should be reported in the cost 
center for Implantable Devices and Medical Supplies, respectively. 
Another option we are considering would distinguish between high-cost 
and low-cost items based on a cost threshold. Under this methodology, 
we would also have one cost center for Medical Supplies and one cost 
center for Devices, but we would instruct hospitals to report items 
that are not movable equipment or a capital expense but are above a 
certain cost threshold in the cost center for Devices. Items costing 
below that threshold would be reported in the cost center for Medical 
Supplies.
    Establishing a cost threshold for cost reporting purposes would 
directly address the problem of charge compression and would enable 
hospitals to easily determine whether an item should be reported in the 
supply or the device cost center. A cost threshold would also 
potentially allow a broader variety of expensive, single use devices 
that do not remain in the patient at discharge to be reported in the 
device cost center (such as specialized catheters or ablation probes). 
While we have a number of concerns with the cost threshold approach, we 
are nevertheless soliciting public comments on whether such an approach 
would be worthwhile to pursue. Specifically, we are concerned that 
establishing a single cost threshold for pricing devices could possibly 
be inaccurate across hospitals. Establishing a threshold would require 
identifying a cost at which hospitals would begin applying reduced 
markup policies. Currently, we do not have data from which to derive a 
threshold. We have anecdotal reports that hospitals change their markup 
thresholds between $15,000 and $20,000 in acquisition costs. Recent 
research on this issue indicated that hospitals with average inpatient 
discharges in DRGs with supply charges greater than $15,000, $20,000, 
and $30,000 have higher supply CCRs (Advamed March 2006).
    Furthermore, although a cost threshold directly addresses charge 
compression, it may not eliminate all charge compression from the 
device cost center because a fixed cost threshold may not accurately 
capture differential markup policies for an individual hospital. At the 
same time, we are also concerned that establishing a cost threshold may 
interfere with the pricing practices of device manufacturers in that 
the prices for certain devices or surgical kits could be inflated to 
ensure that the devices met the cost threshold. We believe our proposed 
approach of identifying a group of items that are relatively expensive 
based on the existing criteria for OPPS device pass-through payment 
status, rather than adopting a cost threshold, would not influence 
pricing by the device industry. In addition, if a cost threshold were 
adopted for distinguishing between high-cost devices and low-cost 
supplies on the cost report, we would need to periodically reassess the 
threshold for changes in markup policies and price inflation over time.
    Another option for distinguishing between high-cost and low-cost 
items for purposes of the cost report would be to divide the Medical 
Supplies cost center based on markup policies by placing items with 
lower than average markups in a separate cost center. This approach 
would center on documentation requirements for differential charging 
practices that would lead hospitals to distinguish between the 
reporting of supplies and devices on different cost report lines. That 
is, because charge compression results from the different markup 
policies that hospitals apply to the supplies and devices they use 
based on the estimated costs of those supplies and devices, isolating 
supplies and devices with different markup policies mitigates 
aggregation in markup policies that cause charge compression and is 
specific to a hospital's internal accounting and pricing practices. If 
requested by the fiscal intermediaries/MACs at audit, hospitals could 
be required to submit documentation of their markup policies to justify 
the way they have reported relatively inexpensive supplies on one line 
and more expensive devices on the other line. We believe that it should 
not be too difficult for hospitals to document their markup practices 
because, as was pointed out by many commenters since the implementation 
of cost-based weights, the source of charge compression is varying 
markup practices. Greater knowledge of the specifics of hospital markup 
practices may allow ultimately for development of standard cost 
reporting instructions that instruct hospitals to report an item as a 
device or a supply based on the type of markup applied to that item. 
This option related to markup practices, the proposal to define devices 
based on four specific criteria, and the third alternative that would 
establish a cost threshold for purposes of distinguishing between high-
cost and low-cost items, could be utilized separately or in some 
combination for purposes of cost report modification. Again, we are 
soliciting comments on these alternative approaches. We are also 
interested in other recommendations for appropriate cost reporting 
improvements that address charge compression.
3. Timeline for Revising the Medicare Cost Report
    As mentioned in the FY 2008 IPPS final rule with comment period (72 
FR 47198), we have begun a comprehensive review of the Medicare 
hospital cost report, and the proposed splitting of the current 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, is part of

[[Page 23547]]

our initiative to update and revise the hospital cost report. Under an 
effort initiated by CMS to update the Medicare hospital cost report to 
eliminate outdated requirements in conjunction with the Paperwork 
Reduction Act, we plan to propose the actual changes to the cost 
reporting form, the attending cost reporting software, and the cost 
report instructions in Chapter 36 of the Medicare Provider 
Reimbursement Manual (PRM), Part II. We expect the proposed revision to 
the Medicare hospital cost report to be issued after publication of 
this IPPS proposed rule. If we were to adopt as final our proposal to 
create one cost center for Medical Supplies Charged to Patients and one 
cost center for Implantable Devices Charged to Patients in the FY 2009 
IPPS final rule, the cost report forms and instructions would reflect 
those changes. We expect the revised cost report would be available for 
hospitals to use when submitting cost reports during FY 2009 (that is, 
for cost reporting periods beginning on or after October 1, 2008). 
Because there is approximately a 3-year lag between the availability of 
cost report data for IPPS and OPPS ratesetting purposes and a given 
fiscal year, we may be able to derive two distinct CCRs, one for 
medical supplies and one for devices, for use in calculating the FY 
2012 IPPS relative weights and the CY 2012 OPPS relative weights.
4. Revenue Codes Used in the MedPAR File
    An important first step in RTI's study (as explained in its draft 
interim March 2007 report) was determining how well the cost report 
charges used to compute CCRs matched to the charges in the MedPAR file. 
This match (or lack thereof) directly affects the accuracy of the DRG 
cost estimates because MedPAR charges are multiplied by CCRs to 
estimate cost. RTI found inconsistent reporting between the cost 
reports and the claims data for charges in several ancillary 
departments (Medical Supplies, Operating Room, Cardiology, and 
Radiology). For example, the data suggested that some hospitals often 
include costs and charges for devices and other medical supplies within 
the Medicare cost report cost centers for Operating Room, Radiology, or 
Cardiology, while other hospitals include them in the Medical Supplies 
Charged to Patients cost center. While the educational initiative 
undertaken by the national hospital associations is encouraging 
hospitals to consistently report costs and charges for devices and 
other medical supplies only in the Medical Supplies Charged to Patients 
cost center, equal attention must be paid to the way in which charges 
are grouped by hospitals in the MedPAR file. Several commenters on the 
FY 2008 IPPS proposed rule supported RTI's recommendation of including 
additional fields in the MedPAR file to disaggregate certain cost 
centers. One commenter stated that the assignment of revenue codes and 
charges to revenue centers in the MedPAR file should be reviewed and 
changed to better reflect hospital accounting practices as reflected on 
the cost report (72 FR 47198).
    In an effort to improve the match between the costs and charges 
included on the cost report and the charges in the MedPAR file, we are 
recommending that certain revenue codes be used for items reported in 
the proposed Medical Supplies Charged to Patients cost center and the 
proposed Implantable Devices Charged to Patients cost center, 
respectively. Specifically, under the proposal to create a cost center 
for implantable devices that remain in the patient upon discharge, 
revenue codes 0275 (Pacemaker), 0276 (Intraocular Lens), and 0278 
(Other Implants) would correspond to implantable devices reported in 
the proposed Implantable Devices Charged to Patients cost center. Items 
for which a hospital may have previously used revenue code 0270 
(General Classification), but actually meet the proposed definition of 
an implantable device that remains in the patient upon discharge should 
instead be billed with the 0278 revenue code. Conversely, relatively 
inexpensive items and supplies that are not implantable and do not 
remain in the patient at discharge would be reported in the proposed 
Medical Supplies Charged to Patients cost center on the cost report, 
and should be billed with revenue codes 0271 (nonsterile supply), 0272 
(sterile supply), and 0273 (take-home supplies), as appropriate. 
Revenue code 0274 (Prosthetic/Orthotic devices) and revenue code 0277 
(Oxygen--Take Home) should be associated with the costs reported on 
lines 66 and 67 for DME--Rented and DME--Sold on the cost report. 
Charges associated with supplies used incident to radiology or to other 
diagnostic services (revenue codes 0621 and 0622 respectively) should 
match those items used incident to those services on the Medical 
Supplies Charged to Patients cost center of the cost report, because, 
under this proposal, supplies furnished incident to a service would be 
reported in the Medical Supplies Charged to Patients cost center (see 
item b. listed above, in the proposed definition of a device). A 
revenue code of 0623 for surgical dressings would similarly be 
associated with the costs and charges of items reported in the proposed 
Medical Supplies Charged to Patients cost center, while a revenue code 
of 0624 for FDA investigational device, if that device does not remain 
in the patient upon discharge, could be associated with items reported 
on the Medical Supplies Charged to Patients cost center as well.
    In general, if an item is reported as an implantable device on the 
cost report, the associated charges should be recorded in the MedPAR 
file with either revenue codes 0275 (Pacemaker), 0276 (Intraocular 
Lens), or 0278 (Other Implants). Likewise, items reported as Medical 
Supplies should receive an appropriate revenue code indicative of 
supplies. We understand that many of these revenue codes have been in 
existence for many years and have been added for purposes unrelated to 
the goal of refining the calculation of cost-based weights. 
Accordingly, we acknowledge that additional instructions relating to 
the appropriate use of these revenue codes may need to be issued. In 
addition, CMS or the hospital associations may need to request new 
revenue codes from the National Uniform Billing Committee (NUBC). In 
either case, we do not believe either should delay use of the new 
Medical Supplies and Implantable Devices CCRs in setting payment rates. 
However, in light of our proposal to create two separate cost centers 
for Medical Supplies Charged to Patients and Implantable Devices 
Charged to Patients, respectively, we are soliciting comments on how 
the existing revenue codes or additional revenue codes could best be 
used in conjunction with the revised cost centers on the cost report.

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

1. General
    In its landmark 1999 report ``To Err is Human: Building a Safer 
Health System,'' the Institute of Medicine found that medical errors, 
particularly hospital-acquired conditions (HACs) caused by medical 
errors, are a leading cause of morbidity and mortality in the United 
States. The report noted that the number of Americans who die each year 
as a result of medical errors that occur in hospitals may be as high as 
98,000. The cost burden of HACs is also high. Total national costs of 
these errors due to lost productivity, disability, and health care 
costs were estimated at $17

[[Page 23548]]

billion to $29 billion.\2\ In 2000, the CDC estimated that hospital-
acquired infections added nearly $5 billion to U.S. health care costs 
every year.\3\ A 2007 study found that, in 2002, 1.7 million hospital-
acquired infections were associated with 99,000 deaths\4\ Research has 
also shown that hospitals are not following recommended guidelines to 
avoid preventable hospital-acquired infections. A 2007 Leapfrog Group 
survey of 1,256 hospitals found that 87 percent of those hospitals do 
not follow recommendations to prevent many of the most common hospital-
acquired infections.\5\
---------------------------------------------------------------------------

    \2\ Institute of Medicine: To Err Is Human: Building a Safer 
Health System, November 1999. Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf.
    \3\ Centers for Disease Control and Prevention: Press Release, 
March 2000. Available at: http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm.
    \4\ Klevens et al. Estimating Health Care-Associated Infections 
and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-
April 2007. Volume 122.
    \5\ 2007 Leapfrog Group Hospital Survey. The Leapfrog Group 
2007. Available at: http://www.leapfroggroup.org/media/file/Leapfrog_hospital_acquired_infections_release.pdf
---------------------------------------------------------------------------

    As one approach to combating HACs, including infections, in 2005 
Congress authorized CMS to adjust for Medicare IPPS hospital payments 
to encourage the prevention of these conditions. The preventable HAC 
provision at section 1886(d)(4)(D) of the Act is part of an array of 
Medicare value-based purchasing (VBP) tools that CMS is 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. CMS' application of VBP tools through various initiatives, 
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.
    The President's FY 2009 Budget outlines another approach for 
addressing serious preventable adverse events (``never events''), 
including HACs. The President's Budget proposal would: (1) Prohibit 
hospitals from billing the Medicare program for ``never events'' and 
prohibit Medicare payment for these events; and (2) require hospitals 
to report occurrence of these events or receive a reduced annual 
payment update.
    Medicare's IPPS encourages hospitals to treat patients efficiently. 
Hospitals 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 many cases, 
complications acquired in the hospital do not generate higher payments 
than the hospital would otherwise receive for uncomplicated cases paid 
under the same DRG. To this extent, the IPPS encourages hospitals to 
avoid complications. However, complications, such as infections, 
acquired in the hospital can generate higher Medicare payments in two 
ways. First, the treatment of complications can increase the cost of a 
hospital stay enough to generate an outlier payment. However, the 
outlier payment methodology requires that a hospital experience a large 
loss on an outlier case, which serves as an incentive for hospitals to 
prevent outliers. Second, under the MS-DRGs that took effect in FY 
2008, 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. If a 
condition acquired during a hospital stay is one of the conditions on 
the CC or MCC list, the hospital currently receives a higher payment 
under the MS-DRGs (prior to the October 1, 2008 effective date of the 
HAC payment provision). (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).) The following is an example of how an MS-DRG 
may be paid.

----------------------------------------------------------------------------------------------------------------
                                                                                    Present on
                                                                                    admission         Average
  Service: MS-DRG Assignment\*\ (Examples below with CC/MCC indicate a single       (status of    payment (based
                           secondary diagnosis only)                                secondary         on 50th
                                                                                    diagnosis)      percentile)
----------------------------------------------------------------------------------------------------------------
Principal Diagnosis............................................................  ...............       $5,347.98
    <bullet> Intracranial hemorrhage or cerebral infarction (stroke) without CC/
     MCC--MS-DRG 066...........................................................
Principal Diagnosis............................................................               Y         6,177.43
    <bullet> Intracranial hemorrhage or cerebral infarction (stroke) with CC--
     MS-DRG 065................................................................
Example Secondary Diagnosis
    <bullet> Dislocation of patella-open due to a fall (code 836.4 (CC)).......
Principal Diagnosis............................................................               N         5,347.98
    <bullet> Intracranial hemorrhage or cerebral infarction (stroke) with CC--
     MS-DRG 065................................................................
Example Secondary Diagnosis
    <bullet> Dislocation of patella-open due to a fall (code 836.4 (CC)).......
Principal Diagnosis............................................................               Y         8,030.28
    <bullet> Intracranial hemorrhage or cerebral infarction (stroke) with MCC--
     MS-DRG 064................................................................
Example Secondary Diagnosis
    <bullet> Stage III pressure ulcer (code 707.23 (MCC))......................
Principal Diagnosis............................................................               N         5,347.98
    <bullet> Intracranial hemorrhage or cerebral infarction (stroke) with MCC--
     MS-DRG 064................................................................
Example Secondary Diagnosis
    <bullet> Stage III pressure ulcer (code 707.23 (MCC))......................
----------------------------------------------------------------------------------------------------------------
\*\ Operating amounts for a hospital whose wage index is equal to the national average.

2. Statutory Authority
    Section 1886(d)(4)(D) of the Act required the Secretary to select 
at least two conditions by October 1, 2007, that are: (a) High cost, 
high volume, or both; (b) assigned to a higher paying DRG when present 
as a secondary diagnosis; and (c) could reasonably have been prevented 
through the application of evidence-based guidelines. Beginning October 
1, 2008, Medicare can no longer assign an inpatient hospital discharge 
to

[[Page 23549]]

a higher paying MS-DRG if a selected HAC was not present on admission. 
That is, the case will be paid as though the secondary diagnosis was 
not present. (Medicare will continue to assign a discharge to a higher 
paying MS-DRG if the selected condition was present on admission.) 
Section 1886(d)(4)(D) of the Act provides that the list of conditions 
can be revised from time to time, as long as the list contains at least 
two conditions. Beginning October 1, 2007, we required hospitals to 
begin submitting information on Medicare claims specifying whether 
diagnoses were present on admission (POA).
    The POA indicator reporting requirement and the HACs payment 
provision apply to IPPS hospitals only. At this time, non-IPPS 
hospitals such as CAHs, LTCHs, IRFs, and hospitals in Maryland 
operating under waivers, among others, are exempt from POA reporting 
and the HAC payment provision. Throughout this section, ``hospital'' 
refers to IPPS hospitals.
3. Public Input
    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), we again sought formal 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 summarized the 
public comments we received on the FY 2008 IPPS proposed rule, 
presented our responses, selected eight conditions to which the HAC 
provision will initially apply, and noted that we would be seeking 
comments on additional HAC candidates in this proposed rule.
4. Collaborative Process
    CMS experts worked with public health and infectious disease 
professionals from the CDC to identify the candidate preventable HACs. 
CMS and CDC staff also collaborated on the process for hospitals to 
submit a POA indicator for each diagnosis listed on IPPS hospital 
Medicare claims.
    On December 17, 2007, CMS and CDC hosted a jointly sponsored HAC 
and POA Listening Session to receive input from interested 
organizations and individuals. The agenda, presentations, audio file, 
and written transcript of the listening session are available on the 
Web site at: http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp. CMS and CDC also received informal comments 
during the listening session and subsequently received numerous written 
comments.
5. Selection Criteria for HACs
    CMS and CDC staff evaluated each candidate condition against the 
criteria established by section 1886(d)(4)(D)(iv) of the Act.
    <bullet> Cost or Volume--Medicare data \6\ must support that the 
selected conditions are high cost, high volume, or both. At this point, 
there are no Medicare claims data indicating which secondary diagnoses 
were POA because POA indicator reporting began only recently; 
therefore, the currently available data for candidate conditions 
includes all secondary diagnoses.
---------------------------------------------------------------------------

    \6\ For this FY 2009 IPPS proposed rule, the DRG analysis is 
based on data from the September 2007 update of the FY 2007 MedPAR 
file, which contains hospital bills received through September 30, 
2007, for discharges through September 30, 2007.
---------------------------------------------------------------------------

    <bullet> Complicating Condition (CC) or Major Complicating 
Condition (MCC)--Selected conditions must be represented by ICD-9-CM 
diagnosis codes that clearly identify the condition, are designated as 
a CC or an MCC, and result in the assignment of the case to an MS-DRG 
that has a higher payment when the code is reported as a secondary 
diagnosis. That is, selected conditions must be a CC or an MCC that 
would, in the absence of this provision, result in assignment to a 
higher paying MS-DRG.
    <bullet> Evidence-Based Guidelines--Selected conditions must be 
reasonably preventable through the application of evidence-based 
guidelines. By reviewing guidelines from professional organizations, 
academic institutions, and entities such as the Healthcare Infection 
Control Practices Advisory Committee (HICPAC), we evaluated whether 
guidelines are available that hospitals should follow to prevent the 
condition from occurring in the hospital.
    <bullet> Reasonably Preventable--Selected conditions must be 
reasonably preventable through the application of evidence-based 
guidelines.
6. HACs Selected in FY 2008 and Proposed Changes to Certain Codes
    The HACs that were selected for the HAC payment provision through 
the FY 2008 IPPS final rule with comment period are listed below. The 
payment provision for these selected HACs will take effect on October 
1, 2008. We refer readers to section II.F.6. of the FY 2008 IPPS final 
rule with comment period (72 FR 47202 through 47218) for a detailed 
analysis supporting the selection of each of these HACs.
BILLING CODE 4120-01-P

[[Page 23550]]

[GRAPHIC][TIFF OMITTED]TP30AP08.000


[[Page 23551]]


[GRAPHIC][TIFF OMITTED]TP30AP08.001

BILLING CODE 4120-01-C

[[Page 23552]]

    We are seeking public comments on the following refinements to two 
of the previously selected HACs:
a. Foreign Object Retained After Surgery: Proposed Inclusion of ICD-9-
CM Code 998.7 (CC)
    In the FY 2008 IPPS final rule with comment period (72 FR 47206), 
we indicated that a foreign body accidentally left in the patient 
during a procedure (ICD-9-CM code 998.4) was one of the conditions 
selected. It has come to our attention that ICD-9-CM diagnosis code 
998.7 (Acute reaction to foreign substance accidentally left during a 
procedure) should also be included. ICD-9-CM code 998.7 describes 
instances in which a patient developed an acute reaction due to a 
retained foreign substance. Therefore, we are proposing to make this 
code subject to the HAC payment provision.
b. Pressure Ulcers: Proposed Changes in Code Assignments
    As discussed in the FY 2008 IPPS final rule with comment period (72 
FR 47205-47206), we referred the need for more detailed ICD-9-CM 
pressure ulcer codes to the CDC. The topic of expanding pressure ulcer 
codes to capture the stage of the ulcer was addressed at the September 
27-28, 2007, meeting of the ICD-9-CM Coordination and Maintenance 
Committee. A summary report of this meeting is available on the Web 
site at: http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm.
    Numerous wound care professionals supported modifying the pressure 
ulcer codes to capture staging information. The stage of the pressure 
ulcer is a powerful predictor of severity and resource utilization. At 
its September 27-28, 2007 meeting, the ICD-9-CM Coordination and 
Maintenance Committee discussed the creation of pressure ulcer codes to 
capture this information. The new codes, along with their proposed CC/
MCC classifications, are shown in Table 6A of the Addendum to this 
proposed rule. The new codes are as follows:
    <bullet> 707.20 (Pressure ulcer, unspecified stage).
    <bullet> 707.21 (Pressure ulcer stage I).
    <bullet> 707.22 (Pressure ulcer stage II).
    <bullet> 707.23 (Pressure ulcer stage III).
    <bullet> 707.24 (Pressure ulcer stage IV).
    While the code titles are final, we are soliciting comment on the 
proposed MS-DRG classifications of these codes, as indicated in Table 
6A of the Addendum to this proposed rule. We are proposing to remove 
the CC/MCC classifications from the current pressure ulcer codes that 
show the site of the ulcer (ICD-9-CM codes 707.00 through 707.09). 
Therefore, the following codes would no longer be a CC:
    <bullet> 707.00 (Decubitus ulcer, unspecified site).
    <bullet> 707.01 (Decubitus ulcer, elbow).
    <bullet> 707.09 (Decubitus ulcer, other site). The following codes 
would no longer be an MCC:
    <bullet> 707.02 (Decubitus ulcer, upper back).
    <bullet> 707.03 (Decubitus ulcer, lower back).
    <bullet> 707.04 (Decubitus ulcer, hip).
    <bullet> 707.05 (Decubitus ulcer, buttock).
    <bullet> 707.06 (Decubitus ulcer, ankle).
    <bullet> 707.07 (Decubitus ulcer, heel).
    We are proposing to instead assign the CC/MCC classifications to 
the stage of the pressure ulcer as shown in Table 6A of the Addendum to 
this proposed rule. We are proposing to classify ICD-9-CM codes 707.23 
and 707.24 as MCCs. We are proposing to classify codes 707.20, 707.21, 
and 707.22 as non-CCs.
    Therefore, we are proposing that, beginning October 1, 2008, the 
codes used to make MS-DRG adjustments for pressure ulcers under the HAC 
provision would include the proposed MCC codes 707.23 and 707.24.
7. HACs Under Consideration as Additional Candidates
    CMS and CDC have diligently worked together and with other 
stakeholders to identify additional HACs that might appropriately be 
subject to the HAC payment provision. If the additional candidate HACs 
are selected in the FY 2009 IPPS final rule, the payment provision will 
take effect for these candidate HACS on October 1, 2008. The statutory 
criteria for each HAC candidate are presented in tabular format. Each 
table contains the following:
    <bullet> HAC Candidate--We are seeking public comment on all HAC 
candidates.
    <bullet> Medicare Data--We are seeking public comment on the 
statutory criterion of high cost, high volume, or both as it applies to 
the HAC candidate.
    <bullet> CC/MCC--We are seeking public comment on the statutory 
criterion that an ICD-9-CM diagnosis code(s) clearly identifies the HAC 
candidate.
    <bullet> Selected Evidence-Based Guidelines--We are seeking public 
comment on the degree to which the HAC candidate is reasonably 
preventable through the application of the identified evidence-based 
guidelines.
a. Surgical Site Infections Following Elective Surgeries

[[Page 23553]]

[GRAPHIC][TIFF OMITTED]TP30AP08.002

    In the FY 2008 IPPS final rule with comment period (72 FR 47213), 
surgical site infections were identified as a broad category for 
consideration, and we selected mediastinitis after coronary artery 
bypass graft (CABG) as one of the initial eight HACs for 
implementation. We are now considering the addition of other surgical 
site infections, particularly those following elective procedures. In 
most cases, patients selected as candidates for elective surgeries 
should have a relatively low-risk profile for surgical site infections.
    The following elective surgical procedures are under consideration:
    <bullet> Total Knee Replacement (81.54): ICD-9-CM codes 996.66 (CC) 
and 998.59 (CC)
    <bullet> Laparoscopic Gastric Bypass (44.38) and Laparoscopic 
Gastroenterostomy (44.39): ICD-9-CM code 998.59 (CC)
    <bullet> Ligation and Stripping of Varicose Veins (38.50 through 
38.53, 38.55, 38.57, and 38.59): ICD-9-CM code 998.59 (CC)
    Evidence-based guidelines for preventing surgical site infections 
emphasize the importance of appropriately using prophylactic 
antibiotics, using clippers rather than razors for hair removal and 
tightly controlling postoperative glucose.
    While we are seeking public comments on the applicability of each 
of the statutory criteria to surgical site infections following 
elective procedures, we are particularly interested in receiving 
comments on the degree of preventability of surgical site infections 
following elective procedures generally, as well as specifically for 
those listed above. We also are seeking public comments on additional 
elective surgical procedures that would qualify for the HAC provision 
by meeting all of the statutory criteria. Based on the public comments 
we receive, we may select some combination of the four procedures 
presented here along with additional conditions that qualify and are 
supported by the comments.
b. Legionnaires' Disease
[GRAPHIC][TIFF OMITTED]TP30AP08.003

    We discussed Legionnaires' Disease in the FY 2008 IPPS final rule 
with comment period (72 FR 47216). Legionnaires' Disease is a type of 
pneumonia caused by the bacterium Legionella pneumophila. It is 
contracted

[[Page 23554]]

by inhaling contaminated water vapor or droplets. It is not spread 
person to person. Individuals at risk include those who are elderly, 
immunocompromised, smokers, or persons with underlying lung disease. 
The bacterium thrives in warm aquatic environments and infections have 
been linked to large industrial water systems, including hospital water 
systems such as air conditioning cooling towers and potable water 
plumbing systems. Prevention depends primarily on regular monitoring 
and decontamination of these water systems. While we are seeking public 
comments regarding the applicability of each of the statutory criteria 
to Legionnaires' Disease, we are particularly interested in receiving 
comments on the degree of preventability of Legionnaires' Disease 
through the application of hospital water system maintenance 
guidelines.
    Legionnaires' Disease is typically acquired outside of the hospital 
setting and may be difficult to diagnose as present on admission. We 
are seeking comments on the degree to which hospital-acquired 
Legionnaires' Disease can be distinguished from community-acquired 
cases.
    We also are seeking public comments on additional water-borne 
pathogens that would qualify for the HAC provision by meeting the 
statutory criteria. Based on the public comments we receive, we may 
finalize some combination of Legionnaires' Disease and additional 
conditions that qualify and are supported by the public comments.
c. Glycemic Control
[GRAPHIC][TIFF OMITTED]TP30AP08.004

    During the December 17, 2007 HAC and POA Listening Session, one of 
the commenters suggested that we explore hyperglycemia and hypoglycemia 
as HACs for selection. NQF's list of Serious Reportable Adverse Events 
includes death or serious disability associated with hypoglycemia that 
occurs during hospitalization.
    Hyperglycemia and hypoglycemia are extremely common laboratory 
findings in hospitalized patients and can be complicating features of 
underlying diseases and some therapies. However, we believe that 
extreme forms of poor glycemic control should not occur while under 
medical care in the hospital setting. Thus, we are considering whether 
the following forms of extreme glucose derangement should be subject to 
the HAC payment provision:
    <bullet> Diabetic Ketoacidosis: ICD-9-CM codes 250.10-250.13 (CC)
    <bullet> Nonketotic Hyperosmolar Coma: ICD-9-CM code 251.0 (CC)
    <bullet> Diabetic Coma: ICD-9-CM codes 250.30-250.33 (CC)
    <bullet> Hypoglycemic Coma: ICD-9-CM codes 250.30-251.0 (CC)
    While we are seeking public comments regarding the applicability of 
each of the statutory criteria to these extreme aberrations in glycemic 
control, we are particularly interested in receiving comments on the 
degree to which these extreme aberrations in glycemic control are 
reasonably preventable, in the hospital setting, through the 
application of evidence-based guidelines. Based on the public comments 
we receive, we may select some combination of these glycemic control-
related conditions as HACs.
d. Iatrogenic Pneumothorax

[[Page 23555]]

[GRAPHIC][TIFF OMITTED]TP30AP08.005

    Iatrogenic pneumothorax refers to the accidental introduction of 
air into the pleural space, which is the space between the lung and the 
chest wall. When air is introduced into this space it partially or 
completely collapses the lung. Iatrogenic pneumothorax can occur during 
any procedure where there is the possibility of air entering pleural 
space, including needle biopsy of the lung, thoracentesis, central 
venous catheter placement, pleural biopsy, tracheostomy, and liver 
biopsy. Iatrogenic pneumothorax can occur secondary to positive 
pressure mechanical ventilation when an air sac in the lung ruptures 
allowing air into the pleural space.
    While we are seeking public comments on the applicability of each 
of the statutory criteria to iatrogenic pneumothorax, we are 
particularly interested in receiving comments on the degree to which 
iatrogenic pneumothorax is reasonably preventable through the 
application of evidence-based guidelines. Based on the public comments 
we receive, we may select iatrogenic pneumothorax as an HAC.
e. Delirium
[GRAPHIC][TIFF OMITTED]TP30AP08.006

    Delirium is a relatively abrupt deterioration in a patient's 
ability to sustain attention, learn, or reason. Delirium is strongly 
associated with aging and treatment of illnesses that are associated 
with hospitalizations. Delirium affects nearly half of hospital patient 
days for individuals age 65 and older, and approximately three-quarters 
of elderly individuals in intensive care units have delirium. About 14 
to 24 percent of hospitalized elderly individuals have delirium at the 
time of admission. Having delirium is a very serious risk factor, with 
1-year mortality of 35 to 40 percent, a rate as high as those 
associated with heart attacks and sepsis. The adverse effects of 
delirium routinely last for months. Delirium is a clinical diagnosis, 
commonly assisted by screening tests such as the Confusion Assessment 
Method.
    Well-established practices, such as reducing certain medications, 
reorienting the patient, assuring sensory input and sleep, and avoiding 
malnutrition and dehydration, prevent 30 to 40 percent of the possible 
cases. While we are seeking public comments on the applicability of 
each of the statutory criteria to delirium, we are particularly 
interested in receiving comments on the degree to which delirium is 
reasonably preventable through the application of evidence-based 
guidelines. Based upon the public comments we receive, we may select 
delirium as an HAC.
f. Ventilator-Associated Pneumonia (VAP)

[[Page 23556]]

[GRAPHIC][TIFF OMITTED]TP30AP08.007

    We discussed ventilator-associated pneumonia (VAP) in the FY 2008 
IPPS final rule with comment period (72 FR 47209-47210). VAP is a 
serious hospital-acquired infection associated with high mortality, 
significantly increased hospital length of stay, and high cost. It is 
typically caused by the aspiration of contaminated gastric and/or 
oropharyngeal secretions. The presence of an endotracheal tube 
facilitates both the contamination of secretions as well as aspiration.
    During the past year, the ICD-9-CM Coordination and Maintenance 
Committee discussed the creation of a new ICD-9-CM code 997.31 to 
identify VAP. This new code is shown in Table 6A of the Addendum to 
this proposed rule. The lack of a specific code was one of the barriers 
to including VAP as an HAC that we discussed in the FY 2008 IPPS final 
rule with comment period. We also discussed the degree to which VAP may 
be reasonably preventable through the application of evidence-based 
guidelines. Specifically, the FY 2008 IPPS final rule with comment 
period referenced the American Association for Respiratory Care's 
Clinical Practice Guidelines at the Web site: http://www.rcjournal.com/cpgs/09.03.0869.html.
    To further investigate the extent to which VAP is reasonably 
preventable, we reviewed published clinical research. The literature, 
including recommendations by CDC and the HICPAC, from 2003 shows 
numerous prevention guidelines that can significantly reduce the 
incidence of VAP in the hospital setting. These guidelines include 
interventions such as educating staff, hand washing, using gowns and 
gloves, properly positioning the patient, elevating the head of the 
bed, changing ventilator tubing, sterilizing reusable equipment, 
applying chlorhexadine solution for oral decontamination, monitoring 
sedation daily, administering stress ulcer prophylaxis, and 
administering pneumococcal vaccinations. Further review of the 
literature, specifically regarding the proportion of VAP cases that 
might be preventable, revealed two large-scale analyses that were 
completed recently. One study concluded that an estimated 40 percent of 
VAP cases are preventable. A second study concluded that at least 20 
percent of nosocomial infections in general (not just VAP) are 
preventable.\7\
---------------------------------------------------------------------------

    \7\ American Association for Respiratory Care Clinical Practice: 
Guideline: Care of the Ventilator Circuit and Its Relation to 
Ventilator Associated Pneumonia. Available at the Web site: http://www.rcjournal.com/cpgs/09.03.0869.html.
---------------------------------------------------------------------------

    During the December 17, 2007 HAC and POA Listing Session, we also 
received comments on evidence-based guidelines for preventing VAP. 
Commenters referenced two articles \8\ \9\ that both state there is a 
high degree of risk associated with endotracheal tube insertions, 
suggesting that VAP may not always be preventable. 
---------------------------------------------------------------------------

    \8\ Ramirez et al.: Prevention Measures for Ventilator-
Associated Pneumonia: A New Focus on the Endotracheal Tube. Current 
Opinion in Infectious Disease, April 2007, Vol.20 (2), pp. 190-197.
    \9\ Safdar et al.: The Pathogenesis of Ventilator-Associated 
Pneumonia: Its Relevance to Developing Effective Strategies for 
Prevention. Respiratory Care, June 2005, Vol. 50, No. 6, pp.725-741.
---------------------------------------------------------------------------

    While we are seeking public comments on the applicability of each 
of the statutory criteria to VAP, we are particularly interested in 
receiving comment on the degree to which VAP

[[Page 23557]]

is reasonably preventable through the application of evidence-based 
guidelines. Based on the public comments we receive, we may select VAP 
as an HAC.
g. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
[GRAPHIC][TIFF OMITTED]TP30AP08.008

    We discussed deep vein thrombosis (DVT) and pulmonary embolism (PE) 
in the FY 2008 IPPS final rule with comment period (72 FR 47215). DVT 
and PE are common events. DVT occurs when a blood clot forms in the 
deep veins of the leg and causes local swelling and inflammation. PE 
occurs when a clot or a piece of a clot migrates from its original site 
into the lungs, causing the death of lung tissue, which can be fatal. 
Risk factors for DVTs and PEs include inactivity, smoking, use of oral 
contraceptives, prolonged bed rest, prolonged sitting with bent knees, 
certain types of cancer and other disease states, certain blood 
clotting disorders, and certain types of orthopedic and other surgical 
procedures. DVT is not always clinically apparent because the 
manifestations of pain, redness, and swelling may develop some time 
after the venous clot forms.
    As we discussed in the FY 2008 IPPS final rule with comment period, 
DVTs and PEs may be preventable in certain circumstances, but it is 
possible that a patient may have a DVT that is difficult to detect on 
admission. We also received comments during the December 17, 2007 HAC 
and POA Listening Session reiterating that not all cases of DVTs and 
PEs are preventable. For example, common patient characteristics such 
as immobility, obesity, severe vessel trauma, and venous stasis put 
certain trauma and joint replacement surgery patients at high risk for 
these conditions.
    In our review of the literature, we found that there are definite 
pharmacologic and nonpharmacologic interventions that may reduce the 
likelihood of developing DVTs and PEs, including exercise, compression 
stockings, intermittent pneumatic boots, aspirin, enoxaparin, 
dalteparin, heparin, coumadin, clopidogrel, and fondaparinux. However, 
the evidence[pi]based guidelines indicate that some patients may still 
develop clots despite these therapies.
    While we are seeking public comments on the applicability of each 
of the statutory criteria to DVTs and PEs, we are particularly 
interested in receiving comments on the degree of preventability of 
DVTs and PEs. We are also interested in comments on determining the 
presence of DVT and PE at admission. Based on the public comments we 
receive, we may select DVTs and PEs as HACs.
h. Staphylococcus aureus Septicemia
[GRAPHIC][TIFF OMITTED]TP30AP08.009


[[Page 23558]]


    We discuss Staphylococcus aureus Septicemia in the FY 2008 IPPS 
final rule with comment period (72 FR 47208). Staphylococcus aureus is 
a bacterium that lives in the nose and on the skin of a large 
percentage of the population. It usually does not cause physical 
illness, but it can cause infections ranging from superficial boils to 
cellulitis to pneumonia to life threatening bloodstream infections 
(septicemia). It usually enters the body through traumatized tissue, 
such as cuts or abrasions, or at the time of invasive procedures. 
Staphylococcus aureus Septicemia can also be a late effect of an injury 
or a surgical procedure. Risk factors for developing Staphylococcus 
aureus Septicemia include advanced age, debilitated state, 
immunocompromised status, and a history of an invasive medical 
procedure.
    CDC has developed evidence-based guidelines for the prevention of 
the Staphylococcus aureus Septicemia. Most preventable cases of 
septicemia are primarily related to the presence of a central venous or 
vascular catheter. During the December 17, 2007 HAC and POA Listening 
Session, commenters noted that intravascular catheter-associated 
infections are only one cause of septicemia. Therefore, catheter-
oriented evidence-based guidelines would not cover all cases of 
Staphylococcus aureus Septicemia.\10\
---------------------------------------------------------------------------

    \10\ Jensen, A.G. Importance of Focus Identification in the 
Treatment of Staphylococcus aureus Bacteremia. 2002. Vol. 52, pp. 
29-36.
---------------------------------------------------------------------------

    We identified evidence-based guidelines that suggest Staphylococcus 
aureus Septicemia is reasonably preventable. These guidelines emphasize 
the importance of effective and fastidious hand washing by both staff 
and visitors, using gloves and gowns where appropriate, applying proper 
decontamination techniques, and exercising contact isolation where 
clinically indicated.
    While we are seeking public comments on the applicability of each 
of the statutory criteria to Staphylococcus aureus infections 
generally, we are particularly interested in receiving comments on the 
degree of preventability of Staphylococcus aureus infections generally, 
and specifically Staphylococcus aureus Septicemia. Based on the public 
comments we receive, we may select Staphylococcus aureus Septicemia as 
an HAC.
i. Clostridium Difficile-Associated Disease (CDAD)
[GRAPHIC][TIFF OMITTED]TP30AP08.010

    We discussed Clostridium difficile-associated disease (CDAD) in the 
FY 2008 IPPS final rule with comment period. Clostridium difficile is a 
bacterium that colonizes the gastrointestinal (GI) tract of a certain 
number of healthy people. Under conditions where the normal flora of 
the gastrointestinal tract is altered, Clostridium difficile can 
flourish and release large enough amounts of a toxin to cause severe 
diarrhea or even life threatening colitis. Risk factors for CDAD 
include prolonged use of broad spectrum antibiotics, gastrointestinal 
surgery, prolonged nasogastric tube insertion, and repeated enemas. 
CDAD can be acquired in the hospital or in the community. Its spores 
can live outside of the body for months and thus can be spread to other 
patients in the absence of meticulous hand washing by care providers 
and others who contact the infected patient.
    We continue to receive strong support in favor of selecting CDAD as 
an HAC. During the December 17, 2007 HAC and POA Listening Session, 
representatives of consumers and purchasers advocated to include CDAD 
as an HAC.
    The evidence-based guidelines for CDAD prevention emphasize that 
hand washing by staff and visitors and effective decontamination of 
environmental surfaces prevent the spread of Clostridium difficile. 
While we are seeking public comments on the applicability of each of 
the statutory criteria to CDADs, we are particularly interested in 
receiving comments on the degree of preventability of CDAD. Based on 
the public comments we receive, we may select CDAD as an HAC.
j. Methicillin-Resistant Staphylococcus aureus (MRSA)

[[Page 23559]]

[GRAPHIC][TIFF OMITTED]TP30AP08.011

    We discussed the special case of methicillin-resistant 
Staphylococcus aureus (MRSA) in the FY 2008 IPPS final rule with 
comment period (72 FR 47212). In October 2007, the CDC published in the 
Journal of the American Medical Association an article citing high 
mortality rates from MRSA, an antibiotic-resistant ``superbug.'' The 
article estimates 19,000 people died from MRSA infections in the United 
States in 2005. The majority of invasive MRSA cases are health care-
related--contracted in hospitals or nursing homes--though community-
acquired MRSA also poses a significant public health concern. Hospitals 
have been focused for years on controlling MRSA through the application 
of CDC's evidence-based guidelines outlining best practices for 
combating the bacterium in that setting.
    MRSA is currently addressed by the HAC payment provision. For every 
infectious condition selected, MRSA could be the etiology of that 
infection. For example, if MRSA were the cause of a vascular catheter-
associated infection (one of the eight conditions selected in the FY 
2008 IPPS final rule with comment period), the HAC payment provision 
would apply to that MRSA infection.
    As we noted in the FY 2008 IPPS final rule with comment period, 
colonization by MRSA is not a reasonably preventable HAC according to 
the current evidence-based guidelines; therefore, MRSA does not meet 
the reasonably preventable statutory criterion for an HAC. An estimated 
32.4 percent of Americans are colonized with MRSA, which may reside in 
the nose or on the skin of asymptomatic carriers.\11\ In addition, in 
last year's final rule with comment period, we noted that there is no 
CC/MCC code available for MRSA, and therefore it also does not meet the 
codeable CC/MCC statutory criterion for an HAC. Only when MRSA causes 
an infection does a codeable condition occur. However, we referenced 
the possibility that new codes for MRSA were being considered by the 
ICD-9-CM Coordination and Maintenance Committee. The creation of unique 
codes to capture MRSA was discussed during the March 19-20, 2008 
Committee meeting. While these codes will enhance the data available 
and our understanding of MRSA, the availability and use of these codes 
will not change the fact that the mere presence of MRSA as a colonizing 
bacterium does not constitute an HAC.
---------------------------------------------------------------------------

    \11\ Kuehnert, M.J., et al.: Prevalence of Staphylococcusa 
aureus Nasal Colonization in the United States, 2001-2002. The 
Journal of Infectious Disease, January 15, 2006; Vol. 193.
---------------------------------------------------------------------------

    Because MRSA as a bacterium does not meet two of our statutory 
criteria, codeable CC/MCC and reasonably preventable through evidence-
based guidelines, we are not proposing MRSA as an HAC. However, we 
recognize the significant public health concerns that were raised by 
representatives of consumers and purchasers at the HAC and POA 
Listening Session, and we are committed to reducing the spread of 
multi-drug resistant organisms, such as MRSA.
    In addition, we are pursuing collaborative efforts with other HHS 
agencies to combat MRSA. The Agency for Healthcare Research and Quality 
(AHRQ) has launched a new initiative in collaboration with CDC and CMS 
to identify and suppress the spread of MRSA and related infections. In 
support of this work, Congress has appropriated $5 million to fund 
research, implementation, management, and evaluation practices that 
mitigate such infections.
    CDC has carried out extensive research on the epidemiology of MRSA 
and effective techniques that could be used to treat the infection and 
reduce its spread. The following Web sites contain information that 
reflect CDC's commitment: (1) http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html (health care-associated MRSA); (2) http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html (community-acquired MRSA); (3) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4908a1.htm; and (4) http://www.cdc.gov/handhygiene/.
    AHRQ has made previous investments in systems research to help 
monitor MRSA and related infections in hospital settings, as reflected 
in material on the Web site at: http://www.guideline.gov/browse/guideline_index.aspx and http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf.
8. Present on Admission (POA) Indicator Reporting
    POA indicator information 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 
No. 5679 (released June 20, 2007), CMS issued instructions requiring 
IPPS hospitals to submit the POA indicator data for all diagnosis codes 
on Medicare 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 at the Web 
site: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf 
(POA

[[Page 23560]]

reporting guidelines begin on page 92). Additional instructions, 
including information regarding CMS's phased implementation of POA 
indicator reporting and application of the POA reporting options, are 
available at the Web site: http://www.cms.hhs.gov/HospitalAcqCond.
    There are five POA indicator reporting options: ``Y,'' ``N,'' 
``W,'' ``U,'' and ``1.'' Under the HAC payment provision, we are 
proposing to pay the CC/MCC MS-DRGs only for those HACs coded as ``Y'' 
and ``W'' indicators. The ``Y'' option indicates that the condition was 
present on admission. The ``W'' indicator affirms that the provider has 
determined, based on data and clinical judgment, that it is not 
possible to document when the onset of the condition occurred. We 
expect that this approach will encourage better documentation and 
promote the public health goals of POA reporting by providing more 
accurate data about the occurrence of HACs in the Medicare population. 
We anticipate that true clinical uncertainty will occur in only a very 
small number of cases. We plan to analyze how frequently the ``W'' 
indicator is used, and we leave open the possibility of proposing in 
future IPPS rulemaking not paying the CC/MCC MS-DRGs for HACs coded 
with the ``W'' indicator. In addition, we plan to analyze whether both 
the ``Y'' and ``W'' indicators are being used appropriately. Medicare 
program integrity initiatives closely monitor for inaccurate coding and 
coding that is inconsistent with medical record documentation. We are 
seeking public comments regarding the proposed treatment of the ``Y'' 
and ``W'' POA reporting options under the HAC payment provision.
    We are proposing to not pay the CC/MMC MS-DRGs for HACs coded with 
the ``N'' indicator. The ``N'' option indicates that the condition was 
not present on admission. We are also proposing to not pay the CC/MCC 
MS-DRGs for HACs coded with the ``U'' indicator. The ``U'' option 
indicates that the medical record documentation is insufficient to 
determine whether the condition was present at the time of admission. 
Not paying for the CC/MCC MS-DRGs for HACs that are coded with the 
``U'' indicator is expected to foster better medical record 
documentation.
    Although we are proposing not paying the CC/MCC MS-DRG for HACs 
coded with the ``U'' indicator, we do recognize there may be some 
exceptional circumstances under which payment might be made. Death, 
elopement (leaving against medical advice), and transfers out of a 
hospital may preclude making an informed determination of whether an 
HAC was present on admission. We are seeking public comments on the 
potential use of the following current patient discharge status codes 
to identify the exceptional circumstances:

                     Patient Discharge Status Codes
------------------------------------------------------------------------
           Form locator code                     Code descriptor
------------------------------------------------------------------------
                       Exception for Patient Death
------------------------------------------------------------------------
20....................................  Expired.
------------------------------------------------------------------------
    Exception for Patient Elopement (Leaving Against Medical Device)
------------------------------------------------------------------------
7.....................................  Left against medical advice or
                                         discontinued care.
------------------------------------------------------------------------
                         Exception for Transfer
------------------------------------------------------------------------
02....................................  Discharged/transferred to a
                                         short-term general hospital for
                                         inpatient care.
03....................................  Discharged/transferred to a
                                         skilled nursing facility (SNF)
                                         with Medicare certification in
                                         anticipation of skilled care.
04....................................  Discharged/transferred to an
                                         intermediate care facility
                                         (ICF).
05....................................  Discharged/transferred to a
                                         designated cancer center or
                                         children's hospital.
06....................................  Discharged/transferred to home
                                         under care of organized home
                                         health service organization.
43....................................  Discharged/transferred to a
                                         Federal health care facility.
50....................................  Hospice-home.
51....................................  Hospice-medical facility
                                         (certified) providing hospice
                                         level of care.
61....................................  Discharged/transferred to a
                                         hospital-based Medicare
                                         approved swing bed.
62....................................  Discharged/transferred to an
                                         inpatient rehabilitation
                                         facility (IRF) including
                                         rehabilitation distinct part
                                         units of a hospital.
63....................................  Discharged/transferred to a
                                         Medicare certified long term
                                         care hospital (LTCH).
64....................................  Discharged/transferred to a
                                         nursing facility certified
                                         under Medicaid but not
                                         certified under Medicare.
65....................................  Discharged/transferred to a
                                         psychiatric hospital or
                                         psychiatric distinct part unit
                                         of a hospital.
66....................................  Discharged/transferred to a
                                         critical access hospital (CAH).
70....................................  Discharged/transferred to
                                         another type of health care
                                         institution not otherwise
                                         defined in this code list.
------------------------------------------------------------------------

    We plan to analyze whether both the ``N'' and ``U'' POA reporting 
options are being used appropriately. The American Health Information 
Management Association (AHIMA) has promulgated Standards of Ethical 
Coding that require accurate coding regardless of the payment 
implications of the diagnoses. That is, diagnoses must be reported 
accurately regardless of their effect on payment. Medicare program 
integrity initiatives closely monitor for inaccurate coding and coding 
inconsistent with medical record documentation. We are seeking public 
comments regarding the proposal to not pay the CC/MCC MS-DRGs for HACs 
coded with ``N'' and ``U'' indicators.
9. Enhancement and Future Issues
    The preventable HAC payment provision is one of CMS' VBP 
initiatives, as noted earlier in this section. VBP ties payment to 
performance through the use of incentives based on quality measures and 
cost of care. The implementation of VBP is rapidly transforming CMS 
from being a passive payer of claims to an active purchaser of higher 
quality, more efficient health care for Medicare beneficiaries. Other 
VBP initiatives include hospital pay for reporting (the RHQDAPU program 
discussed in section IV.B. of the preamble of this proposed rule), 
physician pay for reporting (the Physician Quality Reporting 
Initiative), home health pay for reporting, the Hospital VBP Plan 
Report to Congress (discussed in section IV.C. of the preamble of this 
proposed rule), and various VBP demonstration

[[Page 23561]]

programs across payment settings, including the Premier Hospital 
Quality Incentive Demonstration and the Physician Group Practice 
Demonstration.
    The success of CMS' VBP initiatives depends in large part on the 
validity of the performance measures and on the effectiveness of 
incentives in driving desired changes in behavior that will result in 
greater quality and efficiency. We are committed to enhancing the 
Medicare VBP programs, in close collaboration with stakeholders, to 
fulfill VBP's potential to promise of promoting higher value health 
care for Medicare beneficiaries. It is in this spirit that we seek 
public comment on enhancements to the preventable HACs payment policy 
and to concomitant POA indicator reporting.
    We welcome all public comments presenting ideas and models for 
combating preventable HACs through the application of VBP principles. 
To stimulate reflection and creativity, we present several options:
    <bullet> Risk adjustment could be applied to make the HAC payment 
provision more precise.
    <bullet> Rates of HACs could be collected to obtain a more robust 
longitudinal measure of a hospital's incidence of these conditions.
    <bullet> POA information could be used in various ways to decrease 
the incidence of preventable HACs.
    <bullet> The adoption of ICD-10-PCS could facilitate more precise 
identification of HACs.
    <bullet> The principle behind the HAC payment provision (Medicare 
not paying more for preventable HACs) could be applied to Medicare 
payments in settings of care other than the IPPS.
    <bullet> CMS is using authority other than the HAC payment 
provision to address other events on the NQF's list of Serious 
Reportable Adverse Events.
    We note that we are not proposing new Medicare policy in this 
Enhancements and Future Issues discussion, as some of these approaches 
may require new statutory authority.
a. Risk Adjustment
    To make the HAC payment provision more precise, the adjustments to 
payment made when one of the selected HACs occurs during the 
hospitalization could be further adjusted to account for patient-
specific risk factors. The expected occurrence of an HAC may be greater 
or lesser depending on the health status of the patient, as reflected 
by severity of illness, presence of comorbidities, or other factors. 
Rather than not paying any additional amount for the complication, the 
additional payment for the complication could range from zero for the 
lowest risk patient to the full amount for the highest risk patient. An 
option may be individualized adjustment for every hospitalization based 
on the patient's unique characteristics, but state-of-the-art risk 
adjustment currently precludes such individualized adjustment.
b. Rates of HACs
    Given our limited capability at present for precise patient-level 
risk adjustment, adding a consideration of risk to the criteria for 
selecting HACs could be an alternative. If primarily high-risk patients 
are acquiring a certain condition during hospitalization, that 
condition could be considered a less-fit candidate for selection. Other 
alternatives to precise individualized risk adjustment could be 
adjustment for overall facility case mix or facility case-mix by 
condition. At the highest level, national Medicare program data could 
be used to make adjustments to the payment implications for the 
selected HACs based on expected rates of complications. Another option 
could be to designate certain patient risk factors as exemptions that 
would prohibit or mitigate the application of the HAC payment policy to 
the claims of patients with those risk factors.
    The Medicare Hospital VBP Plan was submitted in a Report to 
Congress on November 21, 2007. The plan includes a performance 
assessment model that scores a hospital's attainment or improvement on 
various measures. The scores for each measure would be summed within 
each domain, such as the clinical process of care domain or the patient 
experience domain, and then the domains would be weighted and summed to 
yield a total performance score. The total performance score would then 
be translated into an incentive payment, proposed to be a certain 
percentage of each MS-DRG payment, using an exchange function. The plan 
also calls for public reporting of hospitals' performance scores by 
domain and in total. (Section IV.C. of this preamble included a related 
discussion of the Hospital VBP Plan Report to Congress.)
    In accordance with this hospital VBP model, a hospital's rates of 
HACs could be included as a domain within each hospital's total 
performance score. The measurement of rates over time could be a more 
meaningful, actionable, and fair way to adjust a hospital's MS-DRG 
payments for the incidence of HACs. The consequence of a higher 
incidence of measured conditions would be a lower VBP incentive 
payment. Public reporting of the measured rates of HACs would give 
hospitals an additional, nonfinancial incentive to prevent occurrence 
of the conditions to avoid lower public ratings.
c. Use of POA Information
    Information obtained from hospitals' reporting of POA data could be 
used in various ways to better understand and prevent the occurrence of 
HACs. The POA information could be provided to health services 
researchers to analyze factors that lead to HACs and disseminate the 
best practices for prevention of HACs. At least two states, New York 
and California, already collect POA data from their hospitals. 
Comparison of the State POA data with the Medicare data could fill in 
gaps in the databases and yield valuable insights about POA data 
validity.
    POA data could also be used to calculate the incidence of HACs by 
hospital. This application of the POA data would be particularly 
powerful if the Medicare POA data were combined with state or private 
sector payer POA data. The Medicare-only or combined quality of care 
information could be initially shared with hospitals and thereafter 
publicly reported to support better healthcare decision making by 
Medicare beneficiaries, other health care consumers, professionals, and 
caregivers.
d. Transition to ICD-10-PCS
    Accurate identification of HACs requires unambiguous and precise 
diagnosis codes. The current ICD-9-CM diagnosis coding system is three 
decades old. It is outdated and contains numerous instances of broad 
and vague codes. Attempts to add necessary detail to the ICD-9-CM 
system are inhibited by lack of expansion capacity. These factors 
negatively affect CMS' attempts to identify HAC cases.
    ICD-10-PCS codes are more precise and capture information using 
more current medical terminology. For example, ICD-9-CM codes for 
pressure ulcers do not provide information about the size, depth, or 
exact location of the ulcer, while ICD-10-PCS has 60 codes to capture 
this information. ICD-10-PCS would also provide codes, beyond the 
current ICD-9-CM codes, that would enable the selection of additional 
surgical complications and adverse drug events.
e. Application of Nonpayment for HACs to Other Settings
    The broad principle of Medicare not paying for preventable health 
care-associated conditions could potentially be applied to Medicare 
payment settings other than IPPS hospitals. Other

[[Page 23562]]

possible settings of care might include hospital outpatient 
departments, SNFs, HHAs, end-stage renal disease facilities, and 
physician practices. The implications would be different for each 
setting, as each payment system is different and the reasonable 
preventability through the application of evidence-based guidelines 
would vary for candidate conditions over the different settings. 
However, alignment of incentives across settings of care is an 
important goal for all of CMS' VBP initiatives, including the HAC 
provision.
    A related application of the broad principle behind the HAC payment 
could be accomplished through modification to the Medicare secondary 
payer policy which would allow us to directly recoup from the provider 
that failed to prevent the occurrence of a preventable condition in one 
setting to pay for all or part of the necessary followup care in a 
second setting. This would help shield the Medicare program from 
inappropriately paying for the downstream effects of a preventable 
condition acquired in the first setting but treated in the second 
setting.
f. Relationship to NQF's Serious Reportable Adverse Events
    CMS is applying its authority to address the events on the NQF's 
list of Serious Reportable Adverse Events (also known as ``never 
events''). In May 2006 testimony before the Senate Finance Committee, 
the CMS Administrator noted that paying hospitals for serious 
preventable events is contrary to the promise that hospital payments 
should support higher quality and efficiency. There is growing 
consensus that health care purchasers should not be paying for these 
events when they occur during a hospitalization. In January 2005, 
HealthPartners, a Minnesota-based not-for-profit HMO, announced that it 
would no longer reimburse hospitals for services associated with events 
enumerated in the Minnesota Adverse Health Care Events Reporting Act 
(essentially the NQF's list of Serious Reportable Adverse Events). 
Further, HealthPartners' contracts preclude hospitals from seeking 
reimbursement from the patient for these costs. During 2007, several 
State hospital associations adopted policies stating that their members 
will not bill payers or patients when these events occur in their 
hospitals.
    In the FY 2008 IPPS final rule with comment period, we adopted 
several items from the NQF's list of events as HACs, including retained 
foreign object after surgery, air embolism, blood incompatibility, 
stage III and IV pressure ulcers, falls, electric shock, and burns. In 
this proposed rule, we are seeking public comments regarding adding 
hypoglycemic coma, which is closely related to NQF's listing of death 
or serious disability associated with hypoglycemia. However, as we 
discussed in the FY 2008 IPPS final rule with comment period, the HAC 
payment provision is not ideally suited to address every condition on 
the NQF's list of Serious Reportable Adverse Events. To address the 
events on the NQF's list beyond the effect of the HAC policy, CMS is 
exploring the application of Medicare authority, including other 
payment provisions, coverage policy, conditions of participation, and 
Quality Improvement Organization (QIO) retrospective review.
    We note that we are not proposing new Medicare policy in this 
discussion of the HAC payment provision for IPPS hospitals, as some of 
these approaches may require new statutory authority. We are seeking 
public comments on these and other options for enhancing the 
preventable HACs payment provision and maximizing the use of POA 
indicator reporting data. We look forward to working with stakeholders 
in the fight against HACs.

G. Proposed Changes to Specific MS-DRG Classifications

1. Pre-MDCs: Artificial Heart Devices
    Heart failure affects more than 5 million patients in the United 
States with 550,000 new cases each year, and causes more than 55,000 
deaths annually. It is a progressive disease that is medically managed 
at all stages, but over time leads to continued deterioration of the 
heart's ability to pump sufficient amounts of adequately oxygenated 
blood throughout the body. When medical management becomes inadequate 
to continue to support the patient, the patient's heart failure would 
be considered to be the end stage of the disease. At this point, the 
only remaining treatment options are a heart transplant or mechanical 
circulatory support. A device termed an artificial heart has been used 
only for severe failure of both the right and left ventricles, also 
known as biventricular failure. Relatively small numbers of patients 
suffer from biventricular failure, but the exact numbers are unknown. 
There are about 4,000 patients approved and waiting to receive heart 
transplants in the United States at any given time, but only about 
2,000 hearts per year are transplanted due to a scarcity of donated 
organs. There are a number of mechanical devices that may be used to 
support the ventricles of a failing heart on either a temporary or 
permanent basis. When it is apparent that a patient will require long-
term support, a ventricular support device is generally implanted and 
may be considered either as a bridge to recovery or a bridge to 
transplantation. Sometimes a patient's prognosis is uncertain, and with 
device support the native heart may recover its function. However when 
recovery is not likely, the patient may qualify as a transplant 
candidate and require mechanical circulatory support until a donor 
heart becomes available. This type of support is commonly supplied by 
ventricular assist devices, (VADs), which are surgically attached to 
the native ventricles but do not replace them.
    Devices commonly called artificial hearts are biventricular heart 
replacement systems that differ from VADs in that a substantial part of 
the native heart, including both ventricles, is removed. When the heart 
remains intact, it remains possible for the native heart to recover its 
function after being assisted by a VAD. However, because the artificial 
heart device requires the resection of the ventricles, the native heart 
is no longer intact and such recovery is not possible. The designation 
``artificial heart'' is somewhat of a misnomer because some portion of 
the native heart remains and there is no current mechanical device that 
fully replaces all four chambers of the heart. Over time, better 
descriptive language for these devices may be adopted.
    In 1986, CMS made a determination that the use of artificial hearts 
was not covered under the Medicare program. To conform to that 
decision, we placed ICD-9-CM procedure code 37.52 (Implantation of 
total replacement heart system) on the GROUPER program's MCE in the 
noncovered procedure list.
    On August 1, 2007, CMS began a national coverage determination 
process for artificial hearts. SynCardia Systems, Inc. submitted a 
request for reconsideration of the longstanding noncoverage policy when 
its device, the CardioWest Temporary Total Artificial Heart (TAH-t) 
System, is used for ``bridge to transplantation'' in accordance with 
the FDA-labeled indication for the device. ``Bridge to 
transplantation'' is a phrase meaning that a patient in end-stage heart 
failure may qualify as a heart transplant candidate, but will require 
mechanical circulatory support until a donor heart becomes available. 
The CardioWest TAH-t System is indicated for use as a bridge to 
transplantation in cardiac transplant-eligible candidates at risk of 
imminent death from biventricular

[[Page 23563]]

failure. The system is intended for use inside the hospital as the 
patient awaits a donor heart. The ultimate desired outcome for 
insertion of the TAH-t is a successful heart transplant, along with the 
potential that offers for cure from heart failure.
    CMS determined that a broader analysis of artificial heart coverage 
was deemed appropriate, as another manufacturer, Abiomed, Inc. has 
developed an artificial heart device, AbioCor[reg] Implantable 
Replacement Heart Device, with different indications. SynCardia 
Systems, Inc has received approval of its device from the FDA for 
humanitarian use as destination therapy for patients in end-stage 
biventricular failure who cannot qualify as transplant candidates. The 
AbioCor[reg] Implantable Replacement Heart Device is indicated for use 
in severe biventricular end-stage heart disease patients who are not 
cardiac transplant candidates and who are less than 75 years old, who 
require multiple inotropic support, who are not treatable by VAD 
destination therapy, and who cannot be weaned from biventricular 
support if they are on such support. The desired outcome for this 
device is prolongation of life and discharge to home.
    On February 1, 2008, CMS published a proposed coverage decision 
memorandum for artificial hearts which stated, in part, that while the 
evidence is inadequate to conclude that the use of an artificial heart 
is reasonable and necessary for Medicare beneficiaries, the evidence is 
promising for the uses of artificial heart devices as described above. 
CMS supports additional research for these devices, and therefore 
proposed that the artificial heart will be covered by Medicare when 
performed under the auspices of a clinical study. The study must meet 
all of the criteria listed in the proposed decision memorandum. This 
proposed coverage decision memorandum may be found on the CMS Web site 
at: http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=211. 
Following consideration of the public comments received, CMS expects to 
make a final decision on or about May 1, 2008.
    The topic of coding of artificial heart devices was discussed at 
the September 27-28, 2007 ICD-9-CM Coordination and Maintenance 
Committee meeting held at CMS in Baltimore, MD. We note that this topic 
was placed on the Committee's agenda because any proposed changes to 
the ICD-9-CM coding system must be discussed at a Committee meeting, 
with opportunity for comment from the public. At the September 2007 
Committee meeting, the Committee accepted oral comments from 
participants and encouraged attendees or anyone with an interest in the 
topic to comment on proposed changes to the code, inclusion terms, or 
exclusion terms. We accepted written comments until October 12, 2007. 
As a result of discussion and comment from the Committee meeting, the 
Committee revised the title of procedure code 37.52 for artificial 
hearts to read ``Implantation of internal biventricular heart 
replacement system.'' In addition, the Committee created new code 37.55 
(Removal of internal biventricular heart replacement system) to 
identify explantation of the artificial heart prior to heart 
transplantation.
    To make conforming changes to the IPPS system with regard to the 
proposed revision to the coverage decision for artificial hearts, in 
this proposed rule, we are proposing to remove procedure code 37.52 
from MS-DRG 215 (Other Heart Assist System Implant) and assign it to 
MS-DRG 001 (Heart Transplant or Implant of Heart Assist System with 
Major Comorbidity or Complication (MCC)) and MS-DRG 002 (Heart 
Transplant or Implant of Heart Assist System without Major Comorbidity 
or Complication (MCC)). In addition, we are proposing to remove 
procedure code 37.52 from the MCE ``Non-Covered Procedure'' edit and 
assign it to the ``Limited Coverage'' edit. We are proposing to include 
in this proposed edit the requirement that ICD-9-CM diagnosis code 
V70.7 (Examination of participant in clinical trial) also be present on 
the claim. We are proposing that claims submitted without both 
procedure code 37.52 and diagnosis code V70.7 would be denied because 
they would not be in compliance with the proposed coverage policy.
    During FY 2008, we are making mid-year changes to portions of the 
GROUPER program that do not affect MS-DRG assignment or ICD-9-CM 
coding. However, as the proposed coverage decision memorandum for 
artificial hearts was published after the CMS contractor's testing and 
release of the mid-year product, the above proposed changes to the MCE 
will not be included in that revision of the GROUPER Version 25.0. 
GROUPER Version 26.0, which will be in use for FY 2009, will contain 
the proposed changes if they are approved. If the proposed revisions to 
the MCE are accepted, the edits in the MCE Version 25.0 will be 
effective retroactive to May 1, 2008. (To reduce confusion, we note 
that the version number of the MCE is one digit lower than the current 
GROUPER version number; that is, Version 26.0 of the GROUPER uses 
Version 25.0 of the MCE.)
2. MDC 1 (Diseases and Disorders of the Nervous System)
a. Transferred Stroke Patients Receiving Tissue Plasminogen Activator 
(tPA)
    In 1996, the FDA approved the use of tissue plasminogen activator 
(tPA), one type of thrombolytic agent that dissolves blood clots. In 
1998, the ICD-9-CM Coordination and Maintenance Committee created code 
99.10 (Injection or infusion of thrombolytic agent) in order to be able 
to uniquely identify the administration of these agents. Studies have 
shown that tPA can be effective in reducing the amount of damage the 
brain sustains during an ischemic stroke, which is caused by blood 
clots that block blood flow to the brain. tPA is approved for patients 
who have blood clots in the brain, but not for patients who have a 
bleeding or hemorrhagic stroke. Thrombolytic therapy has been shown to 
be most effective when used within the first 3 hours after the onset of 
an embolic stroke, but it is contraindicated in hemorrhagic strokes.
    For FY 2006, we modified the structure of CMS DRGs 14 (Intracranial 
Hemorrhage or Cerebral Infarction) and 15 (Nonspecific CVA and 
Precerebral Occlusion without Infarction) by removing the diagnostic 
ischemic (embolic) stroke codes. We created a new CMS DRG 559 (Acute 
Ischemic Stroke with Use of Thrombolytic Agent) which increased 
reimbursement for patients who sustained an ischemic or embolic stroke 
and who also had administration of tPA. The intent of this DRG was not 
to award higher payment for a specific drug but to recognize the need 
for better overall care for this group of patients. Even though tPA is 
indicated only for a small proportion of stroke patients, that is, 
those patients experiencing ischemic strokes treated within 3 hours of 
the onset of symptoms, our data suggested that there was a sufficient 
quantity of patients to support the DRG change. While our goal is to 
make payment relate more closely to resource use, we also note that use 
of tPA in a carefully selected patient population may lead to better 
outcomes and overall care and may lessen the need for postacute care.
    For FY 2008, with the adoption of MS-DRGs, CMS DRG 559 became MS-
DRGs 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). Stroke cases in which no thrombolytic

[[Page 23564]]

agent was administered were grouped to MS-DRGs 064 (Intracranial 
Hemorrhage or Cerebral Infarction with MCC), 065 (Intracranial 
Hemorrhage or Cerebral Infarction with CC), or 066 (Intracranial 
Hemorrhage or Cerebral Infarction without CC/MCC). The MS-DRGs that 
reflect use of a thrombolytic agent, that is, MS-DRGs 061, 062, and 
063, have higher relative weights than the hemorrhagic or cerebral 
infarction MS-DRGs 064, 065, and 066.
    The American Society of Interventional and Therapeutic 
Neuroradiology (ASITN) has made us aware of a treatment issue that is 
of concern to the stroke provider's community. In some instances, 
patients suffering an embolytic or thrombolytic stroke are evaluated 
and given tPA in a community hospital's emergency department, and then 
are transferred to a larger facility's stroke center that is able to 
provide the level of services required by the increased severity of 
these cases. The facility providing the administration of tPA in its 
emergency department does not realize increased reimbursement, as the 
patient is often transferred as soon a possible to a stroke center. The 
facility to which the patient is transferred does not realize increased 
reimbursement, as the tPA was not administered there. The ASITN has 
requested that CMS give permission to code the administration of tPA as 
if it had been given in the receiving facility. This would result in 
the receiving facility being paid the higher weighted MS-DRGs 061, 062, 
or 063 instead of MS-DRGs 064, 065, or 066. The ASITN's rationale is 
that the patients who received tPA in another facility (even though 
administration of tPA may have alleviated some of the worst 
consequences of their strokes) are still extremely compromised and 
require increased health care services that are much more resource 
consumptive than patients with less severe types of stroke. We have 
advised the ASITN that hospitals may not report services that were not 
performed in their facility.
    We recognize that the ASITN's concerns potentially have merit but 
the quantification of the increased resource consumption of these 
patients is not currently possible in the existing ICD-9-CM coding 
system. Without specific length of stay and average charges data, we 
are unable to determine an appropriate MS-DRG for these cases. 
Therefore, we have advised the ASITN to present a request at the 
diagnostic portion of the ICD-9-CM Coordination and Maintenance 
Committee meeting on March 20, 2008, for a code that would recognize 
the fact that the patient had received a thrombolytic agent for 
treatment of the current stroke. If this request is presented at the 
March 20, 2008 meeting, it will not be approved in time to be published 
as a final code in this proposed rule. However, if a diagnosis code is 
created by the National Centers for Health Statistics as a result of 
that meeting, it can be added to the list of codes published in the FY 
2009 IPPS final rule that will go into effect on October 1, 2008. With 
such information appearing on subsequent claims, we will have a better 
idea of how to classify these cases within the MS-DRGs. Therefore, 
because we lack the data to identify these patients, we are not 
proposing an MS-DRG modification for the stroke patients receiving tPA 
in one facility prior to being transferred to another facility.
b. Intractable Epilepsy With Video Electroencephalogram (EEG)
    As we did for FY 2008, we received a request from an individual 
representing the National Association of Epilepsy Centers to consider 
further refinements to the MS-DRGs describing seizures. Specifically, 
the representative recommended that a new MS-DRG be established for 
patients with intractable epilepsy who receive an electroencephalogram 
with video monitoring (vEEG) during their hospital stay. Similar to the 
initial recommendation, the representative stated that patients who 
suffer from uncontrolled seizures or intractable epilepsy are admitted 
to an epilepsy center for a comprehensive evaluation to identify the 
epilepsy seizure type, the cause of the seizure, and the location of 
the seizure. These patients are admitted to the hospital for 4 to 6 
days with 24-hour monitoring that includes the use of EEG video 
monitoring along with cognitive testing and brain imaging procedures.
    Effective October 1, 2007, MS-DRG 100 (Seizures with MCC) and MS-
DRG 101 (Seizures without MCC) were implemented as a result of 
refinements to the DRG system to better recognize severity of illness 
and resource utilization. Once again, the representative applauded CMS 
for making changes in the DRG structure to better recognize differences 
in patient severity. However, the representative stated that a subset 
of patients in MS-DRG 101 who have a primary diagnosis of intractable 
epilepsy and are treated with vEEG are substantially more costly to 
treat than other patients in this MS-DRG and represent the majority of 
patients being evaluated by specialized epilepsy centers. 
Alternatively, the representative stated that he was not requesting any 
change in the structure of MS-DRG 100. According to the representative, 
the number of cases that would fall into this category is not 
significant. The representative further noted that this is a change 
from last year's request.
    Epilepsy is currently identified by ICD-9-CM diagnosis codes 345.0x 
through 345.9x. There are two fifth digits that may be assigned to a 
subset of the epilepsy codes depending on the physician documentation:
    <bullet> ``0'' for without mention of intractable epilepsy.
    <bullet> ``1'' for with intractable epilepsy.
    With the assistance of an outside reviewer, the representative 
analyzed cost data for MS-DRGs 100 and 101, which focused on three 
subsets of patients identified with a primary diagnosis of epilepsy or 
convulsions who also received vEEG (procedure code 89.19):
    <bullet> Patients with a primary diagnosis of epilepsy with 
intractability specified (codes 345.01 through 345.91).
    <bullet> Patients with a primary diagnosis of epilepsy without 
intractability specified (codes 345.00 through 345.90).
    <bullet> Patients with a primary diagnosis of convulsions (codes 
780.39).
    The representative acknowledged that the association did not 
include any secondary diagnoses in its analyses. Based on its results, 
the representative recommended that CMS further refine MS-DRG 101 by 
subdividing cases with a primary diagnosis of intractable epilepsy 
(codes 345.01 through 345.91) when vEEG (code 89.19) is also performed 
into a separate MS-DRG that would be defined as ``MS-DRG XXX'' 
(Epilepsy Evaluation without MCC).
    According to the representative, these cases are substantially more 
costly than the other cases within MS-DRG 101 and are consistent with 
the criteria for dividing MS-DRGs on the basis of CCs and MCCs. In 
addition, the representative stated that the request would have a 
minimal impact on most hospitals but would substantially improve the 
accuracy of payment to hospitals specializing in epilepsy care.
    We performed an analysis using FY 2007 MedPAR data. As shown in the 
table below, we found a total of 54,060 cases in MS-DRG 101 with 
average charges of $14,508 and an average length of stay of 3.69 days. 
There were 879 cases with intractable epilepsy and vEEG with average 
charges of $19,227 and an average length of stay of 5 days.

[[Page 23565]]



----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                             MS-DRG                                    cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
MS-DRG 100--All Cases...........................................          16,142            6.34         $27,623
MS-DRG 100--Cases with Intractable Epilepsy with vEEG (Codes                  69            6.6           26,990
 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91)
MS-DRG 100--Cases with Intractable Epilepsy without vEEG........             328            7.81          32,539
MS-DRG 101--All cases...........................................          54,060            3.69          14,508
MS-DRG 101--Cases with Intractable Epilepsy with vEEG (Codes                 879            5.0           19,227
 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91)
MS-DRG 101--Cased with Intractable Epilepsy without vEEG........           1,351            4.25          14,913
----------------------------------------------------------------------------------------------------------------

    In applying the criteria to establish subgroups, the data do not 
support the creation of a new subdivision for MS-DRG 101 for cases with 
intractable epilepsy and vEEG nor does the data support moving the 879 
cases from MS-DRG 101 to MS-DRG 100. Moving the 879 cases to MS-DRG 100 
would mean moving cases with average charges of approximately $19,000 
into an MS-DRG with average charges of $28,000. Therefore, we are not 
proposing to refine MS-DRG 101 by subdividing cases with a primary 
diagnosis of intractable epilepsy (codes 345.01 through 345.91) when 
vEEG (code 89.19) is also performed into a separate MS-DRG.
3. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Automatic Implantable Cardioverter-Defibrillators (AICD) Lead and 
Generator Procedures
    In the FY 2008 IPPS final rule with comment period (72 FR 47257), 
we created a separate, stand alone DRG for automatic implantable 
cardioverter-defibrillator (AICD) generator replacements and 
defibrillator lead replacements. The new MS-DRG 245 (AICD lead and 
generator procedures) contains the following codes:
    <bullet> 00.52, Implantation or replacement of transvenous lead 
[electrode] into left ventricular coronary venous system.
    <bullet> 00.54, Implantation or replacement of cardiac 
resynchronization defibrillator pulse generator device only [CRT-D].
    <bullet> 37.95, Implantation of automatic cardioverter/
defibrillator leads(s) only.
    <bullet> 37.96, Implantation of automatic cardioverter/
defibrillator pulse generator only.
    <bullet> 37.97, Replacement of automatic cardioverter/defibrillator 
leads(s) only.
    <bullet> 37.98, Replacement of automatic cardioverter/defibrillator 
pulse generator only.
    Commenters on the FY 2008 IPPS proposed rule supported this new MS-
DRG, which recognizes the distinct differences in resource utilization 
between pacemaker and defibrillator generators and leads, but suggested 
that CMS should consider additional refinements for the defibrillator 
generator and leads. In reviewing the standardized charges for the AICD 
leads, the commenter believed that the leads may be more appropriately 
assigned to another DRG such as MS-DRG 243 (Permanent Cardiac Pacemaker 
Implant with CC) or MS-DRG 258 (Cardiac Pacemaker Device Replacement 
with MCC). The commenter recommended that CMS consider moving the 
defibrillator leads back into a pacemaker DRG, either MS-DRG 243 or MS-
DRG 258.
    In response to the commenters, we indicated that the data supported 
separate DRGs for these very different devices (72 FR 47257). We 
indicated that moving the defibrillator leads back into a pacemaker MS-
DRG defeated the purpose of creating separate MS-DRGs for 
defibrillators and pacemakers. Therefore, we finalized MS-DRG 245 as 
proposed with the leads and generator codes listed above.
    After publication of the FY 2008 IPPS final rule with comment 
period, we received a request from a manufacturer that recommended a 
subdivision for MS-DRG 245 (AICD Lead and Generator Procedures). The 
requestor suggested creating a new MS-DRG to separate the implantation 
or replacement of the AICD leads from the implantation or replacement 
of the AICD pulse generators to better recognize the differences in 
resource utilization for these distinct procedures.
    The requestor applauded CMS' decision to create separate MS-DRGs 
for the pacemaker device procedures from the AICD procedures in the FY 
2008 IPPS final rule (72 FR 47257). The requestor further acknowledged 
its support of the clinically distinct MS-DRGs for pacemaker devices. 
Currently, MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacement 
with MCC and without MCC, respectively) describe the implantation or 
replacement of pacemaker generators while MS-DRGs 260, 261, and 262 
(Cardiac Pacemaker Revision Except Device Replacement with MCC, with 
CC, without CC/MCC, respectively) describe the insertion or replacement 
of pacemaker leads.
    The requestor believed that the IPPS ``needs to continue to evolve 
to accurately reflect clinical differences and costs of services.'' As 
such, the requestor recommended that CMS follow the same structure as 
it did with the pacemaker MS-DRGs for MS-DRG 245 to separately identify 
the implantation or replacement of the defibrillator leads (codes 
37.95, 37.97, and 00.52) from the implantation or replacement of the 
pulse generators (codes 37.96, 37.98, 00.54).
    In our analysis of the FY 2007 MedPAR data, we found a total of 
5,546 cases in MS-DRG 245 with average charges of $62,631 and an 
average length of stay of 3.3 days. We found 1,894 cases with 
implantation or replacement of the defibrillator leads (codes 37.95, 
37.97, and 00.52) with average charges of $42, 896 and an average 
length of stay of 3.4 days. We also found a total of 3,652 cases with 
implantation or replacement of the pulse generator (codes 37.96, 37.98, 
00.54) with average charges of $72, 866 and an average length of stay 
of 3.2 days.
    We agree with the requestor that the IPPS should accurately 
recognize differences in resource utilization for clinically distinct 
procedures. As the data demonstrate, average charges for the 
implantation or replacement of the AICD pulse generators are 
significantly higher than for the implantation or replacement of the 
AICD leads. Therefore, we are proposing to create a new MS-DRG 265 to 
separately identify these distinct procedures. The proposed new MS-DRG 
265 would be titled ``AICD Lead Procedures'' and would include 
procedure codes that identify the AICD leads (codes 37.95, 37.97 and 
00.52). The title for MS-DRG 245 would be revised to ``AICD Generator 
Procedures'' and include procedure codes 37.96, 37.98, 00.54. We 
believe these changes would better reflect the clinical differences and 
resources utilized for these distinct procedures.

[[Page 23566]]

b. Left Atrial Appendage Device
    Atrial fibrillation (AF) is the primary cardiac abnormality 
associated with ischemic or embolytic stroke. Most ischemic strokes 
associated with AF are possibly due to an embolism or thrombus that has 
formed in the left atrial appendage. Evidence from studies such as 
transesophageal echocardiography shows left atrial thrombi to be more 
frequent in AF patients with ischemic stroke as compared to AF patients 
without stroke. While anticoagulation medication can be efficient in 
ischemic stroke prevention, there can be problems of safety and 
tolerability in many patients, especially those older than 75 years. 
Chronic warfarin therapy has been proven to reduce the risk of embolism 
but there can be difficulties concerning its administration. Frequent 
blood tests to monitor warfarin INR are required at some cost and 
patient inconvenience. In addition, because warfarin INR is affected by 
a large number of drug and dietary interactions, it can be 
unpredictable in some patients and difficult to manage. The efficacy of 
aspirin for stroke prevention in AF patients is less clear and remains 
controversial. With the known disutility of warfarin and the 
questionable effectiveness of aspirin, a device-based solution may 
provide added protection against thromboembolism in certain patients 
with AF.
    At the April 1, 2004 ICD-9-CM Coordination and Maintenance 
Committee meeting, a proposal was presented for the creation of a 
unique procedure code describing insertion of the left atrial appendage 
filter system. Subsequently, ICD-9-CM code 37.90 (Insertion of left 
atrial appendage device) was created for use beginning October 1, 2004. 
This code was designated as a non-operating room (non-O.R.) procedure, 
and had an effect only on cases in MDC 5, CMS DRG 518 (Percutaneous 
Cardiovascular Procedure without Coronary Artery Stent or Acute 
Myocardial Infarction). With the adoption of MS-DRGs in FY 2008, CMS 
DRG 518 was divided into MS-DRGs 250 and 251 (Percutaneous 
Cardiovascular Procedure without Coronary Artery Stent or AMI with MCC, 
and without MCC, respectively).
    We have reviewed the data concerning this procedure code annually. 
Using FY 2005 MedPAR data for the FY 2007 IPPS final rule, 24 cases 
were reported, and the average charges ($27,620) closely mimicked the 
average charges of the other 22,479 cases in CMS DRG 518 ($28,444). As 
the charges were comparable, we made no recommendations to change the 
CMS DRG assignment for FY 2007.
    Using FY 2006 MedPAR data for the FY 2008 final rule with comment 
period, we divided CMS DRG 518 into the cases that would be reflected 
in the MS-DRG configuration; that is, we divided the cases based on the 
presence or absence of an MCC. There were 35 cases without an MCC with 
average charges of $24,436, again mimicking the 38,002 cases with 
average charges of $32,546. There were 3 cases with MCC with average 
charges of $62,337, compared to the 5,458 cases also with an MCC with 
average charges of $53,864. Again it was deemed that cases with code 
37.90 were comparable to the rest of the cases in CMS DRG 518, and the 
decision was made not to make any changes in the DRG assignment for 
this procedure code. As noted above, CMS DRG 518 became MS-DRGs 250 and 
251 in FY 2008.
    We have received a request regarding code 37.90, and its placement 
within the MS-DRG system for FY 2009. The requestor asked for either 
the reassignment of code 37.90 to an MS-DRG that would adequately cover 
the costs associated with the complete procedure or the creation of a 
new MS-DRG that would reimburse hospitals adequately for the cost of 
the device. The requestor, a manufacturer's representative, reported 
that the device's IDE clinical trial is nearing completion, with the 
conclusion of study enrollment in May 2008. The requestor will continue 
to enroll patients in a Continued Use Registry following completion of 
the trial. The requestor reported that it did not charge hospitals for 
the atrial appendage device, estimated to cost $6,000, during the trial 
period, but it will begin to charge hospitals upon the completion of 
the trial in May. The requestor provided us with its data showing what 
it believed to be a differential of $107 more per case than the payment 
average for MS-DRG 250, and a shortfall of $3,808 per case than the 
payment average for MS-DRG 251.
    The requestor pointed out that code 37.90 is assigned to both MS-
DRGs 250 and 251, but stated that the final MS-DRG assignment would be 
MS-DRG 251 when the patient has a principal diagnosis of atrial 
fibrillation (code 427.31) because AF is not presently listed as a CC 
or an MCC. We would take this opportunity to note that the principal 
diagnosis is used to determine assignment of a case to the correct MDC. 
Secondary or additional diagnosis codes are the only codes that can be 
used to determine the presence of a CC or an MCC.
    With regard to the request to create a specific DRG for the 
insertion of this device entitled ``Percutaneous Cardiovascular 
Procedures with Implantation of a Left Atrial Appendage Device without 
CC/MCC'', we would point out that the payments under a prospective 
payment system are predicated on averages. The device is already 
assigned to MS-DRGs containing other percutaneous cardiovascular 
devices; to create a new MS-DRG specific to this device would be to 
remove all other percutaneously inserted devices and base the MS-DRG 
assignment solely on the presence of code 37.90. This approach negates 
our longstanding method of grouping like procedures, and removes the 
concept of averaging. Further, to ignore the structure of the MS-DRG 
system solely for the purpose of increasing payment for one device 
would set an unwelcome precedent for defining all of the other MS-DRGs 
in the system. We would also point out that the final rule establishing 
the MS-DRGs set forth five criteria, all five of which are required to 
be met, in order to warrant creation of a CC or an MCC subgroup within 
a base MS-DRG. The criteria can be found in the FY 2008 IPPS final rule 
with comment period (72 FR 47169). One of the criteria specifies that 
there will be at least 500 cases in the CC or MCC subgroup. To date, 
there are not enough cases of code 37.90 reported within the MedPAR 
data.
    Using FY 2007 MedPAR data, for this FY 2009 IPPS proposed rule, we 
reviewed MS-DRGs 250 and 251 for the presence of the left atrial 
appendage device. The following table displays our results:

----------------------------------------------------------------------------------------------------------------
                                                       Number of    Average length      Average
                      MS-DRG                             cases          of stay         charges
--------------------------------------------------------------------------------------------------
250--All Cases....................................           6,424            7.72      $60,597.58
250--Cases with code 37.90........................               4            6.50       65,829.51
250--Cases without code 37.90.....................           6,420            7.72       60,594.32
251--All Cases....................................          39,456            2.84       35,719.81

[[Page 23567]]

 
251--Cases with code 37.90........................             101            1.30       20,846.09
251--Cases without code 37.90.....................          39,335            2.85       35,757.98
----------------------------------------------------------------------------------------------------------------

    There were a total of 105 cases with code 37.90 reported for 
Medicare beneficiaries in the 2007 MedPAR data. There are 4 cases with 
an atrial appendage device in MS-DRG 250 that have higher average 
charges than the other 6,420 cases in the MS-DRG, and that have 
slightly shorter lengths of stay by 1.25 days. However, the more 
telling data are located in MS-DRG 251, which shows that the 101 cases 
in which an atrial appendage device was implanted have much lower 
average charges ($20,846.09) than the other 39,355 cases in the MS-DRG, 
with average charges of $35,758.98. The difference in the average 
charges is approximately $14,912, so even when the manufacturer begins 
charging the hospitals the estimated $6,000 for the device, there is 
still a difference of approximately $8,912 in average charges based on 
the comparison within the total MS-DRG 251. Interestingly, the 101 
cases also have an average length of stay of less than half of the 
average length of stay compared to the other cases assigned to that MS-
DRG.
    Because the data do not support either the creation of a unique MS-
DRG or the assignment of procedure code 37.90 to another higher-
weighted MS-DRG, we are not proposing any change to MS-DRGs 250 and 
251, or to code 37.90 for FY 2009. We believe, based on the past 3 
year's comparisons, that this code is appropriately located within the 
MS-DRG structure.
4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 
Connective Tissue): Hip and Knee Replacements and Revisions
    For FY 2009, we again received a request from the American 
Association of Hip and Knee Surgeons (AAHKS), a specialty group within 
the American Academy of Orthopedic Surgeons (AAOS), concerning 
modifications of the lower joint procedure MS-DRGs. The request is 
similar, in some respects, to the AAHKS's request in FY 2008, 
particularly as it relates to separating routine and complex 
procedures. For the benefit of the reader, we are republishing a 
history of the development of DRGs for hip and knee replacements and a 
summary of the AAHKS FY 2008 request that were included in the FY 2008 
IPPS final rule with comment period (72 FR 47222 through 47224) before 
we discuss the AAHKS's more recent request.
a. Brief History of Development of Hip and Knee Replacement Codes
    In the FY 2006 IPPS final rule (70 FR 47303), we deleted CMS DRG 
209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) 
and created two new CMS DRGs: 544 (Major Joint Replacement or 
Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee 
Replacement). The two new CMS DRGs were created because revisions of 
joint replacement procedures are significantly more resource intensive 
than original hip and knee replacements procedures. CMS DRG 544 
included the following procedure code assignments:
    <bullet> 81.51, Total hip replacement.
    <bullet> 81.52, Partial hip replacement.
    <bullet> 81.54, Total knee replacement.
    <bullet> 81.56, Total ankle replacement.
    <bullet> 84.26, Foot reattachment.
    <bullet> 84.27, Lower leg or ankle reattachment.
    <bullet> 84.28, Thigh reattachment.
    CMS DRG 545 included the following procedure code assignments:
    <bullet> 00.70, Revision of hip replacement, both acetabular and 
femoral components.
    <bullet> 00.71, Revision of hip replacement, acetabular component.
    <bullet> 00.72, Revision of hip replacement, femoral component.
    <bullet> 00.73, Revision of hip replacement, acetabular liner and/
or femoral head only.
    <bullet> 00.80, Revision of knee replacement, total (all 
components).
    <bullet> 00.81, Revision of knee replacement, tibial component.
    <bullet> 00.82, Revision of knee replacement, femoral component.
    <bullet> 00.83, Revision of knee replacement, patellar component.
    <bullet> 00.84, Revision of knee replacement, tibial insert 
(liner).
    <bullet> 81.53, Revision of hip replacement, not otherwise 
specified
    <bullet> 81.55, Revision of knee replacement, not otherwise 
specified
    Further, we created a number of new ICD-9-CM procedure codes 
effective October 1, 2005, that better distinguish the many different 
types of joint replacement procedures that are being performed. In the 
FY 2006 IPPS final rule (70 FR 47305), we indicated a commenter had 
requested that, once we receive claims data using the new procedure 
codes, we closely examine data from the use of the codes under the two 
new CMS DRGs to determine if future additional DRG modifications are 
needed.
b. Prior Recommendations of the AAHKS
    Prior to this year, the AAHKS had recommended that we make further 
refinements to the CMS DRGs for knee and hip arthroplasty procedures. 
The AAHKS previously presented data to CMS on the important differences 
in clinical characteristics and resource utilization between primary 
and revision total joint arthroplasty procedures. The AAHKS stated that 
CMS's decision to create a separate DRG for revision of total joint 
arthroplasty (TJA) in October 2005 resulted in more equitable 
reimbursement for hospitals that perform a disproportionate share of 
complex revision of TJA procedures, recognizing the higher resource 
utilization associated with these cases. The AAHKS stated that this 
important payment policy change led to increased access to care for 
patients with failed total joint arthroplasties, and ensured that high 
volume TJA centers could continue to provide a high standard of care 
for these challenging patients.
    The AAHKS further stated that the addition of new, more descriptive 
ICD-9-CM diagnosis and procedure codes for TJA in October 2005 gave it 
the opportunity to further analyze differences in clinical 
characteristics and resource intensity among TJA patients and 
procedures. Inclusive of the preparatory work to submit its 
recommendations, the AAHKS compiled, analyzed, and reviewed detailed 
clinical and resource utilization data from over 6,000 primary and 
revision TJA procedure codes from 4 high volume joint arthroplasty 
centers located within different geographic regions of the United 
States: University of California, San Francisco, CA; Mayo Clinic, 
Rochester, MN; Massachusetts General Hospital, Boston, MA; and the 
Hospital for Special Surgery, New York, NY. Based on its analysis, the 
AAHKS recommended that CMS examine Medicare claims data and consider 
the creation of separate DRGs for total hip and total knee arthroplasty 
procedures. The AAHKS stated that based on the differences between 
patient

[[Page 23568]]

characteristics, procedure characteristics, resource utilization, and 
procedure code payment rates between total hip and total knee 
replacements, separate DRGs were warranted. Furthermore, the AAHKS 
recommended that CMS create separate base DRGs for routine versus 
complex joint revision or replacement procedures as shown below.
Routine Hip Replacements
    <bullet> 00.73, Revision of hip replacement, acetabular liner and/
or femoral head only.
    <bullet> 00.85, Resurfacing hip, total, acetabulum and femoral 
head.
    <bullet> 00.86, Resurfacing hip, partial, femoral head.
    <bullet> 00.87, Resurfacing hip, partial, acetabulum.
    <bullet> 81.51, Total hip replacement.
    <bullet> 81.52, Partial hip replacement.
    <bullet> 81.53, Revision of hip replacement, not otherwise 
specified.
Complex Hip Replacements
    <bullet> 00.70, Revision of hip replacement, both acetabular and 
femoral components.
    <bullet> 00.71, Revision of hip replacement, acetabular component.
    <bullet> 00.72, Revision of hip replacement, femoral component.
Routine Knee Replacements and Ankle Procedures
    <bullet> 00.83, Revision of knee replacement, patellar component.
    <bullet> 00.84, Revision of knee replacement, tibial insert 
(liner).
    <bullet> 81.54, Revision of knee replacement, not otherwise 
specified.
    <bullet> 81.55, Revision of knee replacement, not otherwise 
specified.
    <bullet> 81.56, Total ankle replacement.
Complex Knee Replacements and Other Reattachments
    <bullet> 00.80, Revision of knee replacement, total (all 
components).
    <bullet> 00.81, Revision of knee replacement, tibial component.
    <bullet> 00.82, Revision of knee replacement, femoral component.
    <bullet> 84.26, Foot reattachment.
    <bullet> 84.27, Lower leg or ankle reattachment.
    <bullet> 84.28, Thigh reattachment.
    The AAHKS also recommended the continuation of CMS DRG 471 
(Bilateral or Multiple Major Joint Procedures of Lower Extremity) 
without modifications. CMS DRG 471 included any combination of two or 
more of the following procedure codes:
    <bullet> 00.70, Revision of hip replacement, both acetabular and 
femoral components.
    <bullet> 00.80, Revision of knee replacement, total (all 
components).
    <bullet> 00.85, Resurfacing hip, total, acetabulum and femoral 
head.
    <bullet> 00.86, Resurfacing hip, partial, femoral head.
    <bullet> 00.87, Resurfacing hip, partial, acetabulum.
    <bullet> 81.51, Total hip replacement.
    <bullet> 81.52, Partial hip replacement.
    <bullet> 81.54, Total knee replacement.
    <bullet> 81.56, Total ankle replacement.
c. Adoption of MS-DRGs for Hip and Knee Replacements for FY 2008 and 
AAHKS's Recommendations
    In the FY 2008 IPPS final rule with comment period (72 FR 47222 
through 47226), we adopted MS-DRGs to better recognize severity of 
illness for FY 2008. The MS-DRGs include two new severity of illness 
levels under the then current base DRG 544. We also added three new 
severity of illness levels to the base DRG for Revision of Hip or Knee 
Replacement. The new MS-DRGs are as follows:
    <bullet> MS-DRG 466 (Revision of Hip or Knee Replacement with MCC)
    <bullet> MS-DRG 467 (Revision of Hip or Knee Replacement with CC)
    <bullet> MS-DRG 468 (Revision of Hip or Knee Replacement without 
CC/MCC)
    <bullet> MS-DRG 469 (Major Joint Replacement or Reattachment of 
Lower Extremity with MCC)
    <bullet> MS-DRG 470 (Major Joint Replacement or Reattachment of 
Lower Extremity without MCC)
    We found that the MS-DRGs greatly improved our ability to identify 
joint procedures with higher resource costs. In the final rule, we 
presented data indicating the average charges for each new MS-DRG for 
the joint procedures.
    In the FY 2008 IPPS final rule with comment period, we acknowledged 
the valuable assistance the AAHKS had provided to CMS in creating the 
new joint replacement procedure codes and modifying the joint 
replacement DRGs beginning in FY 2006. These efforts greatly improved 
our ability to categorize significantly different groups of patients 
according to severity of illness. Commenters on the FY 2008 proposed 
rule had encouraged CMS to continue working with the orthopedic 
community, including the AAHKS, to monitor the need for additional new 
DRGs. The commenters stated that MS-DRGs 466 through 470 are a good 
first step. However, they stated that CMS should continue to evaluate 
the data for these procedures and consider additional refinements to 
the MS-DRGs, including the need for additional severity levels. AAHKS 
stated that its data suggest that all three base DRGs (primary 
replacement, revision of major joint replacement, and bilateral joint 
replacement) should be separated into three severity levels (that is, 
MCC, CC, and non-CC). (We had proposed three severity levels for 
revision of hip and knee replacement (MS-DRGs 466, 467, and 468), and 
AAHKS agreed with this 3-level subdivision.)
    The AAHKS recommended that the base DRG for the proposed two 
severity subdivision MS-DRGs for major joint replacement or 
reattachment of lower extremity with and without CC/MCC (MS-DRGs 483 
and 484) be subdivided into three severity levels, as was the case for 
the revision of hip and knee replacement MS-DRGs. AAHKS also 
recommended that the two severity subdivision MS-DRGs for bilateral or 
multiple major joint procedures of lower extremity with and without MCC 
(MS-DRGs 461 and 462) be subdivided three ways for this base DRG. AAHKS 
acknowledged that the three way split would not meet all five of the 
criteria for establishing a subgroup, and stated that these criteria 
were too restrictive, lack face validity, and create perverse admission 
selection incentives for hospitals by significantly overpaying for 
cases without a CC and underpaying for cases with a CC. It recommended 
that the existing five criteria be modified for low volume subgroups to 
assure materiality. For higher volume MS-DRG subgroups, the AAHKS 
recommended that two other criteria be considered, particularly for 
nonemergency, elective admissions:
    <bullet> Is the per-case underpayment amount significant enough to 
affect admission vs. referral decisions on a case-by-case basis?
    <bullet> Is the total level of underpayments sufficient to 
encourage systematic admission vs. referral policies, procedures, and 
marketing strategies?
    The AAHKS also recommended refining the five existing criteria for 
MCC/CC/without subgroups as follows:
    <bullet> Create subgroups if they meet the five existing criteria, 
with cost difference between subgroups ($1,350) substituted for charge 
difference between subgroups ($4,000);
    <bullet> If a proposed subgroup meets criteria number 2 and 3 (at 
least 5 percent and at least 500 cases) but fails one of the others, 
then create the subgroup if either of the following criteria are met:
    [supsqu] At least $1,000 cost difference per case between 
subgroups; or
    [supsqu] At least $1 million overall cost should be shifted to 
cases with a CC (or MCC) within the base DRG for payment weight 
calculations.

[[Page 23569]]

    In response, we indicated that we did not believe it was 
appropriate to modify our five criteria for creating severity 
subgroups. Our data did not support creating additional subdivisions 
based on the criteria. At that time, we believed the criteria we 
established to create subdivisions within a base DRG were reasonable 
and establish the appropriate balance between better recognition of 
severity of illness, sufficient differences between the groups, and a 
reasonable number of cases in each subgroup. However, we indicated that 
we may consider further modifications to the criteria at a later date 
once we have had some experience with MS-DRGs created using the 
proposed criteria.
    The AAHKS indicated in its response to the FY 2008 proposed rule 
that it continued to support the separation of routine and complex 
joint procedures. It believed that certain joint replacement procedures 
have significantly lower average charges than do other joint 
replacements. The AAKHS's data suggest that more routine joint 
replacements are associated with substantially less resource 
utilization than other more complex revision procedures. The AAHKS 
stated that leaving these procedures in the revision MS-DRGs results in 
substantial overpayment for these relatively simple, less costly 
revision procedures, which in turn results in a relative underpayment 
for the more complex revision procedures.
    In response, we examined data on this issue and identified two 
procedure codes for partial knee revisions that had significantly lower 
average charges than did other joint revisions. The two codes are as 
follows:
    <bullet> 00.83 Revision of knee replacement, patellar component
    <bullet> 00.84 Revision of total knee replacement, tibial insert 
(liner)
    The data suggest that these less complex partial knee revisions are 
less resource intensive than other cases assigned to MS-DRGs 466, 467, 
or 468. We examined other orthopedic DRGs to which these two codes 
could be assigned. We found that these cases have very similar average 
charges to those in MS-DRG 485 (Knee Procedures with Principal 
Diagnosis of Infection with MCC), MS-DRG 486 (Knee Procedures with 
Principal Diagnosis of Infection with CC), MS-DRG 487 (Knee Procedures 
with Principal Diagnosis of Infection without CC), MS-DRG 488 (Knee 
Procedures without Principal Diagnosis of Infection with CC or MCC), 
and MS-DRG 489 (Knee Procedures without Principal Diagnosis of 
Infection without CC).
    Given the very similar resource requirements of MS-DRG 485 and the 
fact that these DRGs also contain knee procedures, we moved codes 00.83 
and 00.84 out of MS-DRGs 466, 467, and 468 and into MS-DRGs 485, 486, 
487, 488, and 489. We also indicated that we would continue to monitor 
the revision DRGs to determine if additional modifications are needed.
d. AAHKS' Recommendations for FY 2009
    The AAHKS' current request involves the following recommendations:
    <bullet> That CMS consolidate and reassign certain joint procedures 
that have a diagnosis of an infection or malignancy into MS-DRGs that 
are similar in terms of clinical characteristics and resource 
utilization. The AAKHS further identifies groups called Stage 1 and 2 
procedures that it believes require significant differences in resource 
utilization.
    <bullet> That CMS reclassify certain specific joint procedures, 
which AAHKS refers to as ``routine,'' out of their current MS-DRG 
assignments. The three joint procedures that AAHKS classifies as 
``routine'' are codes 00.73 (Revision of hip replacement, acetabular 
liner and/or femoral head only), 00.83 (Revision of knee replacement, 
patellar component), and 00.84 (Revision of total knee replacement, 
tibial insert (liner)). The AAHKS advocated removing these three 
``routine'' procedures from the following DRGs: MS-DRGs 466, 467, and 
468, MS-DRGs 485, 486, and 487, and MS-DRGs 488 and 489. The AAHKS 
refers to MS-DRGs 466, 467, and 468 as ``complex'' revision DRGs, and 
recommended that the three ``routine'' procedures be moved out of MS-
DRGs 466, 467, and 468 and MS-DRGs 485, 486, and 489 and into MS-DRGs 
469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity 
with and without MCC, respectively). The AAHKS contended that the three 
``routine'' procedures have similar clinical characteristics and 
resource utilization to those in MS-DRGs 469.
    The recommendations suggested by AAHKS are quite complex and 
involve a number of specific code lists and MS-DRG assignment changes. 
We discuss each of these requests in detail below.
    (1) AAHKS Recommendation 1: Consolidate and reassign patients with 
hip and knee prosthesis related infections or malignancies.
    The AAHKS pointed out that deep infection is one of the most 
devastating complications associated with hip and knee replacements. 
These infections have been reported to occur in approximately 0.5 
percent to 3 percent of primary and 4 percent to 6 percent of revision 
total joint replacement procedures. These infections often result in 
the need for multiple reoperations, prolonged use of intravenous and 
oral antibiotics, extended inpatient and outpatient rehabilitation, and 
frequent followup visits. Furthermore, clinical outcomes following 
single- and two-stage revision total joint arthroplasty procedures have 
been less favorable than revision for other causes of failure not 
associated with infection.
    In addition to the clinical impact, the AAHKS stated that infected 
total joint replacement procedures also have substantial economic 
implications for patients, payers, hospitals, physicians, and society 
in terms of direct medical costs, resource utilization, and the 
indirect costs associated with lost wages and productivity. The AAHKS 
stated that the considerable resources required to care for these 
patients has resulted in a strong financial disincentive for physicians 
and hospitals to provide care for patients with infected total joint 
replacements, an increased economic burden on the high volume tertiary 
care referral centers where patients with infected hip replacement 
procedures are frequently referred for definitive management. The AAHKS 
further stated that, in some cases, there are compromised patient 
outcomes due to treatment delays as patients with infected joint 
replacements seek providers who are willing to care for them.
    Once a deep infection of a total joint prosthesis is identified, 
the first stage of treatment involves a hospital admission for removal 
of the infected prosthesis and debridement of the involved bone and 
surrounding tissue. During the same procedure, an antibiotic-
impregnated cement spacer is typically inserted to maintain alignment 
of the limb during the course of antibiotic therapy. The patient is 
then discharged to a rehabilitation facility/nursing home (or to home 
if intravenous therapy can be safely arranged for the patient) for a 6-
week course of IV antibiotic treatment until the infection has cleared.
    After the completion of antibiotic therapy, the hip or knee may be 
reaspirated to look for evidence of persistent infection or eradication 
of infection. A second stage procedure is then undertaken, where the 
patient is readmitted, the hip or knee is reexplored, and the cement 
spacer removed. If there are no signs of persistent infection, a hip or 
knee prosthesis is reimplanted, often using bone graft and costly 
revision implants in order to address extensive bone loss

[[Page 23570]]

and distorted anatomy. Thus, the entire course of treatment for 
patients with infected joint replacements is 4 to 6 months, with an 
additional 6 to 12 months of rehabilitation. Furthermore, clinical 
outcomes following revision for infection are poor relative to outcomes 
following revision for other, aseptic causes. The AAHKS noted that 
patients with bone malignancy have a similar treatment focus--surgery 
to remove diseased tissue, chemotherapy to treat the malignancy, and 
implantation of the new prosthesis. They also have similar resource 
use. For simplicity, the AAHKS' discussion focused on infected joint 
prostheses, but it suggested that the issues it raises would apply to 
patients with a malignancy as well.
    The AAHKS stated that these patients are currently grouped in 
multiple MS-DRGs, and the cases are often ``outliers'' in each one. 
AAHKS proposed to consolidate these patients with similar clinical 
characteristics and treatment into MS-DRGs reflective of their resource 
utilization.
    The AAHKS states that these more severe patients are currently 
classified into the following MS-DRGs:
    <bullet> MS-DRGs 463, 463, and 465 (Wound Debridement and Skin 
Graft Excluding Hand, for Musculoskeletal-Connective Tissue Disease 
with MCC, with CC, without CC/MCC, respectively).
    <bullet> MS-DRGs 480, 481, and 482 (Hip and Femur Procedures Except 
Major Joint with MCC, with CC, without CC/MCC, respectively).
    <bullet> MS-DRGs 485, 486, and 487 (Knee Procedures with Principal 
Diagnosis of Infection and with MCC, with CC, and without CC/MCC, 
respectively).
    <bullet> MS-DRGs 488 and 489 (Knee Procedures without Principal 
Diagnosis of Infection and with CC/MCC and without CC/MCC, 
respectively).
    <bullet> MS-DRGs 495, 496, and 497 (Local Excision and Removal of 
Internal Fixation Devices Except Hip and Femur with MCC, with CC, and 
without CC/MCC, respectively).
    <bullet> Other MS-DRGs (The AAHKS did not specify what these other 
MS-DRGs were.).
    The AAHKS indicated that cases with the severe diagnoses of 
infections, neoplasms, and structural defects have similarities. These 
similarities are due to an overlap of a severe diagnosis (including a 
principal diagnosis of code 996.66 (Infected joint prosthesis) and the 
resulting need for more extensive surgical procedures. The AAHKS stated 
that currently these patients are grouped into MS-DRGs by major 
procedure alone. AAHKS recommended that these cases be grouped into 
what it refers to as Stages 1 and 2 as follows:
    <bullet> Stage 1 would include the removal of an infected 
prosthesis and includes cases in MS-DRGs 463, 464, and 465, 480, 481, 
and 482, 485 through 489, and 495, 496, and 497. Stage 1 joint 
procedure codes would include codes 80.05 (Arthrotomy for removal of 
prosthesis, hip), 80.06 (Arthrotomy for removal of prosthesis, knee), 
00.73 (Revision of hip replacement, acetabular liner and/or femoral 
head only), and 00.84 (Revision of knee replacement, tibial insert 
(liner)).
    <bullet> Stage 2 would include the implant of a new prosthesis and 
includes cases in MS-DRGs 461 and 462, 463, 464, and 465, 466, 467, and 
468, and 469 and 470. Stage 2 joint procedure codes would include codes 
00.70 (Revision of hip replacement, both acetabular and femoral 
components), 00.71 (Revision of hip replacement, acetabular component), 
00.72 (Revision of hip replacement, femoral component), 00.80 (Revision 
of knee replacement, total (all components)), 00.81 (Revision of knee 
replacement, tibial component), 00.82 (Revision of knee replacement, 
femoral component), 00.85 (Resurfacing hip, total, acetabulum and 
femoral head), 00.86 (Resurfacing hip, partial, femoral head), 00.87 
(Resurfacing hip, partial, acetabulum), 81.51 (Total hip replacement), 
81.52 (Partial hip replacement), 81.53 (Revise hip replacement), 81.54 
(Total knee replacement), 81.55 (Revise knee replacement), and 81.56 
(Total ankle replacement).
    As stated earlier, the AAHKS recommended patients with certain more 
severe diagnoses be grouped into a higher severity level. While most of 
AAHKS' comments focused on joint replacement patients with infections, 
the AAHKS also believed that patients with certain neoplasms require 
greater resources. To this group of infections and neoplasms, the AAHKS 
recommended the addition of four codes that capture acquired 
deformities. The AAHKS believed that these codes would capture 
admissions for the second stage of the treatment for an infected joint. 
The AAHKS stated that the significance of these diagnoses when they are 
reported as the principal code position was significant in predicting 
resource utilization. However, the impact was not as significant when 
the diagnosis was reported as a secondary diagnosis. The AAHKS 
recommended that patients with one of the following infection/neoplasm/
defect principal diagnosis codes be segregated into a higher severity 
level.
Stage 1 Infection/Neoplasm/Defect Principal Diagnosis Codes
    <bullet> 170.7 (Malignant neoplasm of long bones of lower limb).
    <bullet> 171.3 (Malignant neoplasm of soft tissue, lower limb, 
including hip).
    <bullet> 711.05 (Pyogenic arthritis, pelvic region and thigh).
    <bullet> 711.06 (Pyogenic arthritis, lower leg).
    <bullet> 730.05 (Acute osteomyelitis, pelvic region and thigh).
    <bullet> 730.06 (Acute osteomyelitis, lower leg).
    <bullet> 730.15 (Chronic osteomyelitis, pelvic region and thigh).
    <bullet> 730.16 (Chronic osteomyelitis, lower leg).
    <bullet> 730.25 (Unspecified osteomyelitis, pelvic region and 
thigh).
    <bullet> 730.26 (Unspecified osteomyelitis, lower leg).
    <bullet> 996.66 (Infection and inflammatory reaction due to 
internal joint prosthesis).
    <bullet> 996.67 (Infection and inflammatory reaction due to other 
internal orthopedic device, implant, and graft).
Stage 2 Infection/Neoplasm/Defect Principal Diagnosis Codes (an 
Asterisk * Shows the Diagnoses Included in Stage 2 That Were Not Listed 
in Stage 1)
    <bullet> 170.7 (Malignant neoplasm of long bones of lower limb).
    <bullet> 171.3 (Malignant neoplasm of soft tissue, lower limb, 
including hip).
    <bullet> 198.5 (Secondary malignant neoplasm of bone and bone 
marrow) .*
    <bullet> 711.05 (Pyogenic arthritis, pelvic region and thigh).
    <bullet> 711.06 (Pyogenic arthritis, lower leg).
    <bullet> 730.05 (Acute osteomyelitis, pelvic region and thigh).
    <bullet> 730.06 (Acute osteomyelitis, lower leg).
    <bullet> 730.15 (Chronic osteomyelitis, pelvic region and thigh).
    <bullet> 730.16 (Chronic osteomyelitis, lower leg).
    <bullet> 730.25 (Unspecified osteomyelitis, pelvic region and 
thigh).
    <bullet> 730.26 (Unspecified osteomyelitis, lower leg).
    <bullet> 736.30 (Acquired deformities of hip, unspecified 
deformity).
    <bullet> 736.39 (Other acquired deformities of hip) .*
    <bullet> 736.6 (Other acquired deformities of knee) .*
    <bullet> 736.89 (Other acquired deformities of other parts of 
limbs). *
    <bullet> 996.66 (Infection and inflammatory reaction due to 
internal joint prosthesis). *
    <bullet> 996.67 (Infection and inflammatory reaction due to other 
internal orthopedic device, implant, and graft). *

[[Page 23571]]

    For the Stage 2 procedures, AAHKS also suggested the use of the 
following secondary diagnosis codes to assign the cases to a higher 
severity level. These conditions would not be the reason the patient 
was admitted to the hospital. They would instead represent secondary 
conditions that were also present on admission or conditions that were 
diagnosed after admission.
Stage 2 Infection/Neoplasm/Defect Secondary Diagnosis Codes
    <bullet> 170.7 (Malignant neoplasm of long bones of lower limb).
    <bullet> 171.3 (Malignant neoplasm of soft tissue, lower limb, 
including hip).
    <bullet> 711.05 (Pyogenic arthritis, pelvic region and thigh).
    <bullet> 711.06 (Pyogenic arthritis, lower leg).
    <bullet> 730.05 (Acute osteomyelitis, pelvic region and thigh).
    <bullet> 730.06 (Acute osteomyelitis, lower leg).
    <bullet> 730.15 (Chronic osteomyelitis, pelvic region and thigh).
    <bullet> 730.16 (Chronic osteomyelitis, lower leg).
    <bullet> 730.25 (Unspecified osteomyelitis, pelvic region and 
thigh).
    <bullet> 730.26 (Unspecified osteomyelitis, lower leg).
    <bullet> 996.66 (Infection and inflammatory reaction due to 
internal joint prosthesis).
    <bullet> 996.67 (Infection and inflammatory reaction due to other 
internal orthopedic device, implant, and graft).
    (2) AAHKS Recommendation 2: Reclassify certain specific joint 
procedures.
    The AAHKS suggested that cases with the infection/neoplasm/defect 
diagnoses listed above be segregated according to the Stage 1 and 2 
groups listed above. The AAHKS made one final recommendation concerning 
joint procedure cases with infections. It identified a subset of 
patients who had a principal diagnosis of 996.66 (Infection and 
inflammatory reaction due to internal joint prosthesis) and who also 
had a secondary diagnosis of sepsis or septicemia. The AAHKS believed 
that these patients are for the most part admitted with both the joint 
infection and sepsis/septicemia present at the time of admission. The 
codes for sepsis/septicemia are classified as MCCs under MS-DRGs. The 
AAHKS believed it is inappropriate to count the secondary diagnosis of 
sepsis/septicemia as a MCC when it is reported with code 996.66. The 
AAHKS believed that counting sepsis and septicemia as a MCC results in 
double counting the infections. It believed that the joint infection 
and septicemia are the same infection. The AAHKS recommended that the 
following sepsis and septicemia codes not count as a MCC when reported 
with code 996.66:
    <bullet> 038.0 (Streptococcal septicemia).
    <bullet> 038.10 (Staphylococcal septicemia, unspecified).
    <bullet> 038.11 (Staphylococcal aureus septicemia).
    <bullet> 038.19 (Other staphylococcal septicemia).
    <bullet> 038.2 (Pneumococcal septicemia [streptococcus pneumonia 
septicemia]).
    <bullet> 038.3 (Septicemia due anaerobes).
    <bullet> 038.40 (Septicemia due to gram-negative organisms).
    <bullet> 038.41 (Hemophilus influenzae [H. Influenzae]).
    <bullet> 038.42 (Escherichia coli [E. Coli]).
    <bullet> 038.43 (Pseudomonas).
    <bullet> 038.44 (Serratia).
    <bullet> 038.49 (Other septicemia due to gram-negative organisms).
    <bullet> 038.8 (Other specified septicemias).
    <bullet> 038.9 (Unspecified septicemia).
    <bullet> 995.91 (Sepsis).
    <bullet> 995.92 (Severe sepsis).
e. CMS' Response to AAHKS' Recommendations
    The MS-DRG modifications proposed by the AAHKS are quite complex 
and have many separate parts. We made changes to the MS-DRGs in FY 2008 
as a result of a request by the AAHKS as discussed above, to recognize 
two types of partial knee replacements as less complex procedures. We 
have no data on how effective the new MS-DRGs for joint procedures are 
in differentiating patients with varying degrees of severity. 
Therefore, we analyzed data reported prior to the adoption of MS-DRGs 
to analyze each of the recommendations made. We begin our analysis by 
focusing first on the more simple aspects of the recommendations made 
by the AAHKS.
(1) Changing the MS-DRG Assignment for Codes 00.73, 00.83, and 00.84
    As discussed previously, in FY 2008, the AAHKS recommended that CMS 
classify certain joint procedures as either routine or complex. We 
examined the data for these cases and found that the following two 
codes had significantly lower charges than the other joint revisions: 
00.83 (Revision of knee replacement, patellar component) and 00.84 
(Revision of knee replacement, tibial insert (liner)). Therefore, we 
moved these two codes to MS-DRGs 485, 486, and 487, and MS-DRGs 488 and 
489.
    As a result of AAHKS' most recent recommendations, we once again 
examined claims data for these two knee procedures (codes 00.83 and 
00.84) as well as its request that we move code 00.73 (Revision of hip 
replacement, acetabular liner and/or femoral head only). Code 00.73 is 
assigned to MS-DRGs 466, 467, and 468. The following tables show our 
findings.

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                             MS-DRG                                    cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
485--All Cases..................................................           1,122           12.20      $64,672.47
485--Cases with Code 00.83 or 00.84.............................             179           11.83       64,446.68
485--Cases without Code 00.83 or 00.84..........................             943           12.27       64,715.33
486--All Cases..................................................           2,061            8.03       40,758.55
486--Cases with Code 00.83 or 00.84.............................             464            7.34       39,864.39
486--Cases without Code 00.83 or 00.84..........................           1,597            8.23       41,018.34
487--All Cases..................................................           1,236            5.67       29,180.88
487--Cases with Code 00.83 or 00.84.............................             284            5.61       31,231.79
487--Cases without Code 00.83 or 00.84..........................             952            5.68       28,569.06
488--All Cases..................................................           2,374            5.17       30,180.80
488--Cases with code 00.83 or 00.84.............................             754            4.09       28,432.06
488--Cases without code 00.83 or 00.84..........................           1,620            5.67       30,994.73
489--All Cases..................................................           5,493            3.04       21,385.67
489--Cases with code 00.83 or 00,.84............................           2,154            3.07       23,122.18
489--Cases without code 00.83 or 00.84..........................           3,339            3.03       20,265.44
469--All cases..................................................          29,030            8.17       56,681.64
470--All Cases..................................................         385,123            3.93       36,126.23
466--All Cases..................................................           3,888            9.18       76,015.66
466--Cases with Code 00.73......................................             273           10.02       71,293.33

[[Page 23572]]

 
466--Cases without Code 00.73...................................           3,616            9.12       76,372.06
467--All Cases..................................................          13,551            5.50       53,431.63
467--Cases with Code 00.73......................................           1,078            5.94       43,635.63
467--Cases without Code 00.73...................................          12,484            5.47       54,284.13
468--All Cases..................................................          19,917            3.94       44,055.62
468--Cases with Code 00.73......................................           1,688            3.93       33,449.22
468--Cases without Code 00.73...................................          18,232            3.94       45,037.09
469--All Cases..................................................          29,030            8.17       56,681.64
470--All Cases..................................................         385,123            3.93       36,126.23
----------------------------------------------------------------------------------------------------------------

    The tables show that codes 00.73, 00.83, and 00.84 are 
appropriately assigned to their current MS-DRGs. The data do not 
support moving these three codes to MS-DRGs 469 and 470. Therefore, we 
are not proposing a change of MS-DRG assignment for codes 00.73, 00.83, 
and 00.84.
(2) Excluding Sepsis and Septicemia From Being a MCC With Code 996.66
    There are cases where a patient may be admitted with an infection 
of a joint prosthesis (code 996.66) and also have sepsis. In these 
cases, it may be possible to perform joint procedures as suggested by 
AAHKS. However, in other cases, a patient may be admitted with an 
infection of a joint prosthesis and then develop sepsis during the 
stay. Because our current data do not indicate whether a condition is 
present on admission, we could not determine whether or not the sepsis 
occurred after admission. Our data have consistently shown that cases 
of sepsis and septicemia require significant resources. Therefore, we 
classified the sepsis and septicemia codes as MCCs. Our clinical 
advisors do not believe it is appropriate to exclude all cases of 
sepsis and septicemia that are reported as a secondary diagnosis with 
code 996.66 from being classified as a MCC. We discuss septicemia as 
part of hospital acquired conditions provision under section II.F. of 
the preamble of this proposed rule. For the purposes of classifying 
sepsis and septicemia as non-CCs when reported with code 996.66, we do 
not support this recommendation. Therefore, we are not proposing that 
the sepsis and septicemia codes be added to the CC exclusion list for 
code 996.66.
(3) Differences Between Stage 1 and 2 Cases With Severe Diagnoses
    We next examined data on AAHKS' suggestion that there are 
significantly differences in resource utilization for cases they refer 
to as Stage 1 and 2. AAHKS stated that this is particularly true for 
those with infections, neoplasms, or structural defects. We used the 
list of procedure codes listed above that AAHKS describes as Stage 1 
and 2 procedures. We also used AAHKS' designated lists of Stage 1 and 2 
principal diagnosis codes to examine this proposal. This proposal 
entails moving cases with a Stage 1 or 2 principal diagnosis and 
procedure out of their current MS-DRG assignment in the following 19 
MS-DRGs and into a newly consolidated set of MS-DRGs: MS-DRGs 463, 464, 
and 465, 480, 481, and 482, 485 through 489, and 495, 496, and 497.
    As can be seen from the information below, there was not a 
significant difference in average charges between these Stage 1 and 
Stage 2 cases that have an MCC.

                         Stage 1.--Cases With Infection, Neoplasm, or Structural Defect
----------------------------------------------------------------------------------------------------------------
                                                                                  Average length      Average
                             Stage 1                                Total cases       of stay         charges
----------------------------------------------------------------------------------------------------------------
With MCC........................................................           1,306            14.1         $79,232
Without MCC.....................................................           4,115             7.6          44,716
----------------------------------------------------------------------------------------------------------------


                         Stage 2.--Cases With Infection, Neoplasm, or Structural Defect
----------------------------------------------------------------------------------------------------------------
                                                                                  Average length      Average
                             Stage 2                                Total cases       of stay         charges
----------------------------------------------------------------------------------------------------------------
With MCC........................................................           1,072            10.9         $80,781
Without MCC.....................................................           5,413             6.0          57,355
----------------------------------------------------------------------------------------------------------------

    Average charges for Stage 1 cases with an MCC was $79,232 compared 
to $80,781 for Stage 2. Stage 1 cases without an MCC had average 
charges of $44,716 compared to $57,355. These data do not support 
reconfiguring the current MS-DRGs based on this new subdivision.
(4) Moving Joint Procedure Cases to New MS-DRGs Based on Secondary 
Diagnoses of Infection
    We examined AAHKS' recommendation that Stage 2 joint cases with 
specific secondary diagnoses of infection or neoplasm be moved out of 
their current MS-DRG assignments and into a newly constructed MS-DRG.
    We are reluctant to make this type of significant DRG change to the 
joint MS-DRGs based on the presence of a secondary diagnosis. This 
results in the movement of cases out of MS-DRGs which were configured 
based on the reason for the admission (for example, principal 
diagnosis) and surgery. The cases would instead be assigned based on 
conditions that are reported as secondary diagnoses. In some cases, the 
infection may have developed or be diagnosed during the admission. This 
would be a significant logic change to the MS-DRGs for joint 
procedures. We have not had an opportunity to examine

[[Page 23573]]

claims data based on hospital discharges under the MS-DRGs which began 
October 1, 2008. Our clinical advisors believe it would be more 
appropriate to wait for data under the new MS-DRG system to determine 
how well the new severity levels are addressing accurate payment for 
these cases before considering this approach to assigning cases to a 
MS-DRG.
(5) Moving Cases With Infection, Neoplasms, or Structural Defects Out 
of 19 MS-DRGs and Into Two Newly Developed MS-DRGs
    The last recommended by AAHKS that we considered was moving cases 
with a principal diagnosis of infection, neoplasm, or structural defect 
from their list of Stage 1 and 2 diagnoses and consolidated them into 
newly constructed and modified MS-DRGs. AAHKS could not identify an 
existing set of MS-DRGs with similar resource utilizations into which 
the Stage 1 cases could be assigned. Therefore, the AAHKS recommended 
that CMS create three new MS-DRGs for Stage 1 cases with infections, 
neoplasms and structural defects which would be titled ``Arthrotomy/
Removal/Component exchange of Infected Hip or Knee Prosthesis with MCC, 
with CC, and without CC/MCC'', respectively.
    The AAHKS recommended moving Stage 2 cases out of MS-DRGs 466, 467, 
and 468, and 469 and 470 and into MS-DRGs 461 and 462. AAHKS 
recommended that MS-DRGs 461 and 462 be renamed ``Major Joint 
Procedures of Lower Extremity--Bilateral/Multiple/Infection/
Malignancy''.
    In reviewing these proposed changes, we had a number of concerns. 
The first concern was that these proposed changes would result in the 
removal of cases with varying average charges from 19 current MS-DRGs 
and consolidating them into two separate sets of MS-DRGs. As the data 
below indicate, the average charges vary from as low as $29,181 in MS-
DRG 487 to $81,089 in MS-DRG 463. Furthermore, the average charges for 
these infection/neoplasm/structural defect cases are very similar to 
other cases in their respective MS-DRG assignments for many of these 
MS-DRGs. There are cases where the average charges are higher. In MS-
DRG 469 and 470, the infection/neoplasm/structural defect cases are 
significantly higher. However, there are only 136 cases in MS-DRG 469 
out of a total of 29,030 cases with these diagnoses. There are only 673 
cases in MS-DRG 470 out of a total of 385,123 cases with one of these 
diagnoses. The table below clearly demonstrates the wide variety of 
charges for cases with these diagnoses.

 
----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                             MS-DRGs                                   cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
463--All Cases..................................................           4,747           16.25      $73,405.46
463--Cases with PDX of Infection/Malignancy/React...............           1,009           17.79       81,089.07
464--All Cases..................................................           5,499           10.21       44,387.73
464--Cases with PDX of Infection/Malignancy/React...............           1,420           10.59       46,800.60
465--All Cases..................................................           2,271            5.95       26,631.57
465--Cases with PDX of Infection/Malignancy/React...............             557           10.59       29,816.40
466--All Cases..................................................           3,888            9.18       76,015.66
466--Cases with PDX of Infection/Malignancy/React...............             890           10.67       79,334.69
467--All Cases..................................................          13,551            5.50       53,431.63
467--Cases with PDX of Infection/Malignancy/React...............           2,401            6.71       58,506.86
468--All Cases..................................................          19,917            3.94       44,055.62
468--Cases with PDX of Infection/Malignancy/React...............           1,994            4.76       54,322.03
469--All Cases..................................................          29,030            8.17       56,681.64
469--Cases with PDX of Infection/Malignancy/React...............             136           11.74       85,256.07
470--All Cases..................................................         385,123            3.93       36,126.23
470--Cases with PDX of Infection/Malignancy/React...............             673            6.44       59,676.31
480--All Cases..................................................          25,391            9.32       52,281.65
480--Cases with PDX of Infection/Malignancy/React...............             880           14.53       76,355.15
481--All Cases..................................................          68,655            5.94       32,963.64
481--Cases with PDX of Infection/Malignancy/React...............             878            8.78       48,655.30
482--All Cases..................................................          45,832            4.86       27,266.20
482--Cases with PDX of Infection/Malignancy/React...............             577            6.19       37,572.38
485--All Cases..................................................           1,122           12.20       64,672.47
485--Cases with PDX of Infection/Malignancy/React...............           1,122           12.20       64,672.47
486--All Cases..................................................           2,061            8.03       40,758.55
486--Cases with PDX of Infection/Malignancy/React...............           2,061            8.03       40,758.55
487--All Cases..................................................           1,236            5.67       29,180.88
487--Cases with PDX of Infection/Malignancy/React...............           1,236            5.67       29,180.88
488--All Cases..................................................           2,374            5.17       30,180.80
488--Cases with PDX of Infection/Malignancy/React...............              31            7.13       50,155.42
489--All Cases..................................................           5,493            3.04       21,385.67
489--Cases with PDX of Infection/Malignancy/React...............              36            3.72       35,313.84
495--All Cases..................................................           1,860           10.94       55,103.91
495--Cases with PDX of Infection/Malignancy/React...............           1,025           11.74       59,453.69
496--All Cases..................................................           5,203            5.95       32,177.29
496--Cases with PDX of Infection/Malignancy/React...............           2,759            6.98       36,940.99
497--All Cases..................................................           6,259            3.01       21,445.60
497--Cases with PDX of Infection/Malignancy/React...............           1,500            5.18       29,966.98
----------------------------------------------------------------------------------------------------------------

    Given the wide variety of charges and the small number of cases 
where there are differences in charges, we do not believe the data 
support the AAHKS' recommendations. The data do not support removing 
these cases from the 19 MS-DRGs above and consolidating them into a new 
set of MS-DRGs, either newly created, or by adding them to

[[Page 23574]]

MS-DRG 461 or 462, which have average charges of $80,718 and $57,355, 
respectively.
    A second major concern involves redefining MS-DRGs 461 and 462 is 
that these MS-DRG currently captures bilateral and multiple joint 
procedures. These MS-DRGs were specifically created to capture a unique 
set of patients who undergo procedures on more than one lower joint. 
Redefining these MS-DRGs to include both single and multiple joints 
undermines the clinical coherence of this MS-DRG. It would create a 
widely diverse group of patients based on either a list of specific 
diagnoses or the fact that the patient had multiple lower joint 
procedures.
f. Conclusion
    The AAHKS recommended a number of complicated, interrelated MS-DRG 
changes to the joint procedure MS-DRGs. We have not yet had the 
opportunity to review data for these cases under the new MS-DRGs. We 
did analyze the impact of these recommendations using cases prior to 
the implementation of MS-DRGs. The recommendations were difficult to 
analyze because there were so many separate logic changes that impacted 
a number of MS-DRGs. We did examine each major suggestion separately, 
and found that our data and clinical analysis did not support making 
these changes. Therefore, we are not proposing any revisions to the 
joint procedure MS-DRGs for FY 2009. We look forward to examining these 
issues once we receive data under the MS-DRG system. We also welcome 
additional recommendations from the AAHKS and others on a more 
incremental approach to resolving its concerns about the ability of the 
current MS-DRGs to adequately capture differences in severity levels 
for joint procedure patients.
5. MDC 18 (Infections and Parasitic Diseases (Systemic or Unspecified 
Sites)): Severe Sepsis
    We received a request from a manufacturer to modify the titles for 
three MS-DRGs with the most significant concentration of severe sepsis 
patients. The manufacturer stated that modification of the titles will 
assist in quality improvement efforts and provide a better reflection 
on the types of patients included in these MS-DRGs. Specifically, the 
manufacturer urged CMS to incorporate the term ``severe sepsis'' into 
the titles of the following MS-DRGs that became effective October 1, 
2007 (FY 2008)
    <bullet> MS-DRG 870 (Septicemia with Mechanical Ventilation 96+ 
Hours).
    <bullet> MS-DRG 871 (Septicemia without Mechanical Ventilation 96+ 
Hours with MCC).
    <bullet> MS-DRG 872 (Septicemia without Mechanical Ventilation 96+ 
Hours without MCC).
    These MS-DRGs were created to better recognize severity of illness 
among patients diagnosed with conditions including septicemia, severe 
sepsis, septic shock, and systemic inflammatory response syndrome 
(SIRS) who are also treated with mechanical ventilation for a specified 
duration of time.
    According to the manufacturer, ``severe sepsis is a common, deadly 
and costly disease, yet the number of patients impacted and the 
outcomes associated with their care remain largely hidden within the 
administrative data set.'' The manufacturer further noted that, 
although improvements have been made in the ICD-9-CM coding of severe 
sepsis (diagnosis code 995.92) and septic shock (diagnosis code 
785.52), results of an analysis demonstrated an unacceptably high 
mortality rate for patients reported to have those conditions. The 
manufacturer believed that revising the titles to incorporate ``severe 
sepsis'' will provide various clinicians and researchers the 
opportunity to improve outcomes for these patients. Therefore, the 
manufacturer recommended revising the current MS-DRG titles as follows:
    <bullet> Proposed Revised MS-DRG 870 (Septicemia or Severe Sepsis 
with Mechanical Ventilation 96+ Hours).
    <bullet> Proposed Revised MS-DRG 871 (Septicemia or Severe Sepsis 
without Mechanical Ventilation 96+ Hours with MCC).
    <bullet> Proposed Revised MS-DRG 872 (Septicemia or Severe Sepsis 
without Mechanical Ventilation 96+ Hours without MCC).
    We agree with the manufacturer that revising the current MS-DRG 
titles to include the term ``severe sepsis'' would better assist in the 
recognition and identification of this disease, which could lead to 
better clinical outcomes and quality improvement efforts. In addition, 
both severe sepsis (diagnosis code 995.92) and septic shock (diagnosis 
code 785.52) are currently already assigned to these three MS-DRGs. 
Therefore, we are proposing to revise the titles of MS-DRGs 870, 871, 
and 872 to reflect severe sepsis in the titles as suggested by the 
manufacturer and listed above for FY 2009.
6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): Traumatic 
Compartment Syndrome
    Traumatic compartment syndrome is a condition in which increased 
pressure within a confined anatomical space that contains blood 
vessels, muscles, nerves, and bones causes a decrease in blood flow and 
may lead to tissue necrosis.
    There are five ICD-9-CM diagnosis codes that were created effective 
October 1, 2006, to identify traumatic compartment syndrome of various 
sites.
    <bullet> 958.90 (Compartment syndrome, unspecified).
    <bullet> 958.91 (Traumatic compartment syndrome of upper 
extremity).
    <bullet> 958.92 (Traumatic compartment syndrome of lower 
extremity).
    <bullet> 958.93 (Traumatic compartment syndrome of abdomen).
    <bullet> 958.99 (Traumatic compartment syndrome of other sites) .
    Cases with one of the diagnosis codes listed above reported as the 
principal diagnosis and no operating room procedure are assigned to 
either MS-DRG 922 (Other Injury, Poisoning and Toxic Effect Diagnosis 
with MCC) or MS-DRG 923 (Other Injury, Poisoning and Toxic Effect 
Diagnosis without MCC) in MDC 21.
    In the FY 2008 IPPS final rule with comment period when we adopted 
the MS-DRGs, we inadvertently omitted the addition of these traumatic 
compartment syndrome codes 958.90 through 958.99 to the multiple trauma 
MS-DRGs 963 (Other Multiple Significant Trauma with MCC), MS-DRG 964 
(Other Multiple Significant Trauma with CC), and MS-DRG 965 (Other 
Multiple Significant Trauma without CC/MCC) in MDC 24 (Multiple 
Significant Trauma). Cases are assigned to MDC 24 based on the 
principal diagnosis of trauma and at least two significant trauma 
diagnosis codes (either as principal or secondary diagnoses) from 
different body site categories. There are eight different body site 
categories as follows:
    <bullet> Significant head trauma.
    <bullet> Significant chest trauma.
    <bullet> Significant abdominal trauma.
    <bullet> Significant kidney trauma.
    <bullet> Significant trauma of the urinary system.
    <bullet> Significant trauma of the pelvis or spine.
    <bullet> Significant trauma of the upper limb.
    <bullet> Significant trauma of the lower limb.
    Therefore, we are proposing to add traumatic compartment syndrome 
codes 958.90 through 958.99 to MS-DRGs 963 and MS-DRG 965 in MDC 24. 
Under

[[Page 23575]]

this proposal, codes 958.90 through 958.99 would be added to the list 
of principal diagnosis of significant trauma. In addition, code 958.91 
would be added to the list of significant trauma of upper limb, code 
958.92 would be added to the list of significant trauma of lower limb, 
and code 958.93 would be added to the list of significant abdominal 
trauma.
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 DRG. For FY 2009, 
we are proposing to make the following changes to the MCE edits:
a. List of Unacceptable Principal Diagnoses in MCE
    Diagnosis code V62.84 (Suicidal ideation) was created for use 
beginning October 1, 2005. At the time the diagnosis code was created, 
it was not clear that the creation of this code was requested in order 
to describe the principal reason for admission to a facility or the 
principal reason for treatment. The NCHS Official ICD-9-CM Coding 
Guidelines therefore categorized the group of codes in V62.X for use 
only as additional or secondary diagnoses. It has been brought to the 
government's attention that the use of this code is hampered by its 
designation as an additional-only diagnosis. NCHS has therefore 
modified the Official Coding Guidelines for FY 2009 by making this code 
acceptable as a principal diagnosis as well as an additional diagnosis. 
In order to conform to this change by NCHS, we are proposing to remove 
code V62.84 from the MCE list of ``Unacceptable Principal Diagnoses'' 
for FY 2009.
b. Diagnoses Allowed for Males Only Edit
    There are four diagnosis codes that were inadvertently left off of 
the MCE edit titled ``Diagnoses Allowed for Males Only.'' These codes 
are located in the chapter of the ICD-9-CM diagnosis codes entitled 
``Diseases of Male Genital Organs.'' We are proposing to add the 
following four codes to this MCE edit: 603.0 (Encysted hydrocele), 
603.1 (Infected hydrocele), 603.8 (Other specified types of hydrocele), 
and 603.9 (Hydrocele, unspecified). We have had no reported problems or 
confusion with the omission of these codes from this section of the 
MCE, but in order to have an accurate product, we are proposing that 
these codes be added for FY 2009.
c. Limited Coverage Edit
    As explained in section II.G.1. of the preamble of this proposed 
rule, we are proposing to remove procedure code 37.52 (Implantation of 
internal biventricular heart replacement system) from the MCE ``Non-
Covered Procedure'' edit and to assign it to the ``Limited Coverage'' 
edit. We are proposing to include in this proposed edit the requirement 
that ICD-9-CM diagnosis code V70.7 (Examination of participant in 
clinical trial) also be present on the claim. We are proposing that 
claims submitted without both procedure code 37.52 and diagnosis code 
V70.7 would be denied because they would not be in compliance with the 
proposed coverage policy explained in section II.G.1. of this preamble.
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 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 ``kidney, ureter and 
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 charge of MS-DRG 1 is higher 
than that of MS-DRG 3, but the average charges of MS-DRGs 4 and 5 are 
higher than the average charge 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 weight the average charge 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 logic underlying the surgical 
hierarchy provides that the GROUPER search for the procedure in the 
most resource-intensive surgical class, in cases involving multiple 
procedures, this result is sometimes unavoidable.
    We note that, notwithstanding the foregoing discussion, there are a 
few instances when a surgical class with a lower average charge is 
ordered above a surgical class with a higher average charge. For 
example, the ``other O.R. procedures'' surgical class is uniformly 
ordered last in the surgical hierarchy of each MDC in which it occurs, 
regardless of the fact that the average charge for the MS-DRG or MS-
DRGs in that surgical class may be higher than that for other surgical 
classes in the MDC. The ``other O.R. procedures'' class is a group of 
procedures that are only infrequently related to the diagnoses in the 
MDC, but are still occasionally performed on patients in the MDC with 
these diagnoses. Therefore, assignment to these surgical classes should 
only occur if no other surgical class more closely related to the 
diagnoses in the MDC is appropriate.
    A second example occurs when the difference between the average 
charges for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
because, as a result of reassigning cases on the basis of the hierarchy 
change, the average charges are likely to shift such that the higher-
ordered surgical class has a lower

[[Page 23576]]

average charge than the class ordered below it.
    For FY 2009, we are proposing a revision of the surgical hierarchy 
for MDC 5 (Diseases and Disorders of the Circulatory System) by placing 
MS-DRG 245 (AICD Generator Procedures) above proposed new MS-DRG 265 
(AICD Lead Procedures).
9. CC Exclusions List
a. Background
    As indicated earlier in the preamble of this proposed rule, under 
the IPPS 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 47152 through 47121).
b. CC Exclusions List for FY 2009
    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:
    <bullet> Chronic and acute manifestations of the same condition 
should not be considered CCs for one another.
    <bullet> Specific and nonspecific (that is, not otherwise specified 
(NOS)) diagnosis codes for the same condition should not be considered 
CCs for one another.
    <bullet> 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.
    <bullet> Codes for the same condition in anatomically proximal 
sites should not be considered CCs for one another.
    <bullet> 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.\12\
---------------------------------------------------------------------------

    \12\ 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; and the FY 2008 final rule 
(72 FR 47130) for the FY 2008 revisions. In the FY 2000 final rule 
(64 FR 41490, July 30, 1999, we did not modify the CC Exclusions 
List because we did not make any changes to the ICD-9-CM codes for 
FY 2000.
---------------------------------------------------------------------------

    For FY 2009, we are proposing to make limited revisions to the CC 
Exclusions List to take into account the changes that will be made in 
the ICD-9-CM diagnosis coding system effective October 1, 2008. (See 
section II.G.11. of the preamble of this proposed rule with comment 
period for a discussion of ICD-9-CM changes.) We are proposing to make 
these changes in accordance with the principles established when we 
created the CC Exclusions List in 1987. In addition, as discussed in 
section II.D.3. of the preamble of this proposed rule, we are 
indicating on the CC exclusion list some updates to reflect the 
exclusion of a few codes from being an MCC under the MS-DRG system that 
we adopted for FY 2008.
    Tables 6G and 6H, Additions to and Deletions from the CC Exclusion 
List, respectively, which will be effective for discharges occurring on 
or after October 1, 2008, are not being published in 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 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.
    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, 2008, the indented diagnoses will not be recognized by 
the GROUPER as valid CCs for the asterisked principal diagnosis.
    To assist readers in the review of 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, we are providing the following 
summaries of those MCC and CC changes.

        Summary of Additions to the MS-DRG MCC List.--Table 6I.1
------------------------------------------------------------------------
                 Code                              Description
------------------------------------------------------------------------
249.10................................  Secondary diabetes mellitus with
                                         ketoacidosis, not stated as
                                         uncontrolled, or unspecified.
249.11................................  Secondary diabetes mellitus with
                                         ketoacidosis, uncontrolled.
249.20................................  Secondary diabetes mellitus with
                                         hyperosmolarity, not stated as
                                         uncontrolled, or unspecified.

[[Page 23577]]

 
249.21................................  Secondary diabetes mellitus with
                                         hyperosmolarity, uncontrolled.
249.30................................  Secondary diabetes mellitus with
                                         other coma, not stated as
                                         uncontrolled, or unspecified.
249.31................................  Secondary diabetes mellitus with
                                         other coma, uncontrolled.
707.23................................  Pressure ulcer, stage III.
707.24................................  Pressure ulcer, stage IV.
777.50................................  Necrotizing enterocolitis in
                                         newborn, unspecified.
777.51................................  Stage I necrotizing
                                         enterocolitis in newborn.
777.52................................  Stage II necrotizing
                                         enterocolitis in newborn.
777.53................................  Stage III necrotizing
                                         enterocolitis in newborn.
780.72................................  Functional quadriplegia.
------------------------------------------------------------------------


       Summary of Deletions From the MS-DRG MCC List.--Table 6I.2
------------------------------------------------------------------------
                 Code                              Description
------------------------------------------------------------------------
136.2.................................  Specific infections by free-
                                         living amebae.
511.8.................................  Other specified forms of pleural
                                         effusion, except tuberculous.
707.02................................  Pressure ulcer, upper back.
707.03................................  Pressure ulcer, lower back.
707.04................................  Pressure ulcer, hip.
707.05................................  Pressure ulcer, buttock.
707.06................................  Pressure ulcer, ankle.
707.07................................  Pressure ulcer, heel.
777.5.................................  Necrotizing enterocolitis in
                                         fetus or newborn.
------------------------------------------------------------------------


         Summary of Additions to the MS-DRG CC List.--Table 6J.1
------------------------------------------------------------------------
                 Code                              Description
------------------------------------------------------------------------
046.11................................  Variant Creutzfeldt-Jakob
                                         disease.
046.19................................  Other and unspecified
                                         Creutzfeldt-Jakob disease.
046.71................................  Gerstmann-Str[auml]ussler-
                                         Scheinker syndrome.
046.72................................  Fatal familial insomnia.
046.79................................  Other and unspecified prion
                                         disease of central nervous
                                         system.
059.01................................  Monkeypox.
059.21................................  Tanapox.
136.29................................  Other specific infections by
                                         free-living amebae.
199.2.................................  Malignant neoplasm associated
                                         with transplant organ.
203.02................................  Multiple myeloma, in relapse.
203.12................................  Plasma cell leukemia, in
                                         relapse.
203.82................................  Other immunoproliferative
                                         neoplasms, in relapse.
204.02................................  Acute lymphoid leukemia, in
                                         relapse.
204.12................................  Chronic lymphoid leukemia, in
                                         relapse.
204.22................................  Subacute lymphoid leukemia, in
                                         relapse.
204.82................................  Other lymphoid leukemia, in
                                         relapse.
204.92................................  Unspecified lymphoid leukemia,
                                         in relapse.
205.02................................  Acute myeloid leukemia, in
                                         relapse.
205.12................................  Chronic myeloid leukemia, in
                                         relapse.
205.22................................  Subacute myeloid leukemia, in
                                         relapse.
205.32................................  Myeloid sarcoma, in relapse.
205.82................................  Other myeloid leukemia, in
                                         relapse.
205.92................................  Unspecified myeloid leukemia, in
                                         relapse.
206.02................................  Acute monocytic leukemia, in
                                         relapse.
206.12................................  Chronic monocytic leukemia, in
                                         relapse.
206.22................................  Subacute monocytic leukemia, in
                                         relapse.
206.82................................  Other monocytic leukemia, in
                                         relapse.
206.92................................  Unspecified monocytic leukemia,
                                         in relapse.
207.02................................  Acute erythremia and
                                         erythroleukemia, in relapse.
207.12................................  Chronic erythremia, in relapse.
207.22................................  Megakaryocytic leukemia, in
                                         relapse.
207.82................................  Other specified leukemia, in
                                         relapse.
208.02................................  Acute leukemia of unspecified
                                         cell type, in relapse.
208.12................................  Chronic leukemia of unspecified
                                         cell type, in relapse.
208.22................................  Subacute leukemia of unspecified
                                         cell type, in relapse.
208.82................................  Other leukemia of unspecified
                                         cell type, in relapse.
208.92................................  Unspecified leukemia, in
                                         relapse.
209.00................................  Malignant carcinoid tumor of the
                                         small intestine, unspecified
                                         portion.
209.01................................  Malignant carcinoid tumor of the
                                         duodenum.
209.02................................  Malignant carcinoid tumor of the
                                         jejunum.
209.03................................  Malignant carcinoid tumor of the
                                         ileum.

[[Page 23578]]

 
209.10................................  Malignant carcinoid tumor of the
                                         large intestine, unspecified
                                         portion.
209.11................................  Malignant carcinoid tumor of the
                                         appendix.
209.12................................  Malignant carcinoid tumor of the
                                         cecum.
209.13................................  Malignant carcinoid tumor of the
                                         ascending colon.
209.14................................  Malignant carcinoid tumor of the
                                         transverse colon.
209.15................................  Malignant carcinoid tumor of the
                                         descending colon.
209.16................................  Malignant carcinoid tumor of the
                                         sigmoid colon.
209.17................................  Malignant carcinoid tumor of the
                                         rectum.
209.20................................  Malignant carcinoid tumor of
                                         unknown primary site.
209.21................................  Malignant carcinoid tumor of the
                                         bronchus and lung.
209.22................................  Malignant carcinoid tumor of the
                                         thymus.
209.23................................  Malignant carcinoid tumor of the
                                         stomach.
209.24................................  Malignant carcinoid tumor of the
                                         kidney.
209.25................................  Malignant carcinoid tumor of
                                         foregut, not otherwise
                                         specified.
209.26................................  Malignant carcinoid tumor of
                                         midgut, not otherwise
                                         specified.
209.27................................  Malignant carcinoid tumor of
                                         hindgut, not otherwise
                                         specified.
209.29................................  Malignant carcinoid tumor of
                                         other sites.
209.30................................  Malignant poorly differentiated
                                         neuroendocrine carcinoma, any
                                         site.
238.77................................  Post-transplant
                                         lymphoproliferative disorder
                                         (PTLD).
279.50................................  Graft-versus-host disease,
                                         unspecified.
279.51................................  Acute graft-versus-host disease.
279.52................................  Chronic graft-versus-host
                                         disease.
279.53................................  Acute on chronic graft-versus-
                                         host disease.
346.60................................  Persistent migraine aura with
                                         cerebral infarction, without
                                         mention of intractable migraine
                                         without mention of status
                                         migrainosus.
346.61................................  Persistent migraine aura with
                                         cerebral infarction, with
                                         intractable migraine, so
                                         stated, without mention of
                                         status migrainosus.
346.62................................  Persistent migraine aura with
                                         cerebral infarction, without
                                         mention of intractable migraine
                                         with status migrainosus.
346.63................................  Persistent migraine aura with
                                         cerebral infarction, with
                                         intractable migraine, so
                                         stated, with status
                                         migrainosus.
511.81................................  Malignant pleural effusion.
511.89................................  Other specified forms of
                                         effusion, except tuberculous.
649.70................................  Cervical shortening, unspecified
                                         as to episode of care or not
                                         applicable.
649.71................................  Cervical shortening, delivered,
                                         with or without mention of
                                         antepartum condition.
649.73................................  Cervical shortening, antepartum
                                         condition or complication.
695.12................................  Erythema multiforme major.
695.13................................  Stevens-Johnson syndrome.
695.14................................  Stevens-Johnson syndrome-toxic
                                         epidermal necrolysis overlap
                                         syndrome.
695.15................................  Toxic epidermal necrolysis.
695.53................................  Exfoliation due to erythematous
                                         condition involving 30-39
                                         percent of body surface.
695.54................................  Exfoliation due to erythematous
                                         condition involving 40-49
                                         percent of body surface.
695.55................................  Exfoliation due to erythematous
                                         condition involving 50-59
                                         percent of body surface.
695.56................................  Exfoliation due to erythematous
                                         condition involving 60-69
                                         percent of body surface.
695.57................................  Exfoliation due to erythematous
                                         condition involving 70-79
                                         percent of body surface.
695.58................................  Exfoliation due to erythematous
                                         condition involving 80-89
                                         percent of body surface.
695.59................................  Exfoliation due to erythematous
                                         condition involving 90 percent
                                         or more of body surface.
997.31................................  Ventilator associated pneumonia.
997.39................................  Other respiratory complications.
998.30................................  Disruption of wound,
                                         unspecified.
998.33................................  Disruption of traumatic wound
                                         repair.
999.81................................  Extravasation of vesicant
                                         chemotherapy.
999.82................................  Extravasation of other vesicant
                                         agent.
------------------------------------------------------------------------


         Summary of Deletions to the MS-DRG CC List.--Table 6J.2
------------------------------------------------------------------------
               Code                              Description
------------------------------------------------------------------------
046.1.............................  Jakob-Creutzfeldt disease.
337.0.............................  Idiopathic peripheral autonomic
                                     neuropathy.
695.1.............................  Erythema multiforme.
707.00............................  Pressure ulcer, unspecified site.
707.01............................  Pressure ulcer, elbow.
707.09............................  Pressure ulcer, other site.
997.3.............................  Respiratory complications.
999.8.............................  Other transfusion reaction.
------------------------------------------------------------------------

    Alternatively, the complete documentation of the GROUPER logic, 
including the current CC Exclusions List, is available from 3M/Health 
Information Systems (HIS), which, under contract with CMS, is 
responsible for updating and maintaining the GROUPER program. The 
current DRG Definitions Manual, Version 25.0, is available for $225.00, 
which includes $15.00 for shipping and handling. Version 26.0 of this 
manual, which will include the final FY 2009 DRG changes, will be 
available in hard copy for $250.00. Version 26.0 of the manual is also 
available on a CD for $200.00; a combination hard copy and CD is 
available for $400.00. These manuals may be obtained by writing 3M/HIS 
at the following address: 100 Barnes Road, Wallingford, CT 06492; or by 
calling (203) 949-0303. Please specify the revision or revisions 
requested.
10. Review of Procedure Codes in MS DRGs 981, 982, and 983; 984, 985, 
and 986; and 987, 988, and 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

[[Page 23579]]

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). 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). 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).
    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 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 
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:
    <bullet> 60.0, Incision of prostate.
    <bullet> 60.12, Open biopsy of prostate.
    <bullet> 60.15, Biopsy of periprostatic tissue.
    <bullet> 60.18, Other diagnostic procedures on prostate and 
periprostatic tissue.
    <bullet> 60.21, Transurethral prostatectomy.
    <bullet> 60.29, Other transurethral prostatectomy.
    <bullet> 60.61, Local excision of lesion of prostate.
    <bullet> 60.69, Prostatectomy, not elsewhere classified.
    <bullet> 60.81, Incision of periprostatic tissue.
    <bullet> 60.82, Excision of periprostatic tissue.
    <bullet> 60.93, Repair of prostate.
    <bullet> 60.94, Control of (postoperative) hemorrhage of prostate.
    <bullet> 60.95, Transurethral balloon dilation of the prostatic 
urethra.
    <bullet> 60.96, Transurethral destruction of prostate tissue by 
microwave thermotherapy.
    <bullet> 60.97, Other transurethral destruction of prostate tissue 
by other thermotherapy.
    <bullet> 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 the only procedures performed are nonextensive 
procedures that are unrelated to the principal diagnosis.\13\
---------------------------------------------------------------------------

    \13\ The original list of the ICD-9-CM procedure codes for the 
procedures we consider nonextensive procedures, if performed with an 
unrelated principal diagnosis, was published in Table 6C in section 
IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part 
of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 
FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final 
rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 
1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), 
and the FY 1998 final rule (62 FR 45981), we moved several other 
procedures from DRG 468 to DRG 477, and some procedures from DRG 477 
to DRG 468. No procedures were moved in FY 1999, as noted in the 
final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 
FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule 
(67 FR 49999) we did not move any procedures from DRG 477. However, 
we did move procedure codes from DRG 468 and placed them in more 
clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), 
we moved several procedures from DRG 468 to DRGs 476 and 477 because 
the procedures are nonextensive. In the FY 2005 final rule (69 FR 
48950), we moved one procedure from DRG 468 to 477. In addition, we 
added several existing procedures to DRGs 476 and 477. In the FY 
2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned 
it to DRG 477. In FY 2007, we moved one procedure from DRG 468 and 
assigned it to DRGs 479, 553, and 554. In FY 2008, no procedures 
were moved, as noted in the final rule with comment period (72 FR 
46241).
---------------------------------------------------------------------------

    For FY 2009, we are not proposing to change the procedures assigned 
among these DRGs.
a. Moving Procedure Codes From MS-DRGs 981 Through 983 or MS-DRGs 987 
Through 989 to MDCs
    We annually conduct a review of procedures producing assignment to 
MS-DRGs 981 through 983 (formerly CMS DRG 468) or MS-DRGs 987 through 
989 (formerly CMS DRG 477) on the basis of volume, by procedure, to see 
if it would be appropriate to move procedure codes out of these DRGs 
into one of the surgical DRGs for the MDC into which the principal 
diagnosis falls. The data are arrayed in two ways for comparison 
purposes. We look at a frequency count of each major operative 
procedure code. We also compare procedures across MDCs by volume of 
procedure codes within each MDC.
    We identify those procedures occurring in conjunction with certain 
principal diagnoses with sufficient frequency to justify adding them to 
one of the surgical DRGs for the MDC in which the diagnosis falls. For 
FY 2009, we are not proposing to remove any procedures from MS-DRGs 981 
through 983 or MS-DRGs 987 through 989.
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, and 987 through 
989 (formerly, CMS DRGs 468, 476, and 477, respectively), to ascertain 
whether any of those procedures should be reassigned from one of these 
three DRGs to another of the three DRGs based on average charges and 
the length of stay. We look at the data for trends such as shifts in 
treatment practice or reporting practice that would make the resulting 
DRG assignment illogical. If we find these shifts, we would propose to 
move cases to keep the DRGs clinically similar or to provide payment 
for the cases in a similar manner. Generally, we move only those 
procedures for which we have an adequate number of discharges to 
analyze the data.
    For FY 2009, we are not proposing to move any procedure codes among 
these DRGs.
c. Adding Diagnosis or Procedure Codes to MDCs
    Based on our review this year, we are not proposing to add any 
diagnosis codes to MDCs for FY 2009.
11. Changes to the 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 used for the reporting of 
diagnoses and procedures performed on a patient. In September 1985, the 
ICD-9-CM Coordination and Maintenance Committee was formed. This is a 
Federal interdepartmental committee, co-chaired by the National Center 
for Health Statistics (NCHS), the Centers for Disease Control and 
Prevention, and CMS, charged with maintaining and updating the ICD-9-CM 
system. The Committee is jointly responsible for approving coding 
changes, and developing errata, addenda, and other modifications to the 
ICD-9-CM to reflect newly developed procedures and technologies and 
newly identified diseases. The Committee is also responsible for 
promoting the use of Federal and non-Federal educational programs and 
other communication techniques with a view toward standardizing coding 
applications and upgrading the quality of the classification system.
    The Official Version of the ICD-9-CM contains the list of valid 
diagnosis and procedure codes. (The Official Version of the ICD-9-CM is 
available from the Government Printing Office on CD-ROM for $27.00 by 
calling (202) 512-1800.) Complete information on ordering the CD-ROM is 
also available at: http://www.cdc.gov/nchs/products/prods/subject/icd96ed.htm. The Official

[[Page 23580]]

Version of the ICD-9-CM is no longer available in printed manual form 
from the Federal Government; it is only available on CD-ROM. Users who 
need a paper version are referred to one of the many products available 
from publishing houses.
    The NCHS has lead responsibility for the ICD-9-CM diagnosis codes 
included in the Tabular List and Alphabetic Index for Diseases, while 
CMS has lead responsibility for the ICD-9-CM procedure codes included 
in the Tabular List and Alphabetic Index for Procedures.
    The Committee encourages participation in the above process by 
health-related organizations. In this regard, the Committee holds 
public meetings for discussion of educational issues and proposed 
coding changes. These meetings provide an opportunity for 
representatives of recognized organizations in the coding field, such 
as the American Health Information Management Association (AHIMA), the 
American Hospital Association (AHA), and various physician specialty 
groups, as well as individual physicians, health information management 
professionals, and other members of the public, to contribute ideas on 
coding matters. After considering the opinions expressed at the public 
meetings and in writing, the Committee formulates recommendations, 
which then must be approved by the agencies.
    The Committee presented proposals for coding changes for 
implementation in FY 2009 at a public meeting held on September 27-28, 
2007 and finalized the coding changes after consideration of comments 
received at the meetings and in writing by December 3, 2007. Those 
coding changes are announced in Tables 6A through 6F in the Addendum to 
this proposed rule. The Committee held its 2008 meeting on March 19-20, 
2008. Proposed new codes for which there was a consensus of public 
support and for which complete tabular and indexing changes can be made 
by May 2008 will be included in the October 1, 2008 update to ICD-9-CM. 
Code revisions that were discussed at the March 19-20, 2008 Committee 
meeting but that could not be finalized in time to include them in the 
Addendum to this proposed rule are not included in Tables 6A through 
6F. These additional codes will be included in Tables 6A through 6F of 
the final rule with comment period and are marked with an asterisk (*).
    Copies of the minutes of the procedure codes discussions at the 
Committee's September 27-28, 2007 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 27-28, 2007 meeting are found at: http://www.cdc.gov/nchs/icd9.htm. Paper copies of these minutes are no longer available and the 
mailing list has been discontinued. These Web sites also provide 
detailed information about the Committee, including information on 
requesting a new code, attending a Committee meeting, and timeline 
requirements and meeting dates.
    We encourage commenters to address suggestions on coding issues 
involving diagnosis codes to: Donna Pickett, Co-Chairperson, ICD-9-CM 
Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo 
Road, Hyattsville, MD 20782. Comments may be sent by E-mail to: 
<a href="/cdn-cgi/l/email-protection#b4d0d2c480f4d7d0d79ad3dbc2"><span class="__cf_email__" data-cfemail="e6828096d2a6858285c8818990">[email protected]</span></a>.
    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: <a href="/cdn-cgi/l/email-protection#4030213432292329216e22322f2f2b337200232d336e2828336e272f36"><span class="__cf_email__" data-cfemail="57273623253e343e3679352538383c246517343a24793f3f2479303821">[email protected]</span></a>.
    The ICD-9-CM code changes that have been approved will become 
effective October 1, 2008. The new ICD-9-CM codes are listed, along 
with their DRG classifications, in Tables 6A and 6B (New Diagnosis 
Codes and New Procedure Codes, respectively) in the Addendum to this 
proposed rule. As we stated above, the code numbers and their titles 
were presented for public comment at the ICD-9-CM Coordination and 
Maintenance Committee meetings. Both oral and written comments were 
considered before the codes were approved. In this proposed rule, we 
are only soliciting comments on the proposed classification of these 
new codes.
    For codes that have been replaced by new or expanded codes, and the 
corresponding new or expanded diagnosis codes are included in Table 6A. 
New procedure codes are shown in Table 6B. Diagnosis codes that have 
been replaced by expanded codes or other codes or have been deleted are 
in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes 
will not be recognized by the GROUPER beginning with discharges 
occurring on or after October 1, 2008. Table 6D contains invalid 
procedure codes. These invalid procedure codes will not be recognized 
by the GROUPER beginning with discharges occurring on or after October 
1, 2008. Revisions to diagnosis code titles are in Table 6E (Revised 
Diagnosis Code Titles), which also includes the MS-DRG assignments for 
these revised codes. Table 6F includes revised procedure code titles 
for FY 2009.
    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 19-20, 2008 Committee meeting 
that received consensus and that are finalized by May 2008, will be 
included in Tables 6A through 6F of the Addendum to the final rule.
    Section 503(a) of Pub. L. 108-173 included a requirement for 
updating ICD-9-CM codes twice a year instead of a single update on 
October 1 of each year. This requirement was included as part of the 
amendments to the Act relating to recognition of new technology under 
the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by 
adding a clause (vii) which states that the ``Secretary shall provide 
for the addition of new diagnosis and procedure codes on April 1 of 
each year, but the addition of such codes shall not require the 
Secretary to adjust the payment (or diagnosis-related group 
classification) * * * until the fiscal year that begins after such 
date.'' This requirement improves the recognition of new technologies 
under the IPPS system by providing information on these new 
technologies at an earlier date. Data will be available 6 months 
earlier than would be possible with updates occurring only once a year 
on October 1.
    While section 1886(d)(5)(K)(vii) of the Act states that the 
addition of new diagnosis and procedure codes on April 1 of each year 
shall not require the Secretary to adjust the payment, or DRG 
classification, under section 1886(d) of the Act until the fiscal year 
that begins after such date, we have to update the DRG software and 
other systems in order to recognize and accept the new codes. We also 
publicize the code changes and the need for a mid-year systems update 
by providers to identify the new codes. Hospitals also have to obtain 
the new code books and encoder updates, and make other system changes 
in order to identify and report the new codes.
    The ICD-9-CM Coordination and Maintenance Committee holds its

[[Page 23581]]

meetings in the spring and fall in order to update the codes and the 
applicable payment and reporting systems by October 1 of each year. 
Items are placed on the agenda for the ICD-9-CM Coordination and 
Maintenance Committee meeting if the request is received at least 2 
months prior to the meeting. This requirement allows time for staff to 
review and research the coding issues and prepare material for 
discussion at the meeting. It also allows time for the topic to be 
publicized in meeting announcements in the Federal Register as well as 
on the CMS Web site. The public decides whether or not to attend the 
meeting based on the topics listed on the agenda. Final decisions on 
code title revisions are currently made by March 1 so that these titles 
can be included in the IPPS proposed rule. A complete addendum 
describing details of all changes to ICD-9-CM, both tabular and index, 
is 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 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, 2008 implementation of an ICD-9-CM 
code at the September 27-28, 2007 Committee meeting. Therefore, there 
were no new ICD-9-CM codes implemented on April 1, 2008.
    We believe that this process captures the intent of section 
1886(d)(5)(K)(vii) of the Act. This requirement was included in the 
provision revising the standards and process for recognizing new 
technology under the IPPS. In addition, the need for approval of new 
codes outside the existing cycle (October 1) arises most frequently and 
most acutely where the new codes will identify new technologies that 
are (or will be) under consideration for new technology add-on 
payments. Thus, we believe this provision was intended to expedite data 
collection through the assignment of new ICD-9-CM codes for new 
technologies seeking higher payments.
    Current addendum and code title information is published on the CMS 
Web site at: 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: www.cdc.gov/nchs/icd9.htm. Information on new, revised, and 
deleted ICD-9-CM codes is also provided to the AHA for publication in 
the Coding Clinic for ICD-9-CM. AHA also distributes information to 
publishers and software vendors.
    CMS also sends copies of all ICD-9-CM coding changes to its 
contractors for use in updating their systems and providing education 
to providers.
    These same means of disseminating information on new, revised, and 
deleted ICD-9-CM codes will be used to notify providers, publishers, 
software vendors, contractors, and others of any changes to the ICD-9-
CM codes that are implemented in April. The code titles are adopted as 
part of the ICD-9-CM Coordination and Maintenance Committee process. 
Thus, although we publish the code titles in the IPPS proposed and 
final rules, they are not subject to comment in the proposed or final 
rules. We will continue to publish the October code updates in this 
manner within the IPPS proposed and final rules. For codes that are 
implemented in April, we will assign the new procedure code to the same 
DRG in which its predecessor code was assigned so there will be no DRG 
impact as far as DRG assignment. 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.

H. Recalibration of MS-DRG Weights

    In section II.E. of the preamble of this proposed rule, we state 
that we are proposing to fully implement the cost-based DRG relative 
weights for FY 2009, which is the third year in the 3-year transition 
period to calculate the relative weights at 100 percent based on costs. 
In the FY 2008 IPPS final rule with comment period (72 FR 47267), as 
recommended by RTI, for FY 2008, we added two new CCRs for a total of 
15 CCRs: one for ``Emergency Room'' and one for ``Blood and Blood 
Products,'' both of which can be derived directly from the Medicare 
cost report.
    In developing the FY 2009 proposed system of weights, we used two 
data sources: claims data and cost report data. As in previous years, 
the claims data source is the MedPAR file. This file is based on fully 
coded diagnostic and procedure data for all Medicare inpatient hospital 
bills. The FY 2007 MedPAR data used in this proposed rule include 
discharges occurring on October 1, 2006, through September 30, 2007, 
based on bills received by CMS through December 2007, 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 2007 MedPAR file used in calculating the 
relative weights includes data for approximately 11,433,806 Medicare 
discharges from IPPS providers. Discharges for Medicare beneficiaries 
enrolled in a Medicare Advantage managed care plan are excluded from 
this analysis. The data exclude CAHs, including hospitals that 
subsequently became CAHs after the period from which the data were 
taken. The second data source used in the cost-based relative weighting 
methodology is the FY 2006 Medicare cost report data files from HCRIS 
(that is, cost reports beginning on or after October 1, 2005, and 
before October 1, 2006), which represents the most recent full set of 
cost report data available. We used the

[[Page 23582]]

December 31, 2007 update of the HCRIS cost report files for FY 2006 in 
setting the relative cost-based weights.
    The methodology we used to calculate the DRG cost-based relative 
weights from the FY 2007 MedPAR claims data and FY 2006 Medicare cost 
report data is as follows:
    <bullet> To the extent possible, all the claims were regrouped 
using the proposed FY 2009 MS-DRG classifications discussed in sections 
II.B. and G. of the preamble of this proposed rule.
    <bullet> 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 2007 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.)
    <bullet> Organ acquisition costs for kidney, heart, heart-lung, 
liver, lung, pancreas, and intestinal (or multivisceral organs) 
transplants continue to be paid on a reasonable cost basis. Because 
these acquisition costs are paid separately from the prospective 
payment rate, it is necessary to subtract the acquisition charges from 
the total charges on each transplant bill that showed acquisition 
charges before computing the average cost for each DRG and before 
eliminating statistical outliers.
    <bullet> Claims with total charges or total length of stay less 
than or equal to zero were deleted. Claims that had an amount in the 
total charge field that differed by more than $10.00 from the sum of 
the routine day charges, intensive care charges, pharmacy charges, 
special equipment charges, therapy services charges, operating 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.
    <bullet> 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.
    <bullet> Statistical outliers were eliminated by removing all cases 
that were beyond 3.0 standard deviations from the mean of the log 
distribution of both the total charges per case and the total charges 
per day for each DRG.
    Once the MedPAR data were trimmed and the statistical outliers were 
removed, the charges for each of the 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, DSH payments, and IME adjustments 
under the capital IPPS as well. Charges were then summed by DRG for 
each of the 15 cost groups so that each DRG had 15 standardized charge 
totals. These charges were then adjusted to cost by applying the 
national average CCRs developed from the FY 2006 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.
BILLING CODE 4120-01-P

[[Page 23583]]

[GRAPHIC][TIFF OMITTED]TP30AP08.012


[[Page 23584]]


[GRAPHIC][TIFF OMITTED]TP30AP08.013


[[Page 23585]]


[GRAPHIC][TIFF OMITTED]TP30AP08.014


[[Page 23586]]


[GRAPHIC][TIFF OMITTED]TP30AP08.015


[[Page 23587]]


[GRAPHIC][TIFF OMITTED]TP30AP08.016


[[Page 23588]]


[GRAPHIC][TIFF OMITTED]TP30AP08.017

BILLING CODE 4120-01-C
    We developed the national average CCRs as follows:
    Taking the FY 2006 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

[[Page 23589]]

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.
    After we multiplied the total charges for each DRG in each of the 
15 cost centers by the corresponding national average CCR, we summed 
the 15 ``costs'' across each DRG to produce a total standardized cost 
for the DRG. The average standardized cost for each DRG was then 
computed as the total standardized cost for the DRG divided by the 
transfer-adjusted case count for the DRG. The average cost for each DRG 
was then divided by the national average standardized cost per case to 
determine the relative weight.
    The new cost-based relative weights were then normalized by an 
adjustment factor of 1.50612 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 2009 are as follows:

------------------------------------------------------------------------
                             Group                                 CCR
------------------------------------------------------------------------
Routine Days..................................................     0.527
Intensive Days................................................     0.476
Drugs.........................................................     0.205
Supplies & Equipment..........................................     0.341
Therapy Services..............................................     0.419
Laboratory....................................................     0.166
Operating Room................................................     0.293
Cardiology....................................................     0.186
Radiology.....................................................     0.171
Emergency Room................................................     0.291
Blood and Blood Products......................................     0.449
Other Services................................................     0.419
Labor & Delivery..............................................     0.482
Inhalation Therapy............................................     0.198
Anesthesia....................................................     0.150
------------------------------------------------------------------------

    As we explained in section II.E. of the preamble of this proposed 
rule, we are proposing to complete our 2-year transition to the MS-
DRGs. For FY 2008, the first year of the transition, 50 percent of the 
relative weight for an MS-DRG was based on the two-thirds cost-based 
weight/one-third charge-based weight calculated using FY 2006 MedPAR 
data grouped to the Version 24.0 (FY 2007) DRGs. The remaining 50 
percent of the FY 2008 relative weight for an MS-DRG was based on the 
two-thirds cost-based weight/one-third charge-based weight calculated 
using FY 2006 MedPAR grouped to the Version 25.0 (FY 2008) MS-DRGs. In 
FY 2009, we are proposing that the relative weights will be based on 
100 percent cost weights computed using the Version 26.0 (FY 2009) MS-
DRGs.
    When we recalibrated the DRG weights for previous years, we set a 
threshold of 10 cases as the minimum number of cases required to 
compute a reasonable weight. We are proposing to use that same case 
threshold in recalibrating the MS-DRG weights for FY 2009. Using the FY 
2007 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. All of the low-volume MS-
DRGs listed below are for newborns. Newborns are unique and require 
separate DRGs that are not mirrored in the adult population. Therefore, 
it remains necessary to retain separate DRGs for newborns. In FY 2009, 
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 2008 
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     FY 2008 FR weight
                       O.R. Procedure Except     (adjusted by percent
                       Sterilization and/or      change in average
                       D&C.                      weight of the cases in
                                                 other MS-DRGs).
789.................  Neonates, Died or         FY 2008 FR weight
                       Transferred to Another    (adjusted by percent
                       Acute Care Facility.      change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
790.................  Extreme Immaturity or     FY 2008 FR weight
                       Respiratory Distress      (adjusted by percent
                       Syndrome, Neonate.        change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
791.................  Prematurity with Major    FY 2008 FR weight
                       Problems.                 (adjusted by percent
                                                 change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
792.................  Prematurity without       FY 2008 FR weight
                       Major Problems.           (adjusted by percent
                                                 change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
793.................  Full-Term Neonate with    FY 2008 FR weight
                       Major Problems.           (adjusted by percent
                                                 change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
794.................  Neonate with Other        FY 2008 FR weight
                       Significant Problems.     (adjusted by percent
                                                 change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
795.................  Normal Newborn..........  FY 2008 FR weight
                                                 (adjusted by percent
                                                 change in average
                                                 weight of the cases in
                                                 other MS-DRGs).
------------------------------------------------------------------------


[[Page 23590]]

I. Proposed Medicare Severity Long-Term Care (MS-LTC-DRG) 
Reclassifications and Relative Weights for LTCHs for FY 2009

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 the 
patient classification system as the ``long-term care diagnosis-related 
groups (LTC-DRGs).'' As discussed in greater detail below, 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 
LTC-DRG relative weights 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 Medicare severity long-term 
care diagnosis related groups (MS-LTC-DRGs) were adopted for the IPPS 
and the LTCH PPS, respectively, effective October 1, 2007 (FY 2008). 
For a full description of the development and implementation 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 Sec.  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 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 represent an increase in the number of DRGs by 207 
(that is, from 538 to 745) (72 FR 47171). In addition to improving the 
DRG system's recognition of severity of illness, we believe the MS-DRGs 
are responsive to the public comments that were made on the FY 2007 
IPPS proposed rule with respect to how we should undertake further DRG 
reform. The MS-DRGs use the CMS DRGs as the starting point for revising 
the DRG system to better recognize resource complexity and severity of 
illness. We have generally retained all of the refinements and 
improvements that have been made to the base DRGs over the years that 
recognize the significant advancements in medical technology and 
changes to medical practice.
    Consistent with section 123 of the BBRA as amended by section 
307(b)(1) of the BIPA and Sec.  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.
    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 beneficiary's stay is assigned. Cases are 
classified into MS-LTC-DRGs for payment based on the following six data 
elements:
    <bullet> Principal diagnosis.
    <bullet> Up to eight additional diagnoses.
    <bullet> Up to six procedures performed.
    <bullet> Age.
    <bullet> Sex.
    <bullet> Discharge status of the patient.
    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. 
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 (see 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.
    Medicare contractors (that is, fiscal intermediaries or MACs) enter 
the clinical and demographic information into their claims processing 
systems and subject this information to a series of automated screening 
processes called the Medicare Code Editor (MCE). These screens are 
designed to identify cases that require further review before 
assignment into a MS-LTC-DRG can be made. During this process, the 
following types of cases are selected for further development:
    <bullet> Cases that are improperly coded. (For example, diagnoses 
are shown that are inappropriate, given the sex of the patient. Code 
68.69 (Other and unspecified radical abdominal hysterectomy) would be 
an inappropriate code for a male.)
    <bullet> Cases including surgical procedures not covered under 
Medicare. (For example, organ transplant in a nonapproved transplant 
center.)
    <bullet> Cases requiring more information. (For example, ICD-9-CM 
codes are required to be entered at their highest level of specificity. 
There are valid 3-digit, 4-digit, and 5-digit codes. That is, code 262 
(Other severe protein-calorie malnutrition) contains all appropriate 
digits, but if it is reported with either fewer or more than 3 digits, 
the claim will be rejected by the MCE as invalid.)
    After screening through the MCE, each claim is classified into the 
appropriate MS-LTC-DRG by the Medicare LTCH GROUPER software.

[[Page 23591]]

The Medicare GROUPER software, which is used under the LTCH PPS, is 
specialized computer software, and is the same GROUPER software program 
used under the IPPS. The GROUPER software was developed as a means of 
classifying each case into a MS-LTC-DRG on the basis of diagnosis and 
procedure codes and other demographic information (age, sex, and 
discharge status). 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 the LTCH 
to review the MS-LTC-DRG assignments made by the Medicare contractor 
and to submit additional information within a specified timeframe as 
specified in Sec.  412.513(c).
    The GROUPER software is used both to classify past cases to measure 
relative hospital resource consumption to establish the 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 classification changes and to recalibrate the MS-DRG and MS-LTC-
DRG relative weights during our annual update under both the IPPS 
(Sec.  412.60(e)) and the LTCH PPS (Sec.  412.517), respectively.
    In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed 
the LTCH PPS annual payment rate update cycle to be effective July 1 
through June 30 instead of October 1 through September 30. In addition, 
because the patient classification system utilized under the LTCH PPS 
uses the same DRGs as those used under the IPPS for acute care 
hospitals, in that same final rule, we explained that the annual update 
of the LTC-DRG classifications and relative weights will continue to 
remain linked to the annual reclassification and recalibration of the 
DRGs used under the IPPS. Therefore, we specified that we will continue 
to update the LTC-DRG classifications and relative weights to be 
effective for discharges occurring on or after October 1 through 
September 30 each year. We further stated that we will publish the 
annual proposed and final update of the LTC-DRGs in same notice as the 
proposed and final update for the IPPS (69 FR 34125).
    In the RY 2009 LTCH PPS proposed rule (73 FR 5351-5352), due to 
administrative considerations as well as in response to numerous 
comments urging CMS to establish one rulemaking cycle that would 
encompass the update of the LTCH PPS payment rates (currently updated 
on a rate year basis, effective July 1) as well as the development of 
the LTC-DRG weights (currently updated on a fiscal year basis, 
effective October 1), we proposed to amend the regulations at Sec.  
412.535 in order to consolidate the rate year and fiscal year 
rulemaking cycles. Specifically, we proposed that the annual update of 
the LTCH PPS payment rates (and description of the methodology and data 
used to calculate these payment rates) and the annual update of the MS-
LTC-DRG classifications and associated weighting factors for LTCHs 
would be effective on October 1 each Federal fiscal year. In order to 
revise the payment rate update (currently on a rate year cycle of July 
1 through June 30) to an October 1 through September 30 cycle, we 
proposed to extend the 2009 rate period to September 30, 2009, so that 
RY 2009 would be 15 months. This proposed 15-month rate period would 
extend from July 1, 2008, through September 30, 2009. We believe that 
extending RY 2009 by 3 months (July, August, and September) would 
provide for a smooth transition to a consolidated annual update for 
both the LTCH PPS payment rates and the LTCH PPS MS-LTC-DRG 
classifications and weighting factors. (We believe that proposing to 
shorten the 2009 rate year period to an October 1 through September 30 
period so that RY 2009 would only be 3 months (that is, July 1, 2008 
through September 30, 2008) would exacerbate the current time-
consuming, biannual update process by resulting in two payment rate 
changes within a very short period of time.) Consequently, under the 
proposal to extend RY 2009 to a 15-month rate period, after September 
30, 2009, when the RY 2009 cycle ends, the LTCH PPS payment rates and 
other policy changes would subsequently be updated on an October 1 
through September 30 cycle in conjunction with the annual update to the 
MS-LTC-DRG classifications and relative weights. Accordingly, the next 
update to the LTCH PPS payment rates, after the proposed 15-month RY 
2009, would begin October 1, 2009, coinciding with the 2010 Federal 
fiscal year.
    In the past, the annual update to the DRGs used under the IPPS has 
been based on the annual revisions to the ICD-9-CM codes and was 
effective each October 1. As discussed in the RY 2009 LTCH PPS proposed 
rule (73 FR 5348-5349), with the implementation of section 503(a) of 
Pub. L. 108-173, there is the possibility that one feature of the 
GROUPER software program may be updated twice during a Federal fiscal 
year (October 1 and April 1) as required by the statute for the IPPS. 
Section 503(a) of Pub. L. 108-173 amended section 1886(d)(5)(K) of the 
Act by adding a new clause (vii) which states that ``the Secretary 
shall provide for the addition of new diagnosis and procedure codes in 
[sic] April 1 of each year, but the addition of such codes shall not 
require the Secretary to adjust the payment (or diagnosis-related group 
classification) * * * until the fiscal year that begins after such 
date.'' This requirement improves the recognition of new technologies 
under the IPPS by accounting for those ICD-9-CM codes in the MedPAR 
claims data earlier than the agency had accounted for new technology in 
the past. In implementing the statutory change, the agency has provided 
that ICD-9-CM diagnosis and procedure codes for new medical technology 
may be created and assigned to existing DRGs in the middle of the 
Federal fiscal year, on April 1. However, this policy change will not 
impact the DRG relative weights in effect for that year, which will 
continue to be updated only once a year (October 1). The use of the 
ICD-9-CM code set is also compliant with the current requirements of 
the Transactions and Code Sets Standards regulations at 45 CFR Parts 
160 and 162, promulgated in accordance with HIPAA.
    As noted above, the patient classification system used under the 
LTCH PPS is the same patient classification system that is used under 
the IPPS. Therefore, the ICD-9-CM codes currently used under both the 
IPPS and the LTCH PPS have the potential of being updated twice a year. 
This requirement is included as part of the amendments to the Act 
relating to recognition of new medical technology under the IPPS.
    Because we do not publish a midyear IPPS rule, any April 1 ICD-9-CM 
coding update will not be published in the Federal Register. Rather, we 
will assign any new diagnosis or procedure codes to the same DRG in 
which its predecessor code was assigned, so that there will be no 
impact on the DRG assignments (as also discussed in section II.G.11. of 
the preamble of this proposed rule). Any coding updates will be 
available through the Web sites provided in section II.G.11. of the 
preamble of this proposed rule and through the Coding Clinic for ICD-9-
CM. Publishers and software vendors currently obtain code changes 
through these sources in order to update their code books and software 
system. If new codes are implemented on April 1, revised code books and 
software systems, including the GROUPER

[[Page 23592]]

software program, will be necessary because the most current ICD-9-CM 
codes must be reported. Therefore, for purposes of the LTCH PPS, 
because each ICD-9-CM code must be included in the GROUPER algorithm to 
classify each case under the correct LTCH PPS, the GROUPER software 
program used under the LTCH PPS would need to be revised to accommodate 
any new codes.
    In implementing section 503(a) of Pub. L. 108-173, there will only 
be an April 1 update if new technology diagnosis and procedure code 
revisions are requested and approved. We note that any new codes 
created for April 1 implementation will be limited to those primarily 
needed to describe new technologies and medical services. However, we 
reiterate that the process of discussing updates to the ICD-9-CM is an 
open process through the ICD-9-CM Coordination and Maintenance 
Committee. Requestors will be given the opportunity to present the 
merits for a new code and to make a clear and convincing case for the 
need to update ICD-9-CM codes for purposes of the IPPS new technology 
add-on payment process through an April 1 update (as also discussed in 
section II.G.11. of the preamble of this proposed rule).
    At the September 27, 2007 ICD-9-CM Coordination and Maintenance 
Committee meeting, there were no requests for an April 1, 2008 
implementation of ICD-9-CM codes. Therefore, the next update to the 
ICD-9-CM coding system will occur on October 1, 2008 (FY 2009). Because 
there were no coding changes suggested for an April 1, 2008 update, the 
ICD-9-CM coding set implemented on October 1, 2008, will continue 
through September 30, 2009 (FY 2009). The update to the ICD-9-CM coding 
system for FY 2009 is discussed in section II.G.11. of the preamble of 
this proposed rule. Accordingly, in this proposed rule, as discussed in 
greater detail below, we are proposing to modify and revise the MS-LTC-
DRG classifications and relative weights to be effective October 1, 
2008 through September 30, 2009 (FY 2009). As discussed in greater 
detail below, the MS-LTC-DRGs for FY 2009 in this proposed rule are the 
same as the MS-DRGs proposed for the IPPS for FY 2009 (GROUPER Version 
26.0) discussed in section II.B. of the preamble to this proposed rule.
2. Proposed Changes in the MS-LTC-DRG Classifications
a. Background
    As discussed earlier, section 123 of Pub. L. 106-113 specifically 
requires that the agency implement a PPS for LTCHs that is a per 
discharge system with a DRG-based patient classification system 
reflecting the differences in patient resources and costs in LTCHs. 
Section 307(b)(1) of Pub. L. 106-554 modified the requirements of 
section 123 of Pub. L. 106-113 by specifically requiring that the 
Secretary examine ``the feasibility and the impact of basing payment 
under such a system [the LTCH PPS] on the use of existing (or refined) 
hospital diagnosis-related groups (DRGs) that have been modified to 
account for different resource use of long-term care hospital patients 
as well as the use of the most recently available hospital discharge 
data.''
    Consistent with section 123 of Pub. L. 106-113 as amended by 
section 307(b)(1) of Pub. L. 106-554 and Sec.  412.515 of our existing 
regulations, the LTCH PPS uses information from LTCH patient records to 
classify patient cases into distinct LTC-DRGs based on clinical 
characteristics and expected resource needs. As described in section 
II.D. of the preamble of this proposed rule, for FY 2008, we adopted 
MS-DRGs under the IPPS because we believe that this system results in a 
significant improvement in the DRG system's recognition of severity of 
illness and resource usage. We stated that we believe these 
improvements in the DRG system are equally applicable to the LTCH PPS. 
The changes we are proposing to make for the FY 2009 IPPS are reflected 
in the proposed FY 2009 GROUPER, Version 26.0, that would be effective 
for discharges occurring on or after October 1, 2008 through September 
30, 2009.
    Consistent with our historical practice of having LTC-DRGs 
correspond to the DRGs applicable under the IPPS, under the broad 
authority of section 123(a) of Pub. L. 106-113, as modified by section 
307(b) of Pub. L. 106-554, under the LTCH PPS for FY 2008, we adopted 
the use of MS-LTC-DRGs, which correspond to the MS-DRGs we adopted 
under the IPPS. In addition, as stated above, we are proposing to use 
the FY 2009 GROUPER Version 26.0 to classify cases effective for LTCH 
discharges occurring on or after October 1, 2008, through September 30, 
2009. The changes to the MS-DRG classification system that we are 
proposing to use under the IPPS for FY 2009 (GROUPER Version 26.0) are 
discussed in section II.B. of the preamble to this proposed rule.
    Under the LTCH PPS, as described in greater detail below, we 
determine relative weights for each of the MS-LTC-DRGs to account for 
the difference in resource use by patients exhibiting the case 
complexity and multiple medical problems characteristic of LTCH 
patients. (Unless otherwise noted in this proposed rule, our MS-LTC-DRG 
analysis is based on LTCH data from the December 2007 update of the FY 
2007 MedPAR file, which contains hospital bills received through 
December 31, 2007, for discharges occurring in FY 2007.)
    LTCHs do not typically treat the full range of diagnoses as do 
acute care hospitals. Therefore, as we discussed in the August 30, 2002 
LTCH PPS final rule (67 FR 55985), which implemented the LTCH PPS, and 
the FY 2008 IPPS final rule with comment period (72 FR 47283), we use 
low-volume quintiles in determining the DRG relative weights for DRGs 
with less than 25 LTCH cases (low-volume MS-LTC-DRGs). Specifically, we 
group those low-volume DRGs into 5 quintiles based on average charges 
per discharge. (A listing of the composition of low-volume quintiles 
for the FY 2008 MS-LTC-DRGs (based on FY 2006 MedPAR data) appears in 
section II.I.3. of the FY 2008 IPPS final rule with comment period (72 
FR 47281 through 47288).) We also adjust for cases in which the stay at 
the LTCH is less than or equal to five-sixths of the geometric average 
length of stay; that is, short-stay outlier cases, as discussed below 
in section II.I.4. of the preamble of this proposed rule.
b. Patient Classifications Into MS-LTC-DRGs
    Generally, under the LTCH PPS, Medicare payment is made at a 
predetermined specific rate for each discharge; that is, payment varies 
by the DRG to which a beneficiary's stay is assigned. Just as cases 
have been classified into the MS-DRGs for acute care hospitals under 
the IPPS (section II.B. of the preamble of this proposed rule), cases 
have been classified into MS-LTC-DRGs for payment under the LTCH PPS 
based on the principal diagnosis, up to eight additional diagnoses, and 
up to six procedures performed during the stay, as well as demographic 
information about the patient. The diagnosis and procedure information 
is reported by the hospital using the ICD-9-CM coding system. Under the 
MS-DRGs for the IPPS and the MS-LTC-DRGs for the LTCH PPS, these 
factors will not change.
    Section II.B. of the preamble of this proposed rule discusses the 
organization of the existing MS-DRGs, which we are maintaining under 
the MS-LTC-DRG system. As noted above, the patient classification 
system for the LTCH PPS is derived from the IPPS DRGs and is similarly 
organized into 25 major diagnostic categories (MDCs).

[[Page 23593]]

Most of these MDCs are based on a particular organ system of the body 
and the remainder involves multiple organ systems (such as MDC 22, 
Burns). Accordingly, the principal diagnosis determines MDC assignment. 
Within most MDCs, cases are then divided into surgical DRGs and medical 
DRGs. Under the MS-DRGs, some surgical and medical DRGs are further 
defined for severity purposes based on the presence or absence of MCCs 
or CCs. The existing MS-LTC-DRGs are similarly categorized. (We refer 
readers to section II.B. of the preamble of this proposed rule for 
further discussion of surgical DRGs and medical DRGs.)
    Therefore, consistent with the MS-DRGs, a base MS-LTC-DRG may be 
subdivided according to three alternatives. The first alternative 
includes division of the DRG into one, two, or three severity levels. 
The most severe level has cases with at least one code that is a major 
CC, referred to as ``with MCC''. The next lower severity level contains 
cases with at least one CC, referred to as ``with CC''. Those DRGs 
without an MCC or a CC are referred to as ``without CC/MCC''. When data 
do not support the creation of three severity levels, the base DRG is 
divided into either two levels or the base is not subdivided.
    The two-level subdivisions consist of one of the following 
subdivisions: ``with CC/MCC'' or ``without CC/MCC.'' In this type of 
subdivision, cases with at least one code that is on the CC or MCC list 
are assigned to the `` CC/MCC'' DRG. Cases without a CC or an MCC are 
assigned to the ``without CC/MCC'' DRG.
    The other type of two-level subdivision is as follows: ``with MCC'' 
and ``without MCC.'' In this type of subdivision, cases with at least 
one code that is on the MCC list are assigned to the ``with MCC'' DRG. 
Cases that do not have an MCC are assigned to the ``without MCC'' DRG. 
This type of subdivision could include cases with a CC code, but no 
MCC.
3. Development of the Proposed FY 2009 MS-LTC-DRG Relative Weights
a. General Overview of Development of the MS-LTC-DRG Relative Weights
    As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 
55981), one of the primary goals for the implementation of the LTCH PPS 
is to pay each LTCH an appropriate amount for the efficient delivery of 
medical care to Medicare patients. The system must be able to account 
adequately for each LTCH's case-mix in order to ensure both fair 
distribution of Medicare payments and access to adequate care for those 
Medicare patients whose care is more costly. To accomplish these goals, 
we have annually adjusted the LTCH PPS standard Federal prospective 
payment system rate by the applicable relative weight in determining 
payment to LTCHs for each case. (As we have noted above, in last year's 
final rule, we adopted the MS-LTC-DRGs for the LTCH PPS beginning in FY 
2008. However, this change in the patient classification system does 
not affect the basic principles of the development of relative weights 
under a DRG-based prospective payment system.
    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 
discussed in detail in the following sections, the basic methodology 
for developing the proposed FY 2009 MS-LTC-DRG relative weights in this 
proposed rule continue to be determined in accordance with the general 
methodology established in the August 30, 2002 LTCH PPS final rule (67 
FR 55989 through 55991). Under the LTCH PPS, relative weights for each 
MS-LTC-DRG are a primary element used to account for the variations in 
cost per discharge and resource utilization among the payment groups 
(Sec.  412.515). To ensure that Medicare patients classified to each 
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. Data
    To calculate the proposed MS-LTC-DRG relative weights for FY 2009, 
we obtained total Medicare allowable charges from FY 2007 Medicare LTCH 
bill data from the December 2007 update of the MedPAR file, which are 
the best available data at this time, and we used the proposed Version 
26.0 of the CMS GROUPER that is also proposed for use under the IPPS to 
classify cases for FY 2009. We also are proposing that if more recent 
data are available, we will use those data and the finalized Version 
26.0 of the CMS GROUPER in establishing the FY 2009 MS-LTC-DRG relative 
weights in the final rule.
    Consistent with our historical methodology, we have excluded the 
data from LTCHs that are all-inclusive rate providers and LTCHs that 
are reimbursed in accordance with demonstration projects authorized 
under section 402(a) of Pub. L. 90-248 or section 222(a) of Pub. L. 92-
603 (We refer readers to the FY 2008 IPPS final rule with comment 
period (72 FR 47282)). Therefore, in the development of the proposed FY 
2009 MS-LTC-DRG relative weights in this proposed rule, we have 
excluded the data of the 17 all-inclusive rate providers and the 2 
LTCHs that are paid in accordance with demonstration projects that had 
claims in the FY 2007 MedPAR file.
c. 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 nonarbitrary 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, we are proposing to 
use a hospital-specific relative value (HSRV) methodology to calculate 
the MS-LTC-DRG relative weights instead of the methodology used to 
determine the MS-DRG relative weights under the IPPS described in 
section II.H. of the preamble of this proposed rule. We believe this 
method will remove this hospital-specific source of bias in measuring 
LTCH average charges. Specifically, we are proposing to reduce the 
impact of the variation in charges across providers on any particular 
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 adjusting those values for the LTCH's case-mix. 
The adjustment for case-mix is needed to rescale the hospital-specific 
relative charge values (which, by definition, average 1.0 for each 
LTCH). The average relative weight for a LTCH is its case-mix, so it is 
reasonable to scale each LTCH's average relative charge value by its 
case-mix. In this way, each LTCH's relative charge

[[Page 23594]]

value is adjusted by its case-mix to an average that reflects the 
complexity of the cases it treats relative to the complexity of the 
cases treated by all other LTCHs (the average case-mix of all LTCHs).
    In accordance with the methodology established in the August 30, 
2002 LTCH PPS final rule (67 FR 55989 through 55991), we continue to 
standardize charges for each case by first dividing the adjusted charge 
for the case (adjusted for short-stay outliers under Sec.  412.529 as 
described in section II.I.4. (step 3) of the preamble of this proposed 
rule) by the average adjusted charge for all cases at the LTCH in which 
the case was treated. Short-stay outliers 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 (Sec.  412.529 and Sec.  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.
    Multiplying by the LTCH's case-mix index accounts for the fact that 
the same relative charges are given greater weight at a LTCH with 
higher average costs than they would at a LTCH with low average costs, 
which is needed to adjust each LTCH's relative charge value to reflect 
its case-mix relative to the average case-mix for all LTCHs. Because we 
standardize charges in this manner, we count charges for a Medicare 
patient at a LTCH with high average charges as less resource intensive 
than they would be at a LTCH with low average charges. For example, a 
$10,000 charge for a case at a LTCH with an average adjusted charge of 
$17,500 reflects a higher level of relative resource use than a $10,000 
charge for a case at a LTCH with the same case-mix, but an average 
adjusted charge of $35,000. We believe that the adjusted charge of an 
individual case more accurately reflects actual resource use for an 
individual LTCH because the variation in charges due to systematic 
differences in the markup of charges among LTCHs is taken into account.
d. Treatment of Severity Levels in Developing Proposed Relative Weights
    Under the proposed MS-LTC-DRGs, for purposes of the proposed 
setting of the relative weights, there would be three different 
categories of DRGs based on volume of cases within specific MS-LTC-
DRGs. MS-LTC-DRGs with at least 25 cases are each assigned a unique 
relative weight; low-volume MS-LTC-DRGs (that is, MS-LTC-DRGs that 
contain between one and 24 cases annually) are grouped into quintiles 
(described below) and assigned the weight of the quintile. No-volume 
MS-LTC-DRGs (that is, no cases in the database were assigned to those 
MS-LTC-DRGs) are crosswalked to other MS-LTC-DRGs based on the clinical 
similarities and assigned the relative weight of the crosswalked MS-
LTC-DRG. (We provide in-depth discussions of our proposed policy 
regarding weight setting for low-volume MS-LTC-DRGs in section 
II.I.3.e. of the preamble of this proposed rule and for no-volume MS-
LTC-DRGs, under Step 5 in section II.I.4. of the preamble of this 
proposed rule.)
    As described above, in response to the need to account for severity 
and pay appropriately for cases, we developed a severity-adjusted 
patient classification system which we adopted for both the IPPS and 
the LTCH PPS in FY 2008. As described in greater detail above, the MS-
LTC-DRG system can accommodate three severity levels: ``with MCC'' 
(most severe); ``with CC,'' and ``without CC/MCC'' (the least severe) 
with each level assigned an individual MS-LTC-DRG number. In cases with 
two subdivisions, the levels are either ``with CC/MCC'' and ``without 
CC/MCC'' or ``with MCC'' and ``without MCC''. For example, under the 
MS-LTC-DRG system, multiple sclerosis and cerebellar ataxia with MCC is 
MS-LTC-DRG 58; multiple sclerosis and cerebellar ataxia with CC is MS-
LTC-DRG 59; and multiple sclerosis and cerebellar ataxia without CC/MCC 
is MS-LTC-DRG 60. For purposes of discussion in this section, the term 
``base DRG'' is used to refer to the DRG category that encompasses all 
levels of severity for that DRG. For example, when referring to the 
entire DRG category for multiple sclerosis and cerebellar ataxia, which 
includes the above three severity levels, we would use the term ``base-
DRG.''
    As noted above, while the LTCH PPS and the IPPS use the same 
patient classification system, the methodology that is used to set the 
DRG weights for use in each payment system differs because the overall 
volume of cases in the LTCH PPS is much less than in the IPPS. As a 
general rule, consistent with the methodology we used when we adopted 
the MS-LTC-DRGs in the FY 2008 IPPS final rule with comment period (72 
FR 47278 through 47281), we are proposing to determine the FY 2009 
relative weights for the MS-LTC-DRGs using the following steps: (1) if 
an MS-LTC-DRG has at least 25 cases, it is assigned its own relative 
weight; (2) if an MS-LTC-DRG has between 1 and 24 cases, it is assigned 
to a quintile for which we will compute a relative weight; and (3) if 
an MS-LTC-DRG has no cases, it is crosswalked to another MS-LTC-DRG 
based upon clinical similarities to assign an appropriate relative 
weight (as described below in detail in Step 5 of the Steps for 
Determining the proposed FY 2009 MS-LTC-DRG Relative Weights). 
Furthermore, in determining the proposed FY 2009 MS-LTC-DRG relative 
weights, when necessary, we are proposing to make adjustments to 
account for nonmonotonicity, as explained below.
    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. Therefore, in the three severity 
levels, weights should increase with severity, from lowest to highest. 
If the weights do not increase (that is, if based on the relative 
weight methodology outlined above, the MS-LTC-DRG with MCC would have a 
lower relative weight than one with CC, or the MS-LTC-DRG without CC/
MCC would have a higher relative weight than either of the others), 
there is a problem with monotonicity. Since the start of the LTCH PPS 
for FY 2003 (67 FR 55990), we have adjusted the setting of the LTC-DRG 
relative weights in order to maintain monotonicity by grouping both 
sets of cases together and establishing a new relative weight for both 
LTC-DRGs. We continue to believe that utilizing nonmonotonic relative 
weights to adjust Medicare payments would result in inappropriate 
payments because, in a nonmonotonic system, cases that are more severe 
and require greater expenditure of medical care resources would be paid 
based on a lower relative weight than cases that are less severe and 
require lower resource use. The procedure for dealing with 
nonmonotonicity under the MS-LTC-DRG classification system is discussed 
in greater detail below in section II.I.4. (Step 6) of the preamble of 
this proposed rule.
e. Proposed Low-Volume MS-LTC-DRGs
    In order to account for MS-LTC-DRGs with low volume (that is, with 
fewer than 25 LTCH cases), consistent with the methodology we 
established when we implemented the LTCH PPS (August 30, 2002; 67 FR 
55984 through 55995), we group 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, for the 
purposes of determining relative weights (72 FR 47283 through 47288). 
In determining the proposed FY

[[Page 23595]]

2009 MS-LTC-DRG relative weights in this proposed rule, we are 
proposing to continue to employ this quintile methodology for proposed 
low-volume MS-LTC-DRGs. In addition, in cases where the initial 
assignment of a low-volume 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 MS-LTC-
DRGs to preserve monotonicity, as discussed in detail below in section 
II.I.4 (Step 6 of the methodology for determining the proposed FY 2009 
MS-LTC-DRG relative weights). In this proposed rule, using LTCH cases 
from the December 2007 update of the FY 2007 MedPAR file, we identified 
290 MS-LTC-DRGs that contained between 1 and 24 cases. This list of 
proposed MS-LTC-DRGs was then divided into one of the proposed 5 low-
volume quintiles, each containing 58 MS-LTC-DRGs (290/5 = 58). We are 
proposing to make the assignment of a low-volume MS-LTC-DRG to a 
specific low-volume quintile by sorting the proposed low-volume MS-LTC-
DRGs in ascending order by average charge in accordance with our 
established methodology. Specifically, for this proposed rule, the 290 
proposed low-volume MS-LTC-DRGs are sorted by ascending order by 
average charge and assigned to a specific proposed low-volume quintile 
(as described below). After sorting the 290 proposed low-volume MS-LTC-
DRGs by average charge in ascending order, we are proposing to group 
the first fifth (1st through 58th) of proposed low-volume MS-LTC-DRGs 
(with the lowest average charge) into Quintile 1. This process is 
repeated through the remaining proposed low-volume MS-LTC-DRGs so that 
each of the 5 proposed low-volume quintiles contains 58 proposed MS-
LTC-DRGs. The highest average charge cases would be grouped into 
Quintile 5. (We note that, consistent with our historical methodology, 
if the number of proposed low-volume MS-LTC-DRGs had not been evenly 
divisible by 5, we would have used the average charge of the proposed 
low-volume MS-LTC-DRG to determine which proposed low-volume quintile 
would have received the additional proposed low-volume MS-LTC-DRG.)
    Accordingly, in order to determine the proposed relative weights 
for the proposed MS-LTC-DRGs with low-volume for FY 2009, we are 
proposing to use the five low-volume quintiles described above. The 
composition of each of the proposed five low-volume quintiles shown in 
the chart below was used in determining the proposed MS-LTC-DRG 
relative weights for FY 2009 (Table 11 of the Addendum of this proposed 
rule). We would determine a proposed relative weight and (geometric) 
average length of stay for each of the proposed five low-volume 
quintiles using the methodology that we are proposing to apply to the 
regular MS-LTC-DRGs (25 or more cases), as described in section II.I.4. 
of the preamble of this proposed rule. We are proposing to assign the 
same relative weight and average length of stay to each of the proposed 
low-volume MS-LTC-DRGs that make up an individual low-volume quintile. 
We note that, as this system is dynamic, it is possible that the number 
and specific type of MS-LTC-DRGs with a low volume of LTCH cases will 
vary in the future. We use the best available claims data in the MedPAR 
file to identify low-volume MS-LTC-DRGs and to calculate the relative 
weights based on our methodology.

        Proposed Composition of Low-Volume Quintiles for FY 2009
------------------------------------------------------------------------
 Proposed MS-LTC-DRG (version   Proposed MS-LTC-DRG description (version
            26.0)                                26.0)
------------------------------------------------------------------------
                           PROPOSED QUINTILE 1
------------------------------------------------------------------------
66...........................  Intracranial hemorrhage or cerebral
                                infarction w/o CC/MCC.
67...........................  Nonspecific cva & precerebral occlusion w/
                                o infarct w MCC.
68...........................  Nonspecific cva & precerebral occlusion w/
                                o infarct w/o MCC.
69...........................  Transient ischemia.
72...........................  Nonspecific cerebrovascular disorders w/o
                                CC/MCC.
79...........................  Hypertensive encephalopathy w/o CC/MCC.
87...........................  Traumatic stupor & coma, coma <1 hr w/o
                                CC/MCC.
89...........................  Concussion w CC.
125..........................  Other disorders of the eye w/o MCC.
135..........................  Sinus & mastoid procedures w CC/MCC.
136..........................  Sinus & mastoid procedures w/o CC/MCC.**
148..........................  Ear, nose, mouth & throat malignancy w/o
                                CC/MCC.
149..........................  Dysequilibrium.
159..........................  Dental & Oral Diseases w/o CC/MCC.
183..........................  Major chest trauma w MCC.
184..........................  Major chest trauma w CC.
185..........................  Major chest trauma w/o CC/MCC.
201..........................  Pneumothorax w/o CC/MCC.
257..........................  Upper limb & toe amputation for circ
                                system disorders w/o CC/MCC.
261..........................  Cardiac pacemaker revision except device
                                replacement w CC.***
263..........................  Vein ligation & stripping.
304..........................  Hypertension w MCC.
305..........................  Hypertension w/o MCC.
311..........................  Angina pectoris.
313..........................  Chest pain.
382..........................  Complicated peptic ulcer w/o CC/MCC.
387..........................  Inflammatory bowel disease w/o CC/MCC.
437..........................  Malignancy of hepatobiliary system or
                                pancreas w/o CC/MCC.
443..........................  Disorders of liver except malig, cirr,
                                alc hepa w/o CC/MCC.
468..........................  Revision of hip or knee replacement w/o
                                CC/MCC.
510..........................  Shoulder, elbow or forearm proc, exc
                                major joint proc w MCC.***
537..........................  Sprains, strains, & dislocations of hip,
                                pelvis & thigh w CC/MCC.

[[Page 23596]]

 
544..........................  Pathological fractures & musculoskelet &
                                conn tiss malig w/o CC/MCC.
547..........................  Connective tissue disorders w/o CC/MCC.
556..........................  Signs & symptoms of musculoskeletal
                                system & conn tissue w/o MCC.
563..........................  Fx, sprn, strn & disl except femur, hip,
                                pelvis & thigh w/o MCC.
601..........................  Non-malignant breast disorders w/o CC/
                                MCC.
618..........................  Amputat of lower limb for endocrine,
                                nutrit, & metabol dis w/o CC/MCC.
642..........................  Inborn errors of metabolism
645..........................  Endocrine disorders w/o CC/MCC.
694..........................  Urinary stones w/o esw lithotripsy w/o
                                MCC.
723..........................  Malignancy, male reproductive system w
                                CC.
726..........................  Benign prostatic hypertrophy w/o MCC.
730..........................  Other male reproductive system diagnoses
                                w/o CC/MCC.
756..........................  Malignancy, female reproductive system w/
                                o CC/MCC.
781..........................  Other antepartum diagnoses w medical
                                complications.
810..........................  Major hematol/immun diag exc sickle cell
                                crisis & coagul w/o CC/MCC.
816..........................  Reticuloendothelial & immunity disorders
                                w/o CC/MCC.
864..........................  Fever of unknown origin.
869..........................  Other infectious & parasitic diseases
                                diagnoses w/o CC/MCC.
880..........................  Acute adjustment reaction & psychosocial
                                dysfunction.
882..........................  Neuroses except depressive.
886..........................  Behavioral & developmental disorders.
895..........................  Alcohol/drug abuse or dependence w
                                rehabilitation therapy.
897..........................  Alcohol/drug abuse or dependence w/o
                                rehabilitation therapy w/o MCC.
917..........................  Poisoning & toxic effects of drugs w MCC.
918..........................  Poisoning & toxic effects of drugs w/o
                                MCC.
958..........................  Other O.R. procedures for multiple
                                significant trauma w CC.
965..........................  Other multiple significant trauma w/o CC/
                                MCC.
------------------------------------------------------------------------
                           PROPOSED QUINTILE 2
------------------------------------------------------------------------
59...........................  Multiple sclerosis & cerebellar ataxia w
                                CC.
60...........................  Multiple sclerosis & cerebellar ataxia w/
                                o CC/MCC.
75...........................  Viral meningitis w CC/MCC.
78...........................  Hypertensive encephalopathy w CC.
83...........................  Traumatic stupor & coma, coma >1 hr w CC.
84...........................  Traumatic stupor & coma, coma >1 hr w/o
                                CC/MCC.
99...........................  Non-bacterial infect of nervous sys exc
                                viral meningitis w/o CC/MCC.
102..........................  Headaches w MCC.
103..........................  Headaches w/o MCC.
121..........................  Acute major eye infections w CC/MCC.
122..........................  Acute major eye infections w/o CC/MCC.
124..........................  Other disorders of the eye w MCC.
153..........................  Otitis media & URI w/o MCC.
156..........................  Nasal trauma & deformity w/o CC/MCC.
157..........................  Dental & Oral Diseases w MCC.
158..........................  Dental & Oral Diseases w CC.
182..........................  Respiratory neoplasms w/o CC/MCC.*
188..........................  Pleural effusion w/o CC/MCC.*
203..........................  Bronchitis & asthma w/o CC/MCC.
254..........................  Other vascular procedures w/o CC/MCC.
294..........................  Deep vein thrombophlebitis w 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.
381..........................  Complicated peptic ulcer w CC.
390..........................  G.I. obstruction w/o CC/MCC.
409..........................  Biliary tract proc except only cholecyst
                                w or w/o c.d.e. w CC.
433..........................  Cirrhosis & alcoholic hepatitis w CC.
440..........................  Disorders of pancreas except malignancy w/
                                o CC/MCC.
446..........................  Disorders of the biliary tract w/o CC/
                                MCC.*
489..........................  Knee procedures w/o pdx of infection w/o
                                CC/MCC.
533..........................  Fractures of femur w MCC.
534..........................  Fractures of femur w/o MCC.
553..........................  Bone diseases & arthropathies w MCC.
578..........................  Skin graft &/or debrid exc for skin ulcer
                                or cellulitis w/o CC/MCC.
584..........................  Breast biopsy, local excision & other
                                breast procedures w CC/MCC.
624..........................  Skin grafts & wound debrid for endoc,
                                nutrit & metab dis w/o CC/MCC.
661..........................  Kidney & ureter procedures for non-
                                neoplasm w/o CC/MCC.
663..........................  Minor bladder procedures w CC.
665..........................  Prostatectomy w MCC.***

[[Page 23597]]

 
669..........................  Transurethral procedures w CC.
671..........................  Urethral procedures w CC/MCC.
688..........................  Kidney & urinary tract neoplasms w/o CC/
                                MCC.
696..........................  Kidney & urinary tract signs & symptoms w/
                                o MCC.
722..........................  Malignancy, male reproductive system w
                                MCC.
759..........................  Infections, female reproductive system w/
                                o CC/MCC.*
815..........................  Reticuloendothelial & immunity disorders
                                w CC.
835..........................  Acute leukemia w/o major O.R. procedure w
                                CC.***
842..........................  Lymphoma & non-acute leukemia w/o CC/MCC.
844..........................  Other myeloprolif dis or poorly diff
                                neopl diag w CC.
845..........................  Other myeloprolif dis or poorly diff
                                neopl diag w/o CC/MCC.
866..........................  Viral illness w/o MCC.
876..........................  O.R. procedure w principal diagnoses of
                                mental illness.
881..........................  Depressive neuroses
923..........................  Other injury, poisoning & toxic effect
                                diag w/o MCC.
929..........................  Full thickness burn w skin graft or inhal
                                inj w/o CC/MCC.
964..........................  Other multiple significant trauma w CC.
976..........................  HIV w major related condition w/o CC/MCC.
------------------------------------------------------------------------
                           PROPOSED QUINTILE 3
------------------------------------------------------------------------
23...........................  Craniotomy w major device implant or
                                acute complex CNS PDX w MCC.***
27...........................  Craniotomy & endovascular intracranial
                                procedures w/o CC/MCC.
53...........................  Spinal disorders & injuries w/o CC/MCC.
58...........................  Multiple sclerosis & cerebellar ataxia w
                                MCC.
82...........................  Traumatic stupor & coma, coma >1 hr w
                                MCC.
98...........................  Non-bacterial infect of nervous sys exc
                                viral meningitis w CC.
113..........................  Orbital procedures w CC/MCC.
116..........................  Intraocular procedures w CC/MCC.
136..........................  Sinus & mastoid procedures w/o CC/MCC.***
152..........................  Otitis media & URI w MCC.
165..........................  Major chest procedures w/o CC/MCC.
168..........................  Other resp system O.R. procedures w/o CC/
                                MCC.
238..........................  Major cardiovascular procedures w/o MCC.
241..........................  Amputation for circ sys disorders exc
                                upper limb & toe w/o CC/MCC.
261..........................  Cardiac pacemaker revision except device
                                replacement w CC.**
262..........................  Cardiac pacemaker revision except device
                                replacement w/o CC/MCC.**
284..........................  Circulatory disorders w AMI, expired w
                                CC.*
287..........................  Circulatory disorders except AMI, w card
                                cath w/o MCC.
369..........................  Major esophageal disorders w CC.
370..........................  Major esophageal disorders w/o CC/MCC.
380..........................  Complicated peptic ulcer w MCC.
384..........................  Uncomplicated peptic ulcer w/o MCC.
424..........................  Other hepatobiliary or pancreas O.R.
                                procedures w CC.
471..........................  Cervical spinal fusion w MCC.
472..........................  Cervical spinal fusion w CC.
476..........................  Amputation for musculoskeletal sys & conn
                                tissue dis w/o CC/MCC.
482..........................  Hip & femur procedures except major joint
                                w/o CC/MCC.
494..........................  Lower extrem & humer proc except hip,
                                foot, femur w/o CC/MCC.
497..........................  Local excision & removal int fix devices
                                exc hip & femur w/o CC/MCC.*
502..........................  Soft tissue procedures w/o CC/MCC.
504..........................  Foot procedures w CC.
505..........................  Foot procedures w/o CC/MCC.
510..........................  Shoulder, elbow or forearm proc, exc
                                major joint proc w MCC.**
511..........................  Shoulder, elbow or forearm proc, exc
                                major joint proc w CC.**
535..........................  Fractures of hip & pelvis w MCC.
542..........................  Pathological fractures & musculoskelet &
                                conn tiss malig w MCC.
555..........................  Signs & symptoms of musculoskeletal
                                system & conn tissue w MCC.
562..........................  Fx, sprn, strn & disl except femur, hip,
                                pelvis & thigh w MCC.
598..........................  Malignant breast disorders w CC.
599..........................  Malignant breast disorders w/o CC/MCC.**
600..........................  Non-malignant breast disorders w CC/MCC.
626..........................  Thyroid, parathyroid & thyroglossal
                                procedures w CC.
630..........................  Other endocrine, nutrit & metab O.R. proc
                                w/o CC/MCC.
665..........................  Prostatectomy w MCC.**
666..........................  Prostatectomy w CC.**
668..........................  Transurethral procedures w MCC.
686..........................  Kidney & urinary tract neoplasms w MCC.
687..........................  Kidney & urinary tract neoplasms w CC.
693..........................  Urinary stones w/o esw lithotripsy w MCC.

[[Page 23598]]

 
725..........................  Benign prostatic hypertrophy w MCC.
744..........................  D&C, conization, laparoscopy & tubal
                                interruption w CC/MCC.
755..........................  Malignancy, female reproductive system w
                                CC.
800..........................  Splenectomy w CC.
809..........................  Major hematol/immun diag exc sickle cell
                                crisis & coagul w CC.
814..........................  Reticuloendothelial & immunity disorders
                                w MCC.
824..........................  Lymphoma & non-acute leukemia w other
                                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.**
836..........................  Acute leukemia w/o major O.R. procedure w/
                                o CC/MCC.**
843..........................  Other myeloprolif dis or poorly diff
                                neopl diag w MCC.
883..........................  Disorders of personality & impulse
                                control.
903..........................  Wound debridements for injuries w/o CC/
                                MCC.
905..........................  Skin grafts for injuries w/o CC/MCC.
922..........................  Other injury, poisoning & toxic effect
                                diag w MCC.
941..........................  O.R. proc w diagnoses of other contact w
                                health services w/o CC/MCC.
963..........................  Other multiple significant trauma w MCC.
989..........................  Non-extensive O.R. proc unrelated to
                                principal diagnosis w/o CC/MCC.
------------------------------------------------------------------------
                           PROPOSED QUINTILE 4
------------------------------------------------------------------------
23...........................  Craniotomy w major device implant or
                                acute complex CNS PDX w MCC.**
24...........................  Craniotomy w major device implant or
                                acute complex CNS PDX w/o MCC.**
28...........................  Spinal procedures w MCC.
29...........................  Spinal procedures w CC.
30...........................  Spinal procedures w/o CC/MCC.
37...........................  Extracranial procedures w MCC.
38...........................  Extracranial procedures w CC.**
42...........................  Periph & cranial nerve & other nerv syst
                                proc w/o CC/MCC.*
77...........................  Hypertensive encephalopathy w MCC.
133..........................  Other ear, nose, mouth & throat O.R.
                                procedures w CC/MCC.
164..........................  Major chest procedures w CC.
237..........................  Major cardiovascular procedures w MCC.
242..........................  Permanent cardiac pacemaker implant w
                                MCC.***
246..........................  Percutaneous cardiovascular proc w drug-
                                eluting stent w MCC.
247..........................  Percutaneous cardiovascular proc w drug-
                                eluting stent w/o MCC.
248..........................  Percutaneous cardiovasc proc w non-drug-
                                eluting stent w MCC.
249..........................  Percutaneous cardiovasc proc w non-drug-
                                eluting stent w/o MCC.**
259..........................  Cardiac pacemaker device replacement w/o
                                MCC.
260..........................  Cardiac pacemaker revision except device
                                replacement w MCC.
262..........................  Cardiac pacemaker revision except device
                                replacement w/o CC/MCC.***
286..........................  Circulatory disorders except AMI, w card
                                cath w MCC.
327..........................  Stomach, esophageal & duodenal proc w CC.
328..........................  Stomach, esophageal & duodenal proc w/o
                                CC/MCC.**
348..........................  Anal & stomal procedures w CC.
358..........................  Other digestive system O.R. procedures w/
                                o CC/MCC.*
405..........................  Pancreas, liver & shunt procedures w MCC.
406..........................  Pancreas, liver & shunt procedures w
                                CC.**
417..........................  Laparoscopic cholecystectomy w/o c.d.e. w
                                MCC.***
466..........................  Revision of hip or knee replacement w
                                MCC.
467..........................  Revision of hip or knee replacement w CC.
469..........................  Major joint replacement or reattachment
                                of lower extremity w MCC.***
478..........................  Biopsies of musculoskeletal system &
                                connective tissue w CC.
481..........................  Hip & femur procedures except major joint
                                w CC.
485..........................  Knee procedures w pdx of infection w MCC.
486..........................  Knee procedures w pdx of infection w CC.
487..........................  Knee procedures w pdx of infection w/o CC/
                                MCC.**
490..........................  Back & neck procedures except spinal
                                fusion w CC/MCC or disc devices.
492..........................  Lower extrem & humer proc except hip,
                                foot, femur w MCC.
493..........................  Lower extrem & humer proc except hip,
                                foot, femur w CC.
503..........................  Foot procedures w MCC.
511..........................  Shoulder, elbow or forearm proc, exc
                                major joint proc w CC.***
513..........................  Hand or wrist proc, except major thumb or
                                joint proc w CC/MCC.
514..........................  Hand or wrist proc, except major thumb or
                                joint proc w/o CC/MCC.**
597..........................  Malignant breast disorders w MCC.
599..........................  Malignant breast disorders w/o CC/MCC.***
625..........................  Thyroid, parathyroid & thyroglossal
                                procedures w MCC.
659..........................  Kidney & ureter procedures for non-
                                neoplasm w MCC.
660..........................  Kidney & ureter procedures for non-
                                neoplasm w CC.
666..........................  Prostatectomy w CC.***

[[Page 23599]]

 
695..........................  Kidney & urinary tract signs & symptoms w
                                MCC.
711..........................  Testes procedures w CC/MCC.
717..........................  Other male reproductive system O.R. proc
                                exc malignancy w CC/MCC.
739..........................  Uterine, adnexa proc for non-ovarian/
                                adnexal malig w MCC.
749..........................  Other female reproductive system O.R.
                                procedures w CC/MCC.
754..........................  Malignancy, female reproductive system w
                                MCC.
802..........................  Other O.R. proc of the blood & blood
                                forming organs w MCC.
808..........................  Major hematol/immun diag exc sickle cell
                                crisis & coagul w MCC.
823..........................  Lymphoma & non-acute leukemia w other
                                O.R. proc w MCC.
896..........................  Alcohol/drug abuse or dependence w/o
                                rehabilitation therapy w MCC.
909..........................  Other O.R. procedures for injuries w/o CC/
                                MCC.*
928..........................  Full thickness burn w skin graft or inhal
                                inj w CC/MCC.
933..........................  Extensive burns or full thickness burns w
                                MV 96+ hrs w/o skin graft.
957..........................  Other O.R. procedures for multiple
                                significant trauma w MCC.
969..........................  HIV w extensive O.R. procedure w MCC.
970..........................  HIV w extensive O.R. procedure w/o MCC.**
984..........................  Prostatic O.R. procedure unrelated to
                                principal diagnosis w MCC.
985..........................  Prostatic O.R. procedure unrelated to
                                principal diagnosis w CC.
------------------------------------------------------------------------
                           PROPOSED QUINTILE 5
------------------------------------------------------------------------
11...........................  Tracheostomy for face, mouth & neck
                                diagnoses w MCC.
12...........................  Tracheostomy for face, mouth & neck
                                diagnoses w CC.
24...........................  Craniotomy w major device implant or
                                acute complex CNS PDX w/o MCC.***
25...........................  Craniotomy & endovascular intracranial
                                procedures w MCC.
26...........................  Craniotomy & endovascular intracranial
                                procedures w CC.
31...........................  Ventricular shunt procedures w MCC.
32...........................  Ventricular shunt procedures w CC.
38...........................  Extracranial procedures w CC.***
132..........................  Cranial/facial procedures w/o CC/MCC.
137..........................  Mouth procedures w CC/MCC.
226..........................  Cardiac defibrillator implant w/o cardiac
                                cath w MCC.
227..........................  Cardiac defibrillator implant w/o cardiac
                                cath w/o MCC.
242..........................  Permanent cardiac pacemaker implant w
                                MCC.**
243..........................  Permanent cardiac pacemaker implant w CC.
244..........................  Permanent cardiac pacemaker implant w/o
                                CC/MCC.
249..........................  Percutaneous cardiovasc proc w non-drug-
                                eluting stent w/o MCC.***
250..........................  Perc cardiovasc proc w/o coronary artery
                                stent or AMI w MCC.
326..........................  Stomach, esophageal & duodenal proc w
                                MCC.
328..........................  Stomach, esophageal & duodenal proc w/o
                                CC/MCC.***
330..........................  Major small & large bowel procedures w
                                CC.
331..........................  Major small & large bowel procedures w/o
                                CC/MCC.
335..........................  Peritoneal adhesiolysis w MCC.
344..........................  Minor small & large bowel procedures w
                                MCC.
347..........................  Anal & stomal procedures w MCC.
353..........................  Hernia procedures except inguinal &
                                femoral w MCC.
406..........................  Pancreas, liver & shunt procedures w
                                CC.***
411..........................  Cholecystectomy w c.d.e. w MCC.
414..........................  Cholecystectomy except by laparoscope w/o
                                c.d.e. w MCC.
415..........................  Cholecystectomy except by laparoscope w/o
                                c.d.e. w CC.
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.
456..........................  Spinal fusion exc cerv w spinal curv,
                                malig or 9+ fusions w MCC.
457..........................  Spinal fusion exc cerv w spinal curv,
                                malig or 9+ fusions w CC.
459..........................  Spinal fusion except cervical 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.
477..........................  Biopsies of musculoskeletal system &
                                connective tissue w MCC.
480..........................  Hip & femur procedures except major joint
                                w MCC.
487..........................  Knee procedures w pdx of infection w/o CC/
                                MCC.***
488..........................  Knee procedures w/o pdx of infection w CC/
                                MCC.
496..........................  Local excision & removal int fix devices
                                exc hip & 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.
514..........................  Hand or wrist proc, except major thumb or
                                joint proc w/o CC/MCC.***
582..........................  Mastectomy for malignancy w CC/MCC.
619..........................  O.R. procedures for obesity w MCC.
653..........................  Major bladder procedures w MCC.
656..........................  Kidney & ureter procedures for neoplasm w
                                MCC.

[[Page 23600]]

 
662..........................  Minor bladder procedures w MCC.
709..........................  Penis procedures w CC/MCC.
713..........................  Transurethral prostatectomy w CC/MCC.
746..........................  Vagina, cervix & vulva procedures w CC/
                                MCC.
826..........................  Myeloprolif disord or poorly diff neopl w
                                maj O.R. proc w MCC.
827..........................  Myeloprolif disord or poorly diff neopl w
                                maj O.R. proc w CC.
829..........................  Myeloprolif disord or poorly diff neopl w
                                other O.R. proc w CC/MCC.
836..........................  Acute leukemia w/o major O.R. procedure w/
                                o CC/MCC.***
855..........................  Infectious & parasitic diseases w O.R.
                                procedure w/o CC/MCC.*
906..........................  Hand procedures for injuries.
927..........................  Extensive burns or full thickness burns w
                                MV 96+ hrs w skin graft.
970..........................  HIV w extensive O.R. procedure w/o
                                MCC.***
------------------------------------------------------------------------
*One of the original 290 proposed low-volume MS-LTC-DRGs initially
  assigned to this proposed low-volume quintile; removed from this
  proposed low-volume quintile in addressing nonmonotonicity (refer to
  step 6 in section II.I.4..of the preamble of this proposed rule).
**One of the original 290 proposed low-volume MS-LTC-DRGs initially
  assigned to a different proposed low-volume quintile but moved to this
  proposed low-volume quintile in addressing nonmonotonicity (refer to
  step 6 in section II.I.4. of the preamble of this proposed rule).
***One of the original 290 proposed low-volume MS-LTC-DRGs initially
  assigned to this proposed low-volume quintile but moved to a different
  proposed low-volume quintile in addressing nonmonotonicity (refer to
  step 6 in section II.I.4. of the preamble 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 
proposed quintile assignment results in appropriate payment for such 
cases and does not result in an unintended financial incentive for 
LTCHs to inappropriately admit these types of cases.
4. Steps for Determining the Proposed FY 2009 MS-LTC-DRG Relative 
Weights
    In general, the proposed FY 2009 MS-LTC-DRG relative weights in 
this proposed rule were determined based on the methodology established 
in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). 
In summary, for FY 2009, we are proposing to group LTCH cases to the 
appropriate proposed MS-LTC-DRG, while taking into account the proposed 
low-volume MS-LTC-DRGs (as described above), before the proposed FY 
2009 MS-LTC-DRG relative weights are determined. After grouping the 
cases to the appropriate proposed MS-LTC-DRG (or proposed low-volume 
quintile), we would calculate the proposed relative weights for FY 2009 
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 
would adjust the number of cases in each proposed MS-LTC-DRG (or 
proposed low-volume quintile) for the effect of short-stay outlier 
cases (as also discussed in greater detail below). The short-stay 
adjusted discharges and corresponding charges are used to calculate 
``relative adjusted weights'' in each proposed MS-LTC-DRG (or proposed 
low-volume quintile) using the HSRV method (described above). In 
general, to determine the proposed FY 2009 MS-LTC-DRG relative weights 
in this proposed rule, we are proposing to use the same methodology we 
used in determining the FY 2008 MS-LTC-DRG relative weights in the FY 
2008 IPPS final rule with comment period (72 FR 47281 through 47299). 
However, we are proposing to make a modification to our methodology for 
determining proposed relative weights for MS-LTC-DRGs with no LTCH 
cases (as discussed in greater detail in Step 5 below). Also, we note 
that, although we are generally proposing to use the same methodology 
in this proposed rule (with the exception noted above) as the 
methodology used in the FY 2008 IPPS final rule with comment, the 
discussion presented below of the steps for determining the proposed FY 
2009 MS-LTC-DRG relative weights varies slightly from the discussion of 
the steps for determining the FY 2008 MS-LTC-DRG relative weights 
(presented in the FY 2008 IPPS final rule with comment) because we are 
taking this opportunity to refine our description to more precisely 
explain our methodology for determining the MS-LTC-DRG relative 
weights.
    As discussed in the FY 2008 IPPS final rule with comment when we 
adopted the MS-LTC-DRGs, the adoption of the MS-LTC-DRGs with either 
two or three severity levels resulted in some slight modifications of 
procedures for assigning relative weights in cases of zero volume and/
or nonmonotonicity (described in detail below) from the methodology we 
established when we implemented the LTCH PPS in the August 30, 2002 
LTCH PPS final rule. As also discussed in the FY 2008 IPPS final rule 
with comment when we adopted the MS-LTC-DRGs, we implemented the MS-
LTC-DRGs with a 2-year transition beginning in FY 2008. For FY 2008, 
the first year of the transition, 50 percent of the relative weight for 
a MS-LTC-DRG was based on the average LTC-DRG relative weight under 
Version 24.0 of the LTC-DRG GROUPER. The remaining 50 percent of the 
relative weight was based on the MS-LTC-DRG relative weight under 
Version 25.0 of the MS-LTC-DRG GROUPER. In FY 2009, the MS-LTC-DRG 
relative weights are based on 100 percent of the MS-LTC-DRG relative 
weights. Accordingly, in determining the proposed FY 2009 MS-LTC-DRG 
relative weights in this proposed rule, there is no longer a need to 
include a step to calculate MS-LTC-DRG transition blended relative 
weights (see Step 7 in the FY 2008 IPPS final rule with comment period 
(72 FR 47295)). Therefore, in this proposed rule, we determined the 
proposed FY 2009 MS-LTC-DRG relative weights based solely on the 
proposed MS-LTC-DRG relative weight under proposed Version 26.0 of the 
MS-LTC-DRG GROUPER, which is discussed in section II.B. of the preamble 
of this proposed rule. Furthermore, we are proposing that we would 
determine the final FY 2009 MS-LTC-DRG relative weights in the final 
rule based on the final Version 26.0 of the MS-LTC-DRG GROUPER that 
will be presented in that same final rule.
    Below we discuss in detail the steps for calculating the proposed 
FY 2009 MS-LTC-DRG relative weights. We note that, as we stated above 
in section II.I.3.b. of the preamble of this proposed rule, we have 
excluded the data of all-inclusive rate LTCHs and LTCHs that

[[Page 23601]]

are paid in accordance with demonstration projects that had claims in 
the FY 2007 MedPAR file.
    Step 1--Remove statistical outliers.
    The first step in the calculation of the proposed FY 2009 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 proposed 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 proposed relative weight 
that does not truly reflect relative resource use among the proposed 
MS-LTC-DRGs.
    Step 2--Remove cases with a length of stay of 7 days or less.
    The 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 2009 MS-LTC-DRG 
relative weights, the value of many relative weights would decrease 
and, therefore, payments would decrease to a level that may no longer 
be appropriate. We do not believe that it would be appropriate to 
compromise the integrity of the payment determination for those LTCH 
cases that actually benefit from and receive a full course of treatment 
at a LTCH, by including data from these very short-stays. Therefore, 
consistent with our historical relative weight methodology, in 
determining the proposed FY 2009 MS-LTC-DRG relative weights, we are 
proposing to remove LTCH cases with a length of stay of 7 days or less.
    Step 3--Adjust charges for the effects of short-stay outliers.
    After removing cases with a length of stay of 7 days or less, we 
are left with cases that have a length of stay of greater than or equal 
to 8 days. As the next step in the calculation of the proposed FY 2009 
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 short-stay 
outliers (as defined in Sec.  412.529(a) in conjunction with Sec.  
412.503 for LTCH discharges occurring on or after October 1, 2008). (We 
note that even if a case was removed in Step 2 (that is, cases with a 
length of stay of 7 days or less), it was paid as a short-stay outlier 
if its length of stay was less than or equal to five-sixths of the 
average length of stay of the MS-LTC-DRG.)
    We would make this adjustment by counting a short-stay outlier as a 
fraction of a discharge based on the ratio of the length of stay of the 
case to the average length of stay for the proposed MS-LTC-DRG for 
nonshort-stay outlier cases. This has the effect of proportionately 
reducing the impact of the lower charges for the short-stay outlier 
cases in calculating the average charge for the proposed MS-LTC-DRG. 
This process produces the same result as if the actual charges per 
discharge of a short-stay outlier case were adjusted to what they would 
have been had the patient's length of stay been equal to the average 
length of stay of the proposed MS-LTC-DRG.
    Counting short-stay outlier cases as full discharges with no 
adjustment in determining the proposed FY 2009 MS-LTC-DRG relative 
weights would lower the proposed FY 2009 MS-LTC-DRG relative weight for 
affected proposed MS-LTC-DRGs because the relatively lower charges of 
the short-stay outlier cases would bring down the average charge for 
all cases within a proposed MS-LTC-DRG. This would result in an 
``underpayment'' for nonshort-stay outlier cases and an ``overpayment'' 
for short-stay outlier cases. Therefore, we are proposing to adjust for 
short-stay outlier cases under Sec.  412.529 in this manner because it 
results in more appropriate payments for all LTCH cases.
    Step 4--Calculate the proposed FY 2009 MS-LTC-DRG relative weights 
on an iterative basis.
    Consistent with our historical relative weight methodology, we are 
proposing to calculate the proposed 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 short-stay outlier adjusted charge per discharge (see step 
3) of the LTCH case (after removing the statistical outliers (see step 
1)) and LTCH cases with a length of stay of 7 days or less (see step 2) 
by the average charge per discharge for the LTCH in which the case 
occurred. The resulting ratio is then multiplied by the LTCH's case-mix 
index to produce an adjusted hospital-specific relative charge value 
for the case. An initial case-mix index value of 1.0 is used for each 
LTCH.
    For each proposed MS-LTC-DRG, the proposed FY 2009 relative weight 
is calculated by dividing the average of the adjusted hospital-specific 
relative charge values (from above) for the MS-LTC-DRG by the overall 
average hospital-specific relative charge value across all cases for 
all LTCHs. Using these recalculated 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 MS-LTC-DRG 
relative weights by its total number of cases. The LTCH's hospital-
specific relative charge values above are multiplied by these hospital-
specific case-mix indexes. These hospital-specific case-mix adjusted 
relative charge values are then used to calculate a new set of MS-LTC-
DRG relative weights across all LTCHs. This iterative process is 
continued until there is convergence between the weights produced at 
adjacent steps, for example, when the maximum difference is less than 
0.0001.
    Step 5--Determine a proposed FY 2009 relative weight for proposed 
MS-LTC-DRGs with no LTCH cases.
    As we stated above, we determine the proposed FY 2009 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 2007 update of the FY 2007 MedPAR file for this proposed 
rule). Of the proposed FY 2009 MS-LTC-DRGs, we identified a number of 
proposed MS-LTC-DRGs for which there were no LTCH cases in the 
database. That is, based on data from the FY 2007 MedPAR file used for 
this proposed rule, no patients who would have been classified to those 
proposed MS-LTC-DRGs were treated in LTCHs during FY 2007 and, 
therefore, no charge data are available for those proposed MS-LTC-DRGs. 
Thus, in the process of determining the proposed MS-LTC-DRG relative 
weights, we are unable to calculate proposed relative weights for these 
proposed MS-LTC-DRGs with no LTCH cases using the methodology described 
in Steps 1 through 4 above. However, because patients with a number of 
the diagnoses under these proposed MS-LTC-DRGs may be treated at LTCHs, 
consistent with our historical methodology, we are proposing to assign 
relative weights to each of the proposed no-volume MS-LTC-DRGs based on 
clinical similarity and relative costliness (with the

[[Page 23602]]

exception of proposed ``transplant'' MS-LTC-DRGs and proposed ``error'' 
MS-LTC-DRGs as discussed below). In general, we are proposing to 
determine proposed FY 2009 relative weights for the proposed MS-LTC-
DRGs with no LTCH cases in the FY 2007 MedPAR file used in this 
proposed rule (that is, proposed ``no-volume MS-LTC-DRGs) by cross-
walking each proposed no-volume MS-LTC-DRG to another proposed MS-LTC-
DRG with a proposed relative weight (determined in accordance with the 
proposed methodology described above). Then, under our proposed 
methodology presented in this proposed rule, the proposed ``no-volume'' 
MS-LTC-DRG would be assigned the same proposed relative weight of the 
proposed MS-LTC-DRG to which it would be cross-walked (as described in 
greater detail below). As noted above, we are proposing to make a 
modification to our methodology for determining proposed relative 
weights for MS-LTC-DRGs with no LTCH cases in this proposed rule, which 
is discussed in greater detail below. As also noted above, even where 
we are not proposing changes to our existing methodology, we are taking 
this opportunity to refine our description to more precisely explain 
our proposed methodology for determining the MS-LTC-DRG relative 
weights in this proposed rule.
    Specifically, in this proposed rule, we are proposing to determine 
the relative weight for each proposed MS-LTC-DRG using total Medicare 
allowable charges reported in the December 2007 update of the FY 2007 
MedPAR file. Of the 746 proposed MS-LTC-DRGs for FY 2009, we identified 
203 proposed MS-LTC-DRGs for which there were no LTCH cases in the 
database (including the 8 proposed ``transplant'' MS-LTC-DRGs and 2 
proposed ``error'' MS-LTC-DRGs). For this proposed rule, as noted 
above, we are proposing to assign proposed relative weights for each of 
the 203 proposed no-volume MS-LTC-DRGs (with the exception of the 8 
proposed ``transplant'' proposed MS-LTC-DRGs and the 2 proposed 
``error'' MS-LTC-DRGs, which are discussed below) based on clinical 
similarity and relative costliness to one of the remaining 543 (746 - 
203 = 543) proposed MS-LTC-DRGs for which we are able to determine 
relative weights, based on FY 2007 LTCH claims data. (For the remainder 
of this discussion, we refer to one of the 543 proposed MS-LTC-DRGs for 
which we are able to determine relative weight as the proposed ``cross-
walked'' MS-LTC-DRG.) Then we are proposing to assign the proposed no-
volume MS-LTC-DRG the proposed relative weight of the proposed cross-
walked MS-LTC-DRG. This proposed approach differs from the one we used 
to determine the FY 2008 MS-LTC-DRG relative weights when there were no 
LTCH cases (see 72 FR 47290). Specifically, in determining the FY 2008 
MS-LTC-DRG relative weights in the FY 2008 IPPS final rule with comment 
period, if the no volume MS-LTC-DRG was cross-walked to a MS-LTC-DRG 
that had 25 or more cases and, therefore, was not in a low-volume 
quintile, we assigned the relative weight of a quintile to a no-volume 
MS-LTC-DRG (rather than assigning the relative weight of the cross-
walked MS-LTC-DRG). While we believe this approach would result in 
appropriate LTCH PPS payments (because it is consistent with our 
methodology for determining relative weights for MS-LTC-DRGs that have 
a low volume of LTCH cases (which is discussed above in section 
II.I.3.e. of this preamble)), upon further review during the 
development of the proposed FY 2009 MS-LTC-DRG relative weights in this 
proposed rule, we now believe that proposing to assign the proposed 
relative weight of the proposed cross-walked MS-LTC-DRG to the proposed 
no-volume MS-LTC-DRG would result in more appropriate LTCH PPS payments 
because those cases generally require equivalent relative resource (and 
therefore should generally have the same LTCH PPS payment). The 
relative weight of each MS-LTC-DRG should reflect relative resource of 
the LTCH cases grouped to that MS-LTC-DRG. Because the proposed no-
volume MS-LTC-DRGs would be cross-walked to other proposed MS-LTC-DRGs 
based on clinical similarity and relative costliness, which usually 
require equivalent relative resource use, we believe that assigning the 
proposed no-volume MS-LTC-DRG the proposed relative weight of the 
proposed cross-walked MS-LTC-DRG would result in appropriate LTCH PPS 
payments. (As explained below in Step 6, when necessary, we are 
proposing to make adjustments to account for nonmonotonicity.)
    Our proposed methodology for determining the proposed relative 
weights for the proposed no-volume MS-LTC-DRGs is as follows: We cross-
walk the proposed no-volume MS-LTC-DRG to a proposed MS-LTC-DRG for 
which there are LTCH cases in the FY 2007 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 then assign the proposed relative weight of the proposed 
cross-walked MS-LTC-DRG as the proposed relative weight for the 
proposed no-volume MS-LTC-DRG such that both of these proposed MS-LTC-
DRGs (that is, the proposed no-volume MS-LTC-DRG and the proposed 
cross-walked MS-LTC-DRG) would have the same proposed relative weight. 
We note that if the proposed cross-walked MS-LTC-DRG had 25 cases or 
more, its proposed relative weight, which was calculated using the 
proposed methodology described in steps 1 through 4 above, would be 
assigned to the proposed no-volume MS-LTC-DRG as well. Similarly, if 
the proposed MS-LTC-DRG to which the proposed no-volume MS-LTC-DRG is 
cross-walked has 24 or less cases, and therefore was designated to one 
of the proposed low-volume quintiles for purposes of determining the 
proposed relative weights, we would assign the proposed relative weight 
of the applicable proposed low-volume quintile to the proposed no-
volume MS-LTC-DRG such that both of these proposed MS-LTC-DRGs (that 
is, the proposed no-volume MS-LTC-DRG and the proposed cross-walked MS-
LTC-DRG) would have the same proposed relative weight. (As we noted 
above, in the infrequent case where nonmonotonicity involving a 
proposed no-volume MS-LTC-DRG results, additional measures as described 
in Step 6 would be required in order to maintain monotonically 
increasing relative weights.)
    For this proposed rule, a list of the proposed no-volume FY 2009 
MS-LTC-DRGs and the proposed FY 2009 MS-LTC-DRG to which it is cross-
walked (that is, the proposed cross-walked MS-LTC-DRG) is shown in the 
chart below.

[[Page 23603]]



                               Proposed No-Volume MS-LTC-DRG Crosswalk for FY 2009
----------------------------------------------------------------------------------------------------------------
                                                                                                 Proposed  cross-
   Proposed  MS-LTC-DRG  (Version 26.0)       Proposed MS-LTC-DRG description (version 26.0)     walked  MS-LTC-
                                                                                                       DRG
----------------------------------------------------------------------------------------------------------------
9........................................  Bone marrow transplant..............................              823
13.......................................  Tracheostomy for face, mouth & neck diagnoses w/o CC/              12
                                            MCC.
20.......................................  Intracranial vascular procedures w PDX hemorrhage w                31
                                            MCC.
21.......................................  Intracranial vascular procedures w PDX hemorrhage w                32
                                            CC.
22.......................................  Intracranial vascular procedures w PDX hemorrhage w/               32
                                            o CC/MCC.
33.......................................  Ventricular shunt procedures w/o CC/MCC.............               32
34.......................................  Carotid artery stent procedure w MCC................               37
35.......................................  Carotid artery stent procedure w 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                70
                                            MCC.
62.......................................  Acute ischemic stroke w use of thrombolytic agent w                71
                                            CC.
63.......................................  Acute ischemic stroke w use of thrombolytic agent w/               72
                                            o CC/MCC.
76.......................................  Viral meningitis w/o CC/MCC.........................               75
88.......................................  Concussion w MCC....................................               89
90.......................................  Concussion w/o CC/MCC...............................               89
114......................................  Orbital procedures w/o CC/MCC.......................              113
115......................................  Extraocular procedures except orbit.................              125
117......................................  Intraocular procedures w/o CC/MCC...................              125
123......................................  Neurological eye disorders..........................              125
129......................................  Major head & neck procedures w CC/MCC or major                    146
                                            device.
130......................................  Major head & neck procedures w/o CC/MCC.............              148
131......................................  Cranial/facial procedures w CC/MCC..................              132
134......................................  Other ear, nose, mouth & throat O.R. procedures w/o               133
                                            CC/MCC.
138......................................  Mouth procedures w/o CC/MCC.........................              137
139......................................  Salivary gland procedures...........................              137
150......................................  Epistaxis w MCC.....................................              152
151......................................  Epistaxis w/o MCC...................................              153
215......................................  Other heart assist system implant...................              238
216......................................  Cardiac valve & oth maj cardiothoracic proc w card                237
                                            cath w MCC.
217......................................  Cardiac valve & oth maj cardiothoracic proc w card                238
                                            cath w CC.
218......................................  Cardiac valve & oth maj cardiothoracic proc w card                238
                                            cath w/o CC/MCC.
219......................................  Cardiac valve & oth maj cardiothoracic proc w/o card              237
                                            cath w MCC.
220......................................  Cardiac valve & oth maj cardiothoracic proc w/o card              238
                                            cath w CC.
221......................................  Cardiac valve & oth maj cardiothoracic proc w/o card              238
                                            cath w/o CC/MCC.
222......................................  Cardiac defib implant w cardiac cath w AMI/HF/shock               242
                                            w MCC.
223......................................  Cardiac defib implant w cardiac cath w AMI/HF/shock               243
                                            w/o MCC.
224......................................  Cardiac defib implant w cardiac cath w/o AMI/HF/                  242
                                            shock w MCC.
225......................................  Cardiac defib implant w cardiac cath w/o AMI/HF/                  243
                                            shock w/o MCC.
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......................              238
233......................................  Coronary bypass w cardiac cath w MCC................              237
234......................................  Coronary bypass w cardiac cath w/o MCC..............              238
235......................................  Coronary bypass w/o cardiac cath w MCC..............              237
236......................................  Coronary bypass w/o cardiac cath w/o MCC............              238
245......................................  AICD generator procedures...........................              244
251......................................  Perc cardiovasc proc w/o coronary artery stent or                 250
                                            AMI w/o MCC.
258......................................  Cardiac pacemaker device replacement w MCC..........              259
265......................................  AICD lead procedures................................              259
285......................................  Circulatory disorders w AMI, expired w/o CC/MCC.....              284
295......................................  Deep vein thrombophlebitis w/o CC/MCC...............              294
296......................................  Cardiac arrest, unexplained w MCC...................              283
297......................................  Cardiac arrest, unexplained w CC....................              284
298......................................  Cardiac arrest, unexplained w/o CC/MCC..............              284
332......................................  Rectal resection w MCC..............................              356
333......................................  Rectal resection w CC...............................              357
334......................................  Rectal resection w/o CC/MCC.........................              358
336......................................  Peritoneal adhesiolysis w CC........................              335
337......................................  Peritoneal adhesiolysis w/o CC/MCC..................              335
338......................................  Appendectomy w complicated principal diag w MCC.....              371
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/               373
                                            MCC.
345......................................  Minor small & large bowel procedures w CC...........              344
346......................................  Minor small & large bowel procedures w/o CC/MCC.....              344

[[Page 23604]]

 
349......................................  Anal & stomal procedures w/o CC/MCC.................              348
350......................................  Inguinal & femoral hernia procedures w MCC..........              348
351......................................  Inguinal & femoral hernia procedures w CC...........              348
352......................................  Inguinal & femoral hernia procedures w/o CC/MCC.....              348
355......................................  Hernia procedures except inguinal & femoral w/o CC/               354
                                            MCC.
383......................................  Uncomplicated peptic ulcer w MCC....................              384
407......................................  Pancreas, liver & shunt procedures w/o CC/MCC.......              406
408......................................  Biliary tract proc except only cholecyst w or w/o                 409
                                            c.d.e. w MCC.
410......................................  Biliary tract proc except only cholecyst w or w/o                 409
                                            c.d.e. w/o CC/MCC.
412......................................  Cholecystectomy w c.d.e. w CC.......................              411
413......................................  Cholecystectomy w c.d.e. w/o CC/MCC.................              411
416......................................  Cholecystectomy except by laparoscope w/o c.d.e. w/o              415
                                            CC/MCC.
419......................................  Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC..              418
420......................................  Hepatobiliary diagnostic procedures w MCC...........              424
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               424
                                            CC/MCC.
434......................................  Cirrhosis & alcoholic hepatitis w/o CC/MCC..........              433
453......................................  Combined anterior/posterior spinal fusion w MCC.....              457
454......................................  Combined anterior/posterior spinal fusion w CC......              457
455......................................  Combined anterior/posterior spinal fusion w/o CC/MCC              457
458......................................  Spinal fusion exc cerv w spinal curv, malig or 9+                 457
                                            fusions w/o CC/MCC.
460......................................  Spinal fusion except cervical w/o MCC...............              459
461......................................  Bilateral or multiple major joint procs of lower                  480
                                            extremity w MCC.
462......................................  Bilateral or multiple major joint procs of lower                  482
                                            extremity w/o MCC.
473......................................  Cervical spinal fusion w/o CC/MCC...................              472
479......................................  Biopsies of musculoskeletal system & connective                   478
                                            tissue w/o CC/MCC.
483......................................  Major joint & limb reattachment proc of upper                     480
                                            extremity w CC/MCC.
484......................................  Major joint & limb reattachment proc of upper                     482
                                            extremity w/o CC/MCC.
491......................................  Back & neck procedures except spinal fusion w/o CC/               490
                                            MCC.
499......................................  Local excision & removal int fix devices of hip &                 498
                                            femur w/o CC/MCC.
506......................................  Major thumb or joint procedures.....................              514
508......................................  Major shoulder or elbow joint procedures w/o CC/MCC.              507
509......................................  Arthroscopy.........................................              505
512......................................  Shoulder, elbow or forearm proc, exc major joint                  511
                                            proc w/o CC/MCC.
517......................................  Other musculoskelet sys & conn tiss O.R. proc w/o CC/             516
                                            MCC.
538......................................  Sprains, strains, & dislocations of hip, pelvis &                 537
                                            thigh w/o CC/MCC.
583......................................  Mastectomy for malignancy w/o CC/MCC................              582
585......................................  Breast biopsy, local excision & other breast                      584
                                            procedures w/o CC/MCC.
614......................................  Adrenal & pituitary procedures w CC/MCC.............              629
615......................................  Adrenal & pituitary procedures w/o CC/MCC...........              630
620......................................  O.R. procedures for obesity w CC....................              619
621......................................  O.R. procedures for obesity w/o CC/MCC..............              619
627......................................  Thyroid, parathyroid & thyroglossal procedures w/o                626
                                            CC/MCC.
654......................................  Major bladder procedures w CC.......................              653
655......................................  Major bladder procedures w/o CC/MCC.................              653
657......................................  Kidney & ureter procedures forneoplasm w CC.........              656
658......................................  Kidney & ureter procedures for neoplasm w/o CC/MCC..              656
664......................................  Minor bladder procedures w/o CC/MCC.................              663
667......................................  Prostatectomy w/o CC/MCC............................              666
670......................................  Transurethral procedures w/o CC/MCC.................              669
672......................................  Urethral procedures w/o CC/MCC......................              671
675......................................  Other kidney & urinary tract procedures w/o CC/MCC..              674
691......................................  Urinary stones w esw lithotripsy w CC/MCC...........              694
692......................................  Urinary stones w esw lithotripsy w/o CC/MCC.........              694
697......................................  Urethral stricture..................................              688
707......................................  Major male pelvic procedures w CC/MCC...............              660
708......................................  Major male pelvic procedures w/o CC/MCC.............              661
710......................................  Penis procedures w/o CC/MCC.........................              709
712......................................  Testes procedures w/o CC/MCC........................              711
714......................................  Transurethral prostatectomy w/o CC/MCC..............              713
715......................................  Other male reproductive system O.R. proc for                      717
                                            malignancy w CC/MCC.
716......................................  Other male reproductive system O.R. proc for                      717
                                            malignancy w/o CC/MCC.
718......................................  Other male reproductive system O.R. proc exc                      717
                                            malignancy w/o CC/MCC.
724......................................  Malignancy, male reproductive system w/o CC/MCC.....              723
734......................................  Pelvic evisceration, rad hysterectomy & rad                       717
                                            vulvectomy w CC/MCC.
735......................................  Pelvic evisceration, rad hysterectomy & rad                       717
                                            vulvectomy w/o CC/MCC.
736......................................  Uterine & adnexa proc for ovarian or adnexal                      754
                                            malignancy w MCC.
737......................................  Uterine & adnexa proc for ovarian or adnexal                      755
                                            malignancy w CC.
738......................................  Uterine & adnexa proc for ovarian or adnexal                      756
                                            malignancy w/o CC/MCC.

[[Page 23605]]

 
740......................................  Uterine, adnexa proc for non-ovarian/adnexal malig w              739
                                            CC.
741......................................  Uterine, adnexa proc for non-ovarian/adnexal malig w/             739
                                            o CC/MCC.
742......................................  Uterine & adnexa proc for non-malignancy w CC/MCC...              755
743......................................  Uterine & adnexa proc for non-malignancy w/o CC/MCC.              756
745......................................  D&C, conization, laparascopy & tubal interruption w/              744
                                            o CC/MCC.
747......................................  Vagina, cervix & vulva procedures w/o CC/MCC........              746
748......................................  Female reproductive system reconstructive procedures              749
750......................................  Other female reproductive system O.R. procedures w/o              749
                                            CC/MCC.
760......................................  Menstrual & other female reproductive system                      744
                                            disorders w CC/MCC.
761......................................  Menstrual & other female reproductive system                      744
                                            disorders w/o CC/MCC.
765......................................  Cesarean section w CC/MCC...........................              744
766......................................  Cesarean section w/o CC/MCC.........................              744
767......................................  Vaginal delivery w sterilization &/or D&C...........              744
768......................................  Vaginal delivery w O.R. proc except steril &/or D&C.              744
769......................................  Postpartum & post abortion diagnoses w O.R.                       744
                                            procedure.
770......................................  Abortion w D&C, aspiration curettage or hysterotomy.              744
774......................................  Vaginal delivery w complicating diagnoses...........              744
775......................................  Vaginal delivery w/o complicating diagnoses.........              744
776......................................  Postpartum & post abortion diagnoses w/o O.R.                     744
                                            procedure.
777......................................  Ectopic pregnancy...................................              744
778......................................  Threatened abortion.................................              759
779......................................  Abortion w/o D&C....................................              759
780......................................  False labor.........................................              759
782......................................  Other antepartum diagnoses w/o medical complications              781
789......................................  Neonates, died or transferred to another acute care               781
                                            facility.
790......................................  Extreme immaturity or respiratory distress syndrome,              781
                                            neonate.
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...................................              800
801......................................  Splenectomy w/o CC/MCC..............................              800
803......................................  Other O.R. proc of the blood & blood forming organs               802
                                            w CC.
804......................................  Other O.R. proc of the blood & blood forming organs               802
                                            w/o CC/MCC.
820......................................  Lymphoma & leukemia w major O.R. procedure w MCC....              823
821......................................  Lymphoma & leukemia w major O.R. procedure w CC.....              824
822......................................  Lymphoma & leukemia w major O.R. procedure w/o CC/                824
                                            MCC.
825......................................  Lymphoma & non-acute leukemia w other O.R. proc w/o               824
                                            CC/MCC.
828......................................  Myeloprolif disord or poorly diff neopl w maj O.R.                827
                                            proc w/o CC/MCC.
830......................................  Myeloprolif disord or poorly diff neopl w other O.R.              829
                                            proc w/o CC/MCC.
837......................................  Chemo w acute leukemia as sdx or w high dose chemo                829
                                            agent w MCC.
838......................................  Chemo w acute leukemia as sdx or w high dose chemo                829
                                            agent w CC.
839......................................  Chemo w acute leukemia as sdx or w high dose chemo                829
                                            agent w/o CC/MCC.
848......................................  Chemotherapy w/o acute leukemia as secondary                      847
                                            diagnosis w/o CC/MCC.
887......................................  Other mental disorder diagnoses.....................              881
894......................................  Alcohol/drug abuse or dependence, left ama..........              881
915......................................  Allergic reactions w MCC............................              918
916......................................  Allergic reactions w/o MCC..........................              918
955......................................  Craniotomy for multiple significant trauma..........               26
956......................................  Limb reattachment, hip & femur proc for multiple                  482
                                            significant trauma.
959......................................  Other O.R. procedures for multiple significant                    958
                                            trauma w/o CC/MCC.
986......................................  Prostatic O.R. procedure unrelated to principal                   985
                                            diagnosis w/o CC/MCC.
----------------------------------------------------------------------------------------------------------------

    To illustrate this methodology for determining the proposed 
relative weights for the proposed MS-LTC-DRGs with no LTCH cases, we 
are providing the following example, which refers to the proposed no-
volume MS-LTC-DRGs crosswalk information for FY 2009 provided in the 
chart above.
    Example: There were no cases in the FY 2007 MedPAR file used for 
this proposed rule for proposed MS-LTC-DRG 61 (Acute ischemic stroke w 
use of thrombolytic agent w MCC). We determined that MS-LTC-DRG 70 
(Nonspecific cebrovascular disorders w MCC) is similar clinically and 
based on resource use to proposed MS-LTC-DRG 61. Therefore, we are 
proposing to assign the same proposed relative weight of proposed MS-
LTC-DRG 70 of 0.8718 for FY 2009 to proposed MS-LTC-DRG 61 (Table 11 of 
the Addendum of this proposed rule).
    Furthermore, for FY 2009, consistent with our historical relative 
weight methodology, we are proposing to establish MS-LTC-DRG relative 
weights of 0.0000 for the following proposed transplant MS-LTC-DRGs: 
Heart Transplant or Implant of Heart Assist System with MCC (MS-LTC-DRG 
1); Heart Transplant or Implant of Heart Assist System without MCC (MS-
LTC-DRG 2); Liver Transplant with MCC or Intestinal Transplant (MS-LTC-
DRG 5);

[[Page 23606]]

Liver Transplant without MCC (MS-LTC-DRG 6); Lung Transplant (MS-LTC-
DRG 7); Simultaneous Pancreas/Kidney Transplant (MS-LTC-DRG 8); 
Pancreas Transplant (MS-LTC-DRG 10); and Kidney Transplant (MS-LTC-DRG 
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. 
Based on our research, we found that most LTCHs only perform minor 
surgeries, such as minor small and large bowel procedures, to the 
extent any surgeries are performed at all. Given the extensive criteria 
that must be met to become certified as a transplant center for 
Medicare, we believe it is unlikely that any LTCHs will become 
certified as a transplant center. In fact, in the more than 20 years 
since the implementation of the IPPS, there has never been a LTCH that 
even expressed an interest in becoming a transplant center.
    If in the future a LTCH applies for certification as a Medicare-
approved transplant center, we believe that the application and 
approval procedure would allow sufficient time for us to determine 
appropriate weights for the MS-LTC-DRGs affected. At the present time, 
we would only include these eight proposed transplant MS-LTC-DRGs in 
the GROUPER program for administrative purposes only. Because we use 
the same GROUPER program for LTCHs as is used under the IPPS, removing 
these proposed MS-LTC-DRGs would be administratively burdensome.
    Again, we note that, as this system is dynamic, it is entirely 
possible that the number of proposed MS-LTC-DRGs with no volume of LTCH 
cases based on the system will vary in the future. We used the most 
recent available claims data in the MedPAR file to identify no-volume 
proposed MS-LTC-DRGs and to determine the proposed relative weights in 
this proposed rule.
    Step 6--Adjust the proposed FY 2009 MS-LTC-DRG relative weights to 
account for nonmonotonically increasing relative weights.
    As discussed in section II.B. of the preamble of this proposed 
rule, the MS-DRGs (used under the IPPS) on which the MS-LTC-DRGs are 
based provide a significant improvement in the DRG system's recognition 
of severity of illness and resource usage. The proposed MS-DRGs contain 
base DRGs that have been subdivided into one, two, or three severity 
levels. Where there are three severity levels, the most severe level 
has at least one code that is referred to as an MCC. The next lower 
severity level contains cases with at least one code that is a CC. 
Those cases without a MCC or a CC are referred to as without CC/MCC. 
When data did not support the creation of three severity levels, the 
base was divided into either two levels or the base was not subdivided. 
The two-level subdivisions could consist of the CC/MCC and the without 
CC/MCC. Alternatively, the other type of two level subdivision could 
consist of the MCC and without MCC.
    In 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 
the ``with CC'' and ``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 do not increase (that is, if within a 
base MS-LTC-DRG, a MS-LTC-DRG with MCC has a lower relative weight than 
one with CC, 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. Consequently, 
in general, we are proposing to combine proposed 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. In 
determining the proposed FY 2009 MS-LTC-DRG relative weights in this 
proposed rule, in general, we are proposing to use the same methodology 
to adjust for nonmonotonicity that we used to determine the FY 2008 MS-
LTC-DRG relative weights in the FY 2008 IPPS final rule with comment 
(72 FR 47293 through 47295). However, as noted above, we are taking 
this opportunity to refine our description to more precisely explain 
our methodology for determining the MS-LTC-DRG relative weights in this 
proposed rule. Specifically, in determining the proposed FY 2009 MS-
LTC-DRG relative weights in this proposed rule, under each of the 
example scenarios provided below, we would combine severity levels 
within a base MS-LTC-DRG as follows:
    The first example of nonmonotonically increasing relative weights 
for a MS-LTC-DRG pertains to a base MS-LTC-DRG with a three-level split 
and each of the three levels has 25 or more LTCH cases and, therefore, 
none of those MS-LTC-DRGs is assigned to one of the five low-volume 
quintiles. In this proposed rule, if nonmonotonicity is detected in the 
proposed relative weights of the proposed MS-LTC-DRGs in adjacent 
severity levels (for example, the proposed relative weight of the 
``with MCC'' (the highest severity level) is less than the ``with CC'' 
(the middle level), or the ``with CC'' is less than the ``without CC/
MCC''), we would combine the nonmonotonic adjacent proposed MS-LTC-DRGs 
and re-determine a proposed relative weight based on the case-weighted 
average of the combined LTCH cases of the nonmonotonic proposed MS-LTC-
DRGs. The case-weighted average charge is calculated by dividing the 
total charges for all LTCH cases in both severity levels by the total 
number of LTCH cases for both proposed MS-LTC-DRGs. The same proposed 
relative weight would be assigned to both affected levels of the base 
MS-LTC-DRG. If nonmonotonicity remains an issue because the above 
process results in a proposed relative weight that is still 
nonmonotonic to the remaining proposed MS-LTC-DRG relative weight 
within the base MS-LTC-DRG, we would combine all three of the severity 
levels to redetermine the proposed relative weights based on the case-
weighted average charge of the combined severity levels. This same 
proposed relative weight is then assigned to each of the proposed MS-
LTC-DRGs in that base MS-LTC-DRG.
    A second example of nonmonotonically increasing relative weights 
for a base MS-LTC-DRG pertains to the situation where there are three 
severity levels and one or more of the severity levels within a base 
MS-LTC-DRG has less than 25 LTCH cases (that is, low-volume). In this 
proposed rule, if nonmonotonicity occurs in the case where either the 
highest or lowest severity level (``with MCC'' or ``without CC/MCC'') 
has 25 LTCH cases or more and the other two severity levels are low-
volume (and therefore the other two severity levels would otherwise be 
assigned the proposed relative weight of the applicable proposed low-
volume quintile(s)), we would combine the data for the cases in the two 
adjacent proposed low-volume MS-LTC-DRGs for the purpose of determining 
a proposed relative weight. If the combination results in at least 25 
cases,

[[Page 23607]]

we re-determine one proposed relative weight based on the case-weighted 
average charge of the combined severity levels and assign this same 
proposed relative weight to each of the severity levels. If the 
combination results in less than 25 cases, based on the case-weighted 
average charge of the combined proposed low-volume MS-LTC-DRGs, both 
proposed MS-LTC-DRGs would be assigned to the appropriate proposed low-
volume quintile (discussed above in section II.I.3.e. of this preamble) 
based on the case-weighted average charge of the combined proposed low-
volume MS-LTC-DRGs. Then the proposed relative weight of the affected 
proposed low-volume quintile would be redetermined and that proposed 
relative weight would be assigned to each of the affected severity 
levels (and all of the proposed MS-LTC-DRGs in the affected proposed 
low-volume quintile). If nonmonotonicity persists, we would combine all 
three severity levels and redetermine one proposed relative weight 
based on the case-weighted average charge of the combined severity 
levels and this same proposed relative weight would be assigned to each 
of the three levels.
    Similarly, in nonmonotonic cases where the middle level has 25 
cases or more but either or both of the lowest or highest severity 
level has less than 25 cases (that is, low volume), we would combine 
the nonmonotonic proposed low-volume MS-LTC-DRG with the middle level 
proposed MS-LTC-DRG of the base MS-LTC-DRG. We would redetermine one 
proposed relative weight based on the case-weighted average charge of 
the combined severity levels and assign this same proposed relative 
weight to each of the affected proposed MS-LTC-DRGs. If nonmonotonicity 
persists, we would combine all three levels for the purpose of 
redetermining a proposed relative weight based on the case-weighted 
average charge of the combined severity levels, and assign that 
proposed relative weight to each of the three severity levels.
    In the case where all three severity levels in the base MS-LTC-DRGs 
are proposed low-volume MS-LTC-DRGs and two of the severity levels are 
nonmonotonic in relation to each other, we would combine the two 
adjacent nonmonotonic severity levels. If that combination results in 
less than 25 cases, both proposed low-volume MS-LTC-DRGs would be 
assigned to the appropriate proposed low-volume quintile (discussed 
above in section II.I.3.e. of this preamble) based on the case-weighted 
average charge of the combined proposed low-volume MS-LTC-DRGs. Then 
the proposed relative weight of the affected proposed low-volume 
quintile would be redetermined and that proposed relative weight would 
be assigned to each of the affected severity levels (and all of the 
proposed MS-LTC-DRGs in the affected proposed low-volume quintile). If 
the nonmonotonicity persists, we would combine all three levels of that 
base MS-LTC-DRG for the purpose of redetermining a proposed relative 
weight based on the case-weighted average charge of the combined 
severity levels, and assign that proposed relative weight to each of 
the three severity levels. If that combination of all three severity 
levels results in less than 25 cases, we would assign that ``combined'' 
base MS-LTC-DRG to the appropriate proposed low-volume quintile based 
on the case-weighted average charge of the combined proposed low-volume 
MS-LTC-DRGs. Then the proposed relative weight of the affected proposed 
low-volume quintile would be redetermined and that proposed relative 
weight would be assigned to each of the affected severity levels (and 
all of the proposed MS-LTC-DRGs in the affected proposed low-volume 
quintile).
    Another example of nonmonotonicity involves a base MS-LTC-DRG with 
three severity levels where at least one of the severity levels has no 
cases. As discussed above in greater detail in Step 5, based on 
resource use intensity and clinical similarity, we propose to cross-
walk a proposed no-volume MS-LTC-DRG to a proposed MS-LTC-DRG that has 
at least one case. Under our proposed methodology for the treatment of 
proposed no-volume MS-LTC-DRGs, the proposed no-volume MS-LTC-DRG would 
be assigned the same proposed relative weight as the proposed MS-LTC-
DRG to which the proposed no-volume MS-LTC-DRG is cross-walked. For 
many proposed no-volume MS-LTC-DRGs, as shown in the chart above in 
Step 5, the application of our proposed methodology results in a 
proposed cross-walk MS-LTC-DRG that is the adjacent severity level in 
the same base MS-LTC-DRG. Consequently, in most instances, the proposed 
no-volume MS-LTC-DRG and the adjacent proposed MS-LTC-DRG to which it 
is cross-walked would not result in nonmonotonicity because both of 
these severity levels would have the same proposed relative weight. (In 
this proposed rule, under our proposed methodology for the treatment of 
proposed no-volume MS-LTC-DRGs, in the case where the proposed no-
volume MS-LTC-DRG is either the highest or lowest severity level, the 
proposed cross-walk MS-LTC-DRG would be the middle level (``with CC'') 
within the same base MS-LTC-DRG, and therefore the proposed no-volume 
MS-LTC-DRG (either the ``with MCC'' or the ``without CC/MCC'') and the 
proposed cross-walk MS-LTC-DRG (the ``with CC'') would have the same 
proposed relative weight. Consequently, no adjustment for monotonicity 
would be necessary.) However, if our proposed methodology for 
determining proposed relative weights for proposed no-volume MS-LTC-
DRGs results in nonmonotonicity with the third severity level in the 
base-MS-LTC-DRG, all three severity levels would be combined for the 
purpose of redetermining one proposed relative weight based on the 
case-weighted average charge of the combined severity levels. This same 
proposed relative weight would be assigned to each of the three 
severity levels in the base MS-LTC-DRG.
    Thus far in the discussion, we have presented examples of 
nonmonotonicity in a base MS-LTC-DRG that has three severity levels. We 
would apply the same process where the base MS-LTC-DRG contains only 
two severity levels. For example, if nonmonotonicity occurs in a base 
MS-LTC-DRG with two severity levels (that is, the proposed relative 
weight of the higher severity level is less than the lower severity 
level), where both of the proposed MS-LTC-DRGs have at least 25 cases 
or where one or both of the proposed MS-LTC-DRGs is low volume (that 
is, less than 25 cases), we would combine the two proposed MS-LTC-DRGs 
of that base MS-LTC-DRG for the purpose of redetermining a proposed 
relative weight based on the combined case-weighted average charge for 
both severity levels. This same proposed relative weight would be 
assigned to each of the two severity levels in the base MS-LTC-DRG. 
Specifically, if the combination of the two severity levels would 
result in at least 25 cases, we would redetermine one proposed relative 
weight based on the case-weighted average charge and assign that 
proposed relative weight to each of the two proposed MS-LTC-DRGs. If 
the combination results in less than 25 cases, we would assign both 
proposed MS-LTC-DRGs to the appropriate proposed low-volume quintile 
(discussed above in section II.I.3.e. of this preamble) based on their 
combined case-weighted average charge. Then the proposed relative 
weight of the affected proposed low-volume quintile would be 
redetermined and that proposed relative

[[Page 23608]]

weight would be assigned to each of the affected severity levels.
    Step 7--Calculate the proposed FY 2009 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 under section 
123 of Pub. L. 106-113 as amended by section 307(b) of Pub. L. 106-554 
to develop the LTCH PPS, beginning with the MS-LTC-DRG update for FY 
2008, the annual update to the MS-LTC-DRG classifications and relative 
weights will be done in a budget neutral manner such that estimated 
aggregate LTCH PPS payments would be unaffected, that is, would be 
neither greater than nor less than the estimated aggregate LTCH PPS 
payments that would have been made without the MS-LTC-DRG 
classification and relative weight changes. Specifically, in that same 
final rule, we established under Sec.  412.517(b) that the annual 
update to the MS-LTC-DRG classifications and relative weights be done 
in a budget neutral manner. For a detailed discussion on the 
establishment of the requirement to update the MS-LTC-DRG 
classifications and relative weights in a budget neutral manner, we 
refer readers to the RY 2008 LTCH PPS final rule (72 FR 26880 through 
26884). Updating the MS-LTC-DRGs in a budget neutral manner results in 
an annual update to the individual MS-LTC-DRG classifications and 
relative weights based on the most recent available data to reflect 
changes in relative LTCH resource use. To accomplish this, 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 MS-LTC-DRG classifications and relative weights 
for FY 2009 based on the most recent available data and include a 
proposed budget neutrality adjustment that would be applied in 
determining the proposed MS-LTC-DRG relative weights.
    To ensure budget neutrality in updating the proposed MS-LTC-DRG 
classifications and proposed relative weights under Sec.  412.517(b), 
consistent with the budget neutrality methodology we established in the 
FY 2008 IPPS final rule with comment period (72 FR 47295 through 
47296), in determining the proposed budget neutrality adjustment for FY 
2009 in this proposed rule, we are proposing to use a method that is 
similar to the methodology used under the IPPS. Specifically, for FY 
2009, after recalibrating the proposed MS-LTC-DRG relative weights as 
we do under the methodology as described in detail in Steps 1 through 6 
above, we would calculate and apply a normalization factor to those 
relative weights to ensure that estimated payments are not influenced 
by changes in the composition of case types or the changes being 
proposed to the classification system. That is, the proposed 
normalization adjustment is intended to ensure that the recalibration 
of the proposed MS-LTC-DRG relative weights (that is, the process 
itself) neither increases nor decreases total estimated payments.
    To calculate the proposed normalization factor for FY 2009, we 
would use the following steps: (1) We use the most recent available 
claims data (FY 2007) and the proposed MS-LTC-DRG relative weights 
(determined above in Steps 1 through 6 above) to calculate the average 
CMI; (2) we group the same claims data (FY 2007) using the FY 2008 
GROUPER (Version 25.0) and FY 2008 relative weights (established in the 
FY 2008 IPPS final rule with comment period (72 FR 47295 through 
47296)) and calculate the average CMI; and (3), we compute the ratio of 
these average CMIs by dividing the average CMI determined in step (2) 
by the average CMI determined in step (1). In determining the proposed 
MS-LTC-DRG relative weights for FY 2009, based on the latest available 
LTCH claims data, the normalization factor is estimated as 1.038266, 
which would be applied in determining each proposed MS-LTC-DRG relative 
weight. That is, each proposed MS-LTC-DRG relative weight would be 
multiplied by 1.038266 in the first step of the budget neutrality 
process. Accordingly, the proposed relative weights in Table 11 in the 
Addendum of this proposed rule reflect this proposed normalization 
factor. We also ensure that estimated aggregate LTCH PPS payments 
(based on the most recent available LTCH claims data) after 
reclassification and recalibration (the new proposed FY 2009 MS-LTC-DRG 
classifications and relative weights) are equal to estimated aggregate 
LTCH PPS payments (for the same most recent available LTCH claims data) 
before reclassification and recalibration (the existing FY 2008 MS-DRG 
classifications and relative weights). Therefore, we would calculate 
the proposed budget neutrality adjustment factor by simulating 
estimated total payments under both sets of GROUPERs and relative 
weights using current LTCH PPS payment policies (RY 2008) and the most 
recent available claims data (from the FY 2007 MedPAR file).
    Accordingly, we are proposing to use RY 2008 LTCH PPS rates and 
policies in determining the proposed FY 2009 budget neutrality 
adjustment in this proposed rule, using the following steps: (1) We 
simulate estimated total payments using the normalized proposed 
relative weights under GROUPER Version 26.0 (as described above); (2) 
we simulate estimated total payments using the FY 2008 GROUPER (Version 
25.0) and FY 2008 MS-LTC-DRG relative weights (as established in the FY 
2008 IPPS final rule (72 FR 47295 through 47296)); (3) we calculate the 
ratio of these estimated total payments by dividing the estimated total 
payments determined in step (2) by the estimated total payments 
determined in step (1). Then, each of the normalized proposed relative 
weights is multiplied by the proposed budget neutrality factor to 
determine the budget neutral proposed relative weight for each proposed 
MS-LTC-DRG.
    Accordingly, in determining the proposed MS-LTC-DRG relative 
weights for FY 2009 in this proposed rule, based on the most recent 
available LTCH claims data, we are proposing a budget neutrality factor 
of 0.99965, which would be applied to the normalized proposed relative 
weights (described above). The proposed FY 2009 MS-LTC-DRG relative 
weights in Table 11 in the Addendum of this proposed rule reflect this 
proposed budget neutrality factor. Furthermore, we expect that we will 
have established payments rates and policies for RY 2009 prior to the 
development of the FY 2009 IPPS final rule. Therefore, for purposes of 
determining the FY 2009 budget neutrality factor in the final rule, we 
are proposing that we would simulate estimated total payments using the 
most recent LTCH PPS payment policies and LTCH claims data that are 
available at that time.
    Table 11 in the Addendum to this proposed rule lists the proposed 
MS-LTC-DRGs and their respective proposed budget neutral relative 
weights, geometric mean length of stay, and five-sixths of the 
geometric mean length of stay (used in the determination of short-stay 
outlier payments under Sec.  412.529) for FY 2009.

J. 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

[[Page 23609]]

that a medical service or technology will be considered new if it meets 
criteria established by the Secretary after notice and opportunity for 
public comment. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that 
the process must apply to a new medical service or technology if, 
``based on the estimated costs incurred with respect to discharges 
involving such service or technology, the DRG prospective payment rate 
otherwise applicable to such discharges under this subsection is 
inadequate.''
    The regulations implementing this provision establish three 
criteria for new medical services and technologies to receive an 
additional payment. First, 42CFR412.87(b)(2) states that a specific 
medical service or technology will be considered new for purposes of 
new medical service or technology add-on payments until such time as 
Medicare data are available to fully reflect the cost of the technology 
in the 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 
DRG weights. For example, data from discharges occurring during FY 2007 
are used to calculate the FY 2009 DRG weights in this proposed rule. 
Section 412.87(b)(2) of our existing regulations provides that ``a 
medical service or technology may be considered new within 2 or 3 years 
after the point at which data begin to become available reflecting the 
ICD-9-CM code assigned to the new medical service or technology 
(depending on when a new code is assigned and data on the new medical 
service or technology become available for DRG recalibration). After 
CMS has recalibrated the DRGs based on available data to reflect the 
costs of an otherwise new medical service or technology, the medical 
service or technology will no longer be considered ``new'' under the 
criterion for this section.''
    The 2-year to 3-year period during which a medical service or 
technology can be considered new would ordinarily begin on the date on 
which the medical service or technology received FDA approval or 
clearance. (We note that, for purposes of this section of the proposed 
rule, we refer to both FDA approval and FDA clearance as FDA 
``approval.'') However, in some cases, initially there may be 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 approval is received in cases where the 
product initially was generally unavailable to Medicare patients 
following FDA approval, such as in the case of a national noncoverage 
determination, or if there was some documented delay in bringing the 
product onto the market after that approval (for instance, component 
production or drug production has been postponed following FDA approval 
due to shelf life concerns or manufacturing issues). After the DRGs 
have been recalibrated to reflect the costs of an otherwise new medical 
service or technology, the medical service or technology is no longer 
eligible for special add-on payment for new medical services or 
technologies (Sec.  412.87(b)(2)). For example, an approved new 
technology that received FDA approval in October 2007 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, 2010 (the start 
of FY 2011). Because the FY 2011 DRG weights would be calculated using 
FY 2009 MedPAR data, the costs of such a new technology would be fully 
reflected in the FY 2011 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 2011 and thereafter.
    Section 412.87(b)(3) further provides that, to be eligible for the 
add-on payment for new medical services or technologies, the 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 whether a new technology 
would be inadequately paid under the applicable DRG-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 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 DRG to which the new medical service or technology 
is assigned (or the case-weighted average of all relevant DRGs, if the 
new medical service or technology occurs in more than one 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 in section XIX. 
of the interim final rule with comment period published in the Federal 
Register on November 27, 2007, contained the final thresholds that are 
being used to evaluate applications for new technology add-on payments 
for FY 2009 (72 FR 66888 through 66892). An applicant must demonstrate 
that the cost threshold is met using information from inpatient 
hospital claims.
    With regard to the issue of whether the HIPAA Privacy Rule at 45 
CFR Parts 160 and 164 applies to claims information that providers 
submit with applications for new technology add-on payments, we 
addressed this issue in the September 7, 2001 final rule that 
established the new technology add-on payment regulations (66 FR 
46917). In the preamble to that final rule, we explained that health 
plans, including Medicare, and providers that conduct certain 
transactions electronically, including the hospitals that would be 
receiving payment under the FY 2001 IPPS final rule, are required to 
comply with the HIPAA Privacy Rule. We further explained how such 
entities could meet the applicable HIPAA 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 of Civil Rights has since 
amended the HIPAA Privacy Rule, but the results remain. The HIPAA 
Privacy Rule no longer requires covered entities to obtain consent from 
patients to use or disclose 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), and the Standards for Privacy of Individually 
Identifiable Health Information published in the Federal

[[Page 23610]]

Register on August 14, 2002, for a full discussion of changes in 
consent requirements.)
    Section 412.87(b)(1) of our existing regulations provides that a 
new technology is an appropriate candidate for an additional payment 
when it represents ``an advance that substantially improves, relative 
to technologies previously available, the diagnosis or treatment of 
Medicare beneficiaries.'' For example, a new technology represents a 
substantial clinical improvement when it reduces mortality, decreases 
the number of hospitalizations or physician visits, or reduces recovery 
time compared to the technologies previously available. (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 Sec.  
412.88, if the costs of the discharge (determined by applying CCRs as 
described in Sec.  412.84(h)) exceed the full DRG payment, 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 case. If the amount by which the 
actual costs of a new medical service or technology case exceeds the 
full DRG payment (including payments for IME and DSH, but excluding 
outlier payments) by more than the 50-percent marginal cost factor, 
Medicare payment is limited to the full 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 DRG classifications and relative weights must be made in a 
manner that ensures that aggregate payments to hospitals are not 
affected. Therefore, in the past, we accounted for projected payments 
under the new medical service and technology provision during the 
upcoming fiscal year at the same time we estimated the payment effect 
of changes to the DRG classifications and recalibration. The impact of 
additional payments under this provision was then included in the 
budget neutrality factor, which was applied to the standardized amounts 
and the hospital-specific amounts. 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, add-on payments for new 
medical services or technologies for FY 2005 and later years have not 
been budget neutral.
    Applicants for add-on payments for new medical services or 
technologies for FY 2010 must submit a formal request, including a full 
description of the clinical applications of the medical service or 
technology and the results of any clinical evaluations demonstrating 
that the new medical service or technology represents a substantial 
clinical improvement, along with a significant sample of data to 
demonstrate the medical service or technology meets the high-cost 
threshold. Complete application information, along with final deadlines 
for submitting a full application, will be available on our Web site 
at: http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp#TopOfPage. 
To allow interested parties to identify the new medical services or 
technologies under review before the publication of the proposed rule 
for FY 2010, the Web site will also list the tracking forms completed 
by each applicant.
    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. It is co-chaired 
by the Director of the Center for Medicare Management (CMM), who is 
also designated as the CTI's Executive Coordinator, and the Director of 
the Office of Clinical Standards and Quality (OCSQ).
    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, and at the same time 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 promotion of better evidence development, 
which is critical for improving the quality of care for Medicare 
beneficiaries.
    The agency plans to continue its Open Door forums with stakeholders 
who are interested in CTI's initiatives. In addition, to improve 
understanding of CMS processes for coverage, coding, and payment and 
how to access them, the CTI is developing an ``innovator's guide'' to 
these processes. This guide will, for example, outline regulation 
cycles and application deadlines. The intent is to consolidate this 
information, much of which is already available in a variety of CMS 
documents and in various places on CMS's Web site, in a user-friendly 
format. In the meantime, we invite any product developers with specific 
issues involving the agency to contact us 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 information on CTI activities to 
stakeholders, including Medicare beneficiaries, advocates, medical 
product manufacturers, providers, and health policy experts, and other 
stakeholders with useful information on CTI initiatives. 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 <a href="/cdn-cgi/l/email-protection#efacbba6af8c829cc187879cc1888099"><span class="__cf_email__" data-cfemail="7c3f28353c1f110f5214140f521b130a">[email protected]</span></a> or from the 
``Contact Us'' section of the CTI home page (http://www.cms.hhs.gov/CouncilonTechInnov/).
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--

[[Page 23611]]

    <bullet> 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;
    <bullet> Make public and periodically update a list of the services 
and technologies for which applications for add-on payments are 
pending;
    <bullet> Accept comments, recommendations, and data from the public 
regarding whether a service or technology represents a substantial 
clinical improvement; and
    <bullet> 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 2009 
before publication of the FY 2009 IPPS proposed rule, we published a 
notice in the Federal Register on December 28, 2007 (72 FR 73845 
through 73847), and held a town hall meeting at the CMS Headquarters 
Office in Baltimore, MD, on February 21, 2008. 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 2009 new medical service and 
technology add-on payment applications before the publication of the FY 
2009 IPPS proposed rule.
    Approximately 70 individuals attended the town hall meeting in 
person, while approximately 20 additional participants listened over an 
open telephone line. Each of the four FY 2009 applicants presented 
information on its technology, including a focused discussion of data 
reflecting the substantial clinical improvement aspect of the 
technology. We received two comments during the town hall meeting, 
which are summarized below. We considered each applicant's presentation 
made at the town hall meeting, as well as written comments submitted on 
each applicant's application, in our evaluation of the new technology 
add-on applications for FY 2009 in this proposed rule. We have 
summarized these comments below or, if applicable, indicated that no 
comments were received at the end of the discussion of each 
application.
    Comment: One commenter addressed the substantial clinical 
improvement criterion. A medical device association stated that CMS' 
interpretation of the statutory criteria for new technology add-on 
payments is narrow and makes it difficult for potential applicants, 
especially small manufacturing companies, to qualify for new technology 
add-on payments. The commenter urged CMS to ``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.
    Response: With respect to the comment that CMS has a narrow 
interpretation of the statute that makes it difficult for applicants to 
meet the statutory criteria for a new technology add-on payment, we 
note that we have already specifically addressed the issue in the past 
(71 FR 47997 and 72 FR 47301). In addition, we addressed the comment 
concerning automatically deeming technologies granted a humanitarian 
device exemption (HDE) at 72 FR 47302. Further, because the purpose of 
the new technology town hall meeting was to discuss substantial 
clinical improvement of pending applications, we are not providing a 
response to the unrelated comments in this proposed rule.
    Comment: One commenter, a medical technology association, submitted 
comments in reference to the MS-DRGs and the need to account for 
complexity as well as severity in making refinements to the DRG 
classification system. The commenter also made the following comments: 
CMS should raise the new technology marginal cost factor, adjust the 
newness policy to begin with the issuance of an ICD-9-CM code instead 
of the FDA approval date, provide access to the quarterly MedPAR 
updates, and allow for the use of external data for determining new 
technology payments (when CMS determines that the external data are 
unbiased and valid).
    Response: Section 1886(d)(5)(K)(viii) of the Act requires that CMS 
accept comments, recommendations, and data from the public regarding 
whether a service or technology represents a substantial clinical 
improvement. Because the comments above are not related to the 
substantial clinical improvement criterion of pending applications, we 
are not providing a response to them in this proposed rule.
3. FY 2009 Status of Technologies Approved for FY 2008 Add-On Payments
    We did not approve any applications for new technology add-on 
payments for FY 2008. For additional information, refer to the FY 2008 
IPPS final rule with comment period (72 FR 47305 through 47307).
4. FY 2009 Applications for New Technology Add-On Payments
    We received four applications to be considered for new technology 
add-on payment for FY 2009. A discussion of each of these applications 
is presented below. We note that, in the past, we have considered 
applications that had not yet received FDA approval, but were 
anticipating FDA approval prior to publication of the IPPS final rule. 
In such cases, we generally provide a more limited discussion of those 
technologies in the proposed rule because it is not known if these 
technologies will meet the newness criterion in time for us to conduct 
a complete analysis in the final rule. This year, three out of four 
applicants do not yet have FDA approval. Consequently, we have 
presented a limited analysis of them in this proposed rule.
a. CardioWest<SUP>TM</SUP> Temporary Total Artificial Heart System 
(CardioWest<SUP>TM</SUP> TAH-t)
    SynCardia Systems, Inc. submitted an application for approval of 
the CardioWest<SUP>TM</SUP> temporary Total Artificial Heart system 
(TAH-t) for new technology add-on payments for FY 2009. The TAH-t is a 
technology that is used as a bridge to heart transplant device for 
heart transplant-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.

[[Page 23612]]

    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. Some of the FDA's post-
approval requirements include that the manufacturer agree to provide a 
post-approval study demonstrating that the success of the device at one 
center can be reproduced at other centers. The study was to include at 
least 50 patients who will be followed up to 1 year, including (but not 
limited to) the following endpoints; survival to transplant, adverse 
events, and device malfunction.
    Presently, Medicare does not cover artificial heart devices, 
including the TAH-t. However, on February 01, 2008, CMS proposed to 
reverse a national noncoverage determination that would extend coverage 
to this technology within the confines of an FDA-approved clinical 
study. (To view the proposed National Coverage Determination (NCD), we 
refer readers to the CMS Web site at http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=211&.) 
Should this proposal be finalized, it would become effective on May 01, 
2008. Because Medicare's existing coverage policy with respect to this 
device has precluded it from being paid for by Medicare, we would not 
expect the costs associated with this technology to be currently 
reflected in the data used to determine MS-DRGs relative weights. As we 
have indicated in the past, 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 
represents one such case. We also note 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) (described below in the cost threshold discussion) since the 
time of its FDA approval, because the TAH-t has not been covered under 
the Medicare program (and, therefore, no Medicare payment has been made 
for this technology), this code is not ``used with respect to inpatient 
hospital services for which payment'' is made under the IPPS, and thus 
we assume that none of the costs associated with this technology would 
be reflected in the Medicare claims data used to recalibrate the MS-DRG 
weights. For this reason, despite its FDA approval date, it appears 
that this technology would still be eligible to be considered ``new'' 
for purposes of the new technology add-on payment if and when the 
proposal to reverse the national noncoverage determination concerning 
this technology is finalized. Therefore, based on this information, it 
appears that the TAH-t would meet the newness criterion on the date 
that Medicare coverage begins, should the proposed NCD be finalized.
    In an effort to demonstrate that TAH-t would meet the cost 
criterion, the applicant submitted data based on 28 actual cases of the 
TAH-t. The data included 6 cases (or 21.4 percent of cases) from 2005, 
13 cases (or 46.5 percent of cases) from 2006, 7 cases (or 25 percent 
of cases) from 2007, and 2 cases (or 7.1 percent of cases) from 2008. 
Currently, cases involving the TAH-t are assigned to MS-DRG 215 (Other 
Heart Assist System Implant). As discussed below in this section, we 
are proposing to remove the TAH-t from MS-DRG 215 and reassign the TAH-
t to MS-DRGs 001 (Heart Transplant or Implant of Heart Assist System 
with MCC) and 002 (Heart Transplant or Implant of Heart Assist System 
without MCC). Therefore, to determine if the technology meets the cost 
criterion, it is appropriate to compare the average standardized charge 
per case to the thresholds for MS-DRGs 001, 002, and 215 included in 
Table 10 of the November 27, 2007 interim final rule (72 FR 66888 
through 66889). The thresholds for MS-DRGs 001, 002, and 215 from Table 
10 are $345,031, $178,142, and $151,824, respectively. Based on the 28 
cases the applicant submitted, the average standardized charge per case 
was $731,632. Because the average standardized charge per case is much 
greater than the thresholds cited above for MS-DRG 215 (and MS-DRGs 001 
and 002, should the proposal to reassign the TAH-t be finalized), the 
applicant asserted that the TAH-t meets the cost criterion whether or 
not the costs were analyzed by using either a case-weighted threshold 
or case-weighted standardized charge per case.
    In addition to analyzing the costs of actual cases involving the 
TAH-t, the applicant searched the FY 2006 MedPAR file to identify cases 
involving patients who would have potentially been eligible to receive 
the TAH-t. The applicant submitted three different MedPAR analyses. The 
first MedPAR analysis involved a search for cases using ICD-9-CM 
diagnosis code 428.0 (Congestive heart failure) in combination with 
ICD-9-CM procedure code 37.66 (Insertion of implantable heart assist 
system), and an inpatient hospital length of stay greater than or equal 
to 60 days. The applicant found two cases that met this criterion, 
which had an average standardized charge per case of $821,522. The 
second MedPAR analysis searched for cases with ICD-9-CM diagnosis code 
428.0 (Congestive heart failure) and one or more of the following ICD-
9-CM procedure codes: 37.51 (Heart transplant), 37.52 (Implantation of 
total heart replacement system), 37.64 (Removal of heart assist 
system), 37.66 (Insertion of implantable heart assist system), or 37.68 
(Insertion of percutaneous external heart assist device), and a length 
of stay greater than or equal to 60 days. The applicant found 144 cases 
that met this criterion, which had an average standardized charge per 
case of $841,827. The final MedPAR analysis searched for cases with 
ICD-9-CM procedure code 37.51 (Heart transplant) in combination with 
one of the following ICD-9-CM procedure codes: 37.52 (Implantation of 
total heart replacement system), 37.65 (Implantation of external heart 
system), or 37.66 (Insertion of implantable heart assist system). The 
applicant found 37 cases that met this criterion, which had an average 
standardized charge per case of $896,601. Because only two cases met 
the criterion for the first analysis, consistent with historical 
practice, we would not consider it to be of statistical significance 
and, therefore, would not rely upon it to demonstrate whether the TAH-t 
would meet the cost threshold. However, both of the additional analyses 
seem to provide an adequate number of cases to demonstrate whether the 
TAH-t would meet the cost threshold. We assume that none of the costs 
associated with this technology would be reflected in the MedPAR 
analyses that the applicant used to demonstrate that the technology 
would meet the cost criterion. We note that, under all three of the 
analyses the applicant performed, it identified cases that would have 
been eligible for the TAH-t, but did not remove charges that

[[Page 23613]]

were unrelated to the TAH-t, nor did the applicant insert a proxy of 
charges related to the TAH-t. However, as stated above, the average 
standardized charge per case is much greater than any of the thresholds 
for MS-DRGs 001, 002, and 215. Therefore, even if the applicant were to 
approximate what the costs of cases eligible to receive the TAH-t would 
have been by removing non-TAH-t associated charges and inserting 
charges related to the TAH-t, it appears that the average standardized 
charges per case for cases eligible for the TAH-t would exceed the 
relevant thresholds from Table 10 (as discussed above) and would 
therefore appear to meet the cost criterion. We invite public comment 
on whether TAH-t meets the cost criterion.
    As noted in section II.G. of this preamble, we are proposing to 
remove the TAH-t from MS-DRG 215 and reassign the TAH-t to MS-DRGs 001 
and 002. As stated earlier, CMS is proposing to reverse a national 
noncoverage determination that would extend coverage to artificial 
heart devices within the confines of an FDA-approved clinical study, 
effective May 1, 2008. If this proposal is finalized, the MCE will 
require both the procedure code 37.52 (Implantation of total 
replacement heart system) and the diagnosis code reflecting clinical 
trial--V70.7 (Examination of participant in clinical trial). As we have 
previously mentioned, the TAH-t appears to meet the cost thresholds for 
MS-DRGs 001, 002, and 215. Therefore, its proposed reassignment from 
MS-DRG 215 to MS-DRGs 001 and 002 should have no material effect on 
meeting the cost thresholds in MS-DRGs 001 and 002 should the 
reassignment proposal be finalized.
    The manufacturer states that the TAH-t is the only mechanical 
circulatory support device intended as a bridge-to-transplant for 
patients with irreversible biventricular failure. It also asserts that 
the TAH-t improves clinical outcomes because it has been shown to 
reduce mortality in patients who are otherwise in end-stage heart 
failure. In addition, the manufacturer claims that the TAH-t provides 
greater hemodynamic stability and end-organ perfusion, thus making 
patients who receive it better candidates for eventual heart 
transplant. We welcome comments from the public regarding whether the 
TAH-t represents a substantial clinical improvement.
    We did not receive any written comments or public comments at the 
town hall meeting regarding the substantial clinical improvement 
aspects of this technology.
b. Emphasys Medical Zephyr[reg] Endobronchial Valve (Zephyr[reg] EBV)
    Emphasys Medical submitted an application for new technology add-on 
payments for FY 2009 for the Emphasys Medical Zephyr[reg] Endobronchial 
Valve (Zephyr[reg] EBV). The Zephyr[reg] EBV is intended to treat 
patients with emphysema by reducing volume in the diseased, 
hyperinflated portion of the emphysematous lung with fewer risks and 
complications than with more invasive surgical alternatives. 
Zephyr[reg] EBV therapy involves placing small, one-way valves in the 
patients' airways to allow air to flow out of, but not into, the 
diseased portions of the lung thus reducing the hyperinflation. A 
typical procedure involves placing three to four valves in the target 
lobe using a bronchoscope, and the procedure takes approximately 20 to 
40 minutes to complete. The Zephyr[reg] EBVs are designed to be 
relatively easy to place, and are intended to be removable so that, 
unlike more risky surgical alternatives such as Lung Volume Reduction 
Surgery (LVRS) or Lung Transplant, the procedure has the potential to 
be fully reversible.
    Currently, the Zephyr[reg] EBV has yet to receive approval from the 
FDA, but the manufacturer indicated to CMS that it expects to receive 
its FDA approval in the second or third quarter of 2008. Because the 
technology is not yet approved by the FDA, we will limit our discussion 
of this technology to data that the applicant submitted, rather than 
make specific proposals with respect to whether the device would meet 
the new technology add-on criteria.
    In an effort to demonstrate that the Zephyr[reg] EBV would meet the 
cost criterion, the applicant searched the FY 2006 MedPAR file for 
cases with one of the following ICD-9-CM diagnosis codes: 492.0 
(Emphysematous bleb), 492.8 (Other emphysema, NEC), or 496 (Chronic 
airway obstruction, NEC). Based on the diagnosis codes searched by the 
applicant, cases of the Zephyr[reg] EBV would be most prevalent in MS-
DRGs 190 (Chronic Obstructive Pulmonary Disease with MCC), 191 (Chronic 
Obstructive Pulmonary Disease with CC), and 192 (Chronic Obstructive 
Pulmonary Disease without CC/MCC). The applicant found 1,869 cases (or 
12.8 percent of cases) in MS-DRG 190, 5,789 cases (or 39.5 percent of 
cases) in MS-DRG 191, and 6,995 cases (or 47.7 percent of cases) in MS-
DRG 192 (which equals a total of 14,653 cases). The average 
standardized charge per case was $21,567 for MS-DRG 190, $15,494 for 
MS-DRG 191, and $11,826 for MS-DRG 192. The average standardized charge 
per case does not include charges related to the Zephyr[reg] EBV; 
therefore, it is necessary to add the charges related to the device to 
the average standardized charge per case in evaluating the cost 
threshold criteria. Although the applicant submitted data related to 
the estimated cost of the Zephyr[reg] EBV per case, the applicant noted 
that the cost of the device was proprietary information because the 
device is not yet available on the open market. The applicant estimates 
$23,920 in charges related to the Zephyr[reg] EBV (based on a 100 
percent charge markup of the cost of the device). In addition to case-
weighting the data based on the amount of cases that the applicant 
found in the FY 2006 MedPAR file, the applicant case-weighted the data 
based on its own projections of how many Medicare cases it would expect 
to map to MS-DRGs 190, 191, and 192 in FY 2009. The applicant projects 
that, 5 percent of the cases would map to MS-DRG 190, 15 percent of the 
cases would map to MS-DRG 191, and 80 percent of the cases would map to 
MS-DRG 192. Adding the charges related to the device to the average 
standardized charge per case (based on the applicant's projected case 
distribution) resulted in a case-weighted average standardized charge 
per case of $36,782 ($12,862 plus $23,920). Using the thresholds 
published in Table 10 (72 FR 66889), the case-weighted threshold for 
MS-DRGs 190, 191, and 192 was $18,394. Because the case-weighted 
average standardized charge per case for the applicable MS-DRGs exceed 
the case-weighted threshold amount, the applicant maintains that the 
Zephyr[reg] EBV would meet the cost criterion. As noted above, the 
applicant also performed a case-weighted analysis of the data based on 
the 14,653 cases the applicant found in the FY 2006 MedPAR file. Based 
on this analysis, the applicant found that the case-weighted average 
standardized charge per case ($38,441 based on the 14,653 cases) 
exceeded the case-weighted threshold ($20,606 based on the 14,653 
cases). Based on both analyses described above, it appears that the 
applicant would meet the cost criterion. We invite public comment on 
whether Zephyr[reg] EBV meets the cost criterion.
    The applicant asserts that the Zephyr[reg] EBV is a substantial 
clinical improvement because it provides a new therapy along the 
continuum of care for patients with emphysema that offers improvement 
in lung function over standard medical therapy while incurring 
significantly less risk than more invasive treatments such as LVRS

[[Page 23614]]

and lung transplant. Specifically, the applicant submitted data from 
the ongoing pivotal Endobronchial Valve for Emphysema Palliation (VENT) 
trial,\14\ which compared 220 patients who received EBV treatment to 
101 patients who received standard medical therapy, including 
bronchodilators, steroids, mucolytics, and supplemental oxygen. At 6 
months, patients who received the Zephyr[reg] EBV had an average of 7.2 
percent and 5.8 percent improvement (compared to standard medical 
therapy) in the primary effectiveness endpoints of the Forced 
Expiratory Volume in 1 second test (FEV1), and the 6 Minute Walk Test 
(6MWT), respectively. Both results were determined by the applicant to 
be statistically significant. The FEV1 results were determined using 
the t-test parametric confidence intervals (the p value determined 
using the one-side t-test adjusted for unequal variance) and the 6MWT 
results were determined using the Mann-Whitney nonparametric confidence 
intervals (the p value was calculated using the one-sided Wilcoxon rank 
sum test). However, the data also showed that patients who received the 
Zephyr[reg] EBV experienced a number of adverse events, including 
hemoptyis, pneumonia, respiratory failure, pneumothorax, and COPD 
exacerbations, as well as valve migrations and expectorations that, in 
some cases, required repeat bronchoscopy. The manufacturer also 
submitted the VENT pivotal trial 1-year follow-up data, but has 
requested that the data not be disclosed because it has not yet been 
presented publicly nor published in a peer-reviewed journal.
---------------------------------------------------------------------------

    \14\ Strange, Charlie., et al., design of the Endobronchial 
Valve for Emphysema Palliation trial (VENT): A Nonsurgical Method of 
Lung Volume Reduction, BMC Pulmonary Medicine. 2007; 7:10.
---------------------------------------------------------------------------

    While CMS recognizes that the Zephyr[reg] EBV therapy is 
significantly less risky than LVRS and lung transplant, we are 
concerned that the benefits as shown in the VENT pivotal trial may not 
outweigh the risks when compared with medical therapy alone. Further, 
we note that, according to the applicant, the Zephyr[reg] EBV is 
intended for use in many patients who are ineligible for LVRS and/or 
lung transplant (including those too sick to undergo more invasive 
surgery and those with lower lobe predominant disease distribution), 
but that certain patients (that is, those with upper lobe predominant 
disease distribution) could be eligible for either surgery or the 
Zephyr[reg] EBV. We welcome comments from the public on both the 
patient population who would be eligible for the technology, and 
whether the Zephyr[reg] EBV represents a substantial clinical 
improvement in the treatment of patients with emphysema.
    We received written comments from the manufacturer and its 
presenters at the town hall meeting clarifying some questions that were 
raised at the town hall meeting. Specifically, these commenters 
explained that, in general, the target population for the Zephyr[reg] 
EBV device was the same population that could benefit from LVRS, and 
also includes some patients who were too sick to undergo surgery. The 
commenters also explained that patients with emphysema with more 
heterogeneous lung damage were more likely to benefit from the device.
    We welcome public comments regarding where exactly this technology 
falls in the continuum of care of patients with emphysema, and for whom 
the risk/benefit ratio is most favorable.
c. Oxiplex[reg]
    FzioMed, Inc. submitted an application for new technology add-on 
payments for FY 2009 for Oxiplex[reg]. Oxiplex[reg] is an absorbable, 
viscoelastic gel made of carboxymethylcellulose (CMC) and polyethylene 
oxide (PEO) that is intended to be surgically implanted during a 
posterior discectomy, laminotomy, or laminectomy. The manufacturer 
asserts that the gel reduces the potential for inflammatory mediators 
that injure, tether, or antagonize the nerve root in the epidural space 
by creating an acquiescent, semi-permeable environment to protect 
against localized debris. These proinflammatory mediators 
(phospholipase A and nitric oxide), induced or extruded by 
intervertebral discs, may be responsible for increased pain during 
these procedures. The manufacturer also asserts that Oxiplex[reg] is a 
unique material in that it coats tissue, such as the nerve root in the 
epidural space, to protect the nerve root from the effects of 
inflammatory mediators originating from either the nucleus pulposus, 
from blood derived inflammatory cells, or cytokines during the healing 
process.
    Oxiplex[reg] is expecting to receive premarket approval from the 
FDA by June 2008. Because the technology is not yet approved by the 
FDA, we will limit our discussion of this technology to data that the 
applicant submitted, rather than make specific proposals with respect 
to whether the device would meet the new technology add-on payment 
criteria.
    With regard to the newness criterion, we are concerned that 
Oxiplex[reg] may be substantially similar to adhesion barriers that 
have been on the market for several years. We also note that 
Oxiplex[reg] has been marketed as an adhesion barrier in other 
countries outside of the United States. The manufacturer maintains that 
Oxiplex[reg] is different from adhesion barriers in several ways, 
including chemical composition, method of action, surgical application 
(that is, it is applied liberally to the nerve root and surrounding 
neural tissues as opposed to minimally only to nerve elements), and 
tissue response (noninflammatory as opposed to inflammatory). We 
welcome comments from the public on this issue.
    In an effort to demonstrate that the technology meets the cost 
criterion, the applicant searched the FY 2006 MedPAR file for cases 
with ICD-9-CM procedure codes 03.09 (Other exploration and 
decompression of spinal canal) or 80.51 (Excision of interveterbral 
disc) that mapped to CMS DRGs 499 and 500 (CMS DRGs 499 and 500 are 
crosswalked to MS-DRGs 490 and 491 (Back and Neck Procedures except 
Spinal Fusion with or without CC)). Because these cases do not include 
charges associated with the technology, the applicant determined it was 
necessary to add an additional $7,143 in charges to the average 
standardized charge per case of cases that map to MS-DRGs 490 and 491. 
(To do this, the applicant used a methodology of inflating the costs of 
the technology by the average CCR computed by using the average costs 
and charges for supplies for cases with ICD-9-CM procedure codes 03.09 
and 80.51 that map to MS-DRGs 490 and 491). Of the 221,505 cases the 
applicant found, 95,340 cases (or 43 percent of cases) would map to MS-
DRG 490, which has an average standardized charge of $60,301, and 
126,165 cases (or 57 percent of cases) would map to MS-DRG 491, which 
has an average standardized charge per case of $43,888. This resulted 
in a case-weighted average standardized charge per case of $50,952. The 
case-weighted threshold for MS-DRGs 490 and 491 was $27,481. Because 
the case-weighted average standardized charge per case exceeds the 
case-weighted threshold in MS-DRGs 490 and 491, the applicant maintains 
that Oxiplex[reg] would meet the cost criterion. We invite public 
comment on whether Oxiplex[reg] meets the cost criterion.
    The manufacturer maintains that Oxiplex[reg] is a substantial 
clinical improvement because it ``creates a protective environment 
around the neural tissue that limits nerve root exposure to post-
surgical irritants and damage and thus reduces adverse outcomes 
associated with Failed Back

[[Page 23615]]

Surgery Syndrome (FBSS) following surgery.'' The manufacturer also 
claims that the Oxiplex[reg] gel reduces leg and back pain after 
discectomy, laminectomy, and laminotomy. The manufacturer also asserts 
that the use of Oxiplex[reg] is consistent with fewer revision 
surgeries. (During the FDA Investigational Device Exemption (IDE) 
trial, one Oxiplex[reg] patient required revision surgery compared to 
six control patients.) However, as we noted previously in this section, 
we are concerned that Oxiplex[reg] may be substantially similar to 
adhesion barriers that have been on the market for several years. We 
are also concerned that even if we were to determine that Oxiplex is 
not substantially similar to existing adhesion barriers, there may 
still be insufficient evidence to support the manufacturer's claims 
that Oxiplex[reg] reduces pain associated with spinal surgery. In 
addition, we have found no evidence to support the manufacturer's 
claims regarding mode of action, degree of dural healing, degree of 
wound healing, and local tissue response such as might be shown in 
animal studies. We welcome comments from the public regarding whether 
Oxiplex[reg] represents a substantial clinical improvement.
    We did not receive any written comments or public comments at the 
town hall meeting regarding the substantial clinical improvement 
aspects of this technology.
d. TherOx Downstream[reg] System
    TherOx, Inc. submitted an application for new technology add-on 
payments for FY 2009 for the TherOx Downstream[reg] System 
(Downstream[reg] System). The Downstream[reg] System uses 
SuperSaturatedOxygen Therapy (SSO2) that is designed to limit 
myocardial necrosis by minimizing microvascular damage in acute 
myocardial infarction (AMI) patients following intervention with 
Percutaneous Transluminal Coronary Angioplasty (PTCA), and coronary 
stent placement by perfusing the affected myocardium with blood that 
has been supersaturated with oxygen. SSO2 therapy refers to the 
delivery of superoxygenated arterial blood directly to areas of 
myocardial tissue that have been reperfused using PTCA and stent 
placement, but which may still be at risk. The desired effect of SSO2 
therapy is to reduce infarct size and thus preserve heart muscle and 
function. The DownStream[reg] System is the console portion of a 
disposable cartridge-based system that withdraws a small amount of the 
patient's arterial blood, mixes it with a small amount of saline, and 
supersaturates it with oxygen to create highly oxygen-enriched blood. 
The superoxygenated blood is delivered directly to the infarct-related 
artery via the TherOx infusion catheter. SSO2 therapy is a catheter 
laboratory-based procedure. Additional time in the catheter lab area is 
an average of 100 minutes. The manufacturer claims that the SSO2 
therapy duration lasts 90 minutes and requires an additional 10 minutes 
post-procedure preparation for transfer time. The TherOx 
Downstream[reg] System is currently not FDA approved; however, the 
manufacturer states that it expects to receive FDA approval in the 
second quarter of 2008. Because the technology is not yet approved by 
the FDA, we will limit our discussion of this technology to data that 
the applicant submitted, rather than make specific proposals with 
respect to whether the device would meet the new technology add-on 
criteria.
    In an effort to demonstrate that it would meet the cost criterion, 
the applicant submitted two analyses. The applicant believes that cases 
that would be eligible for the Downstream[reg] System would most 
frequently group to MS-DRGs 246 (Percutaneous Cardiovascular Procedure 
with Drug-Eluting Stent with MCC or 4+Vessels/Stents), 247 
(Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without 
MCC), 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting 
Stent with MCC or 4+Vessels/Stents), and 249 (Percutaneous 
Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC). The 
first analysis used data based on 83 clinical trial patients from 10 
clinical sites. Of the 83 cases, 78 were assigned to MS-DRGs 246, 247, 
248, or 249. The data showed that 32 of these patients were 65 years 
old or older. There were 12 cases (or 15.4 percent of cases) in MS-DRG 
246, 56 cases (or 71.8 percent of cases) in MS-DRG 247, 2 cases (or 2.6 
percent of cases) in MS-DRG 248, and 8 cases (or 10.3 percent of cases) 
in MS-DRG 249. (The remaining five cases grouped to MS-DRGs that the 
technology would not frequently group to and therefore are not included 
in this analysis.) The average standardized charge per case for MS-DRGs 
246, 247, 248, and 249 was $66,730, $53,963, $54,977, and $41,594, 
respectively. The case-weighted average standardized charge per case 
for the four MS-DRGs listed above is $54,665. Based on the threshold 
from Table 10 (72 FR 66890), the case-weighted threshold for the four 
MS-DRGs listed above was $49,303. The applicant also searched the FY 
2006 MedPAR file to identify cases that would be eligible for the 
Downstream[reg] System. The applicant specifically searched for cases 
with primary ICD-9-CM diagnosis code 410.00 (Acute myocardial 
infarction of anterolateral wall with episode of care unspecified), 
410.01 (Acute myocardial infarction of anterolateral wall with initial 
episode of care), 410.10 (Acute myocardial infarction of other anterior 
wall with episode of care unspecified), or 410.11 (Acute myocardial 
infarction of other anterior wall with initial episode of care) in 
combination with ICD-9-CM procedure code of 36.06 (Insertion of non-
drug-eluting coronary artery stent(s)) or 36.07 (Insertion of drug-
eluting coronary artery stent(s)). The applicant's search found 13,527 
cases within MS-DRGs 246, 247, 248, and 249 distributed as follows: 
2,287 cases (or 16.9 percent of cases) in MS-DRG 246; 9,691 cases (or 
71.6 percent of cases) in MS-DRG 247; 402 cases (or 3 percent of cases) 
in MS-DRG 248; and 1,147 cases (or 8.5 percent of cases) in MS-DRG 249. 
Not including the charges associated with the technology, the geometric 
mean standardized charge per case for MS-DRGs 246, 247, 248, and 249 
was $59,631, $42,357, $49,718 and $37,446, respectively. Therefore, 
based on this analysis, the total case-weighted geometric mean 
standardized charge per case across these MS-DRGs was $45,080. The 
applicant estimated that it was necessary to add an additional $21,620 
in charges to the total case-weighted geometric mean standardized 
charge per case. The applicant included charges for supplies and tests 
related to the technology, charges for 100 minutes of additional 
procedure time in the catheter laboratory and charges for the 
technology itself in the additional charge amount referenced above. The 
inclusion of these charges would result in a total case-weighted 
geometric mean standardized charge per case of $66,700. The case-
weighted threshold for MS-DRGs 246, 247, 248, and 249 (from Table 10 
(72 FR 66889)) was $49,714. Because the total case-weighted average 
standardized charge per case from the first analysis and the case-
weighted geometric mean standardized charge per case from the second 
analysis exceeds the applicable case-weighted threshold, the applicant 
maintains the Downstream[reg] System would meet the cost criterion. We 
invite public comment on whether Downstream[reg] System meets the cost 
criterion.
    The applicant asserts that the Downstream[reg] System is a 
substantial clinical improvement because it reduces infarct size in 
acute AMI where PTCA and stent placement have also been performed. Data 
was submitted from the Acute Myocardial Infarction Hyperbaric

[[Page 23616]]

Oxygen Treatment (AMIHOT) II trial, which was presented at the October 
2007 Transcatheter Cardiovascular Therapeutics conference, but has not 
been published in peer reviewed literature, that showed an average of 
6.5 percent reduction in infarct size as measured with Tc-99m Sestamibi 
imaging in patients who received supersaturated oxygen therapy. We note 
that those patients also showed a significantly higher incidence of 
bleeding complications. While we recognize that a reduction of infarct 
size may correlate with improved clinical outcomes, we question whether 
the degree of infarct size reduction found in the trial represents a 
substantial clinical improvement, particularly in light of the apparent 
increase in bleeding complications. We welcome comments from the public 
on this matter.
    We received one written comment from the manufacturer clarifying 
questions that were raised at the town hall meeting. Specifically, the 
commenter explained the methodology of Tc-99m Sestamibi scanning and 
interpretation in the AMIHOT II trial. In addition, the commenter 
explained that the AMIHOT \15\ and AMIHOT II trials did not attempt to 
measure differences in heart failure outcomes nor mortality outcomes.
---------------------------------------------------------------------------

    \15\ Oneill, WW., et al., Acute Myocardial Infarction with 
Hyperoxemic Therapy (AMIHOT): A Prospective Randomized Trial of 
Intracoronary Hyperoxemic Reperfusion after Percutaneous Coronary 
Intervention. Journal of the American College of Cardiology, Vol. 
50, No. 5, 2007, pp. 397-405.
---------------------------------------------------------------------------

5. Proposed Regulatory Change
    Section 1886(d)(5)(K)(i) of the Act directs us to establish a 
mechanism to recognize the cost of new medical services and 
technologies under the IPPS, with such mechanism established after 
notice and opportunity for public comment. In accordance with this 
authority, we established at Sec.  412.87(b) of our regulations 
criteria that a medical service or technology must meet in order to 
qualify for the additional payment for new medical services and 
technologies. Specifically, we evaluate applications for new medical 
service or technology add-on payment by determining whether they meet 
the criteria of newness, adequacy of payment, and substantial clinical 
improvement.
    As stated in section III.J.1. of the preamble of this proposed 
rule, Sec.  412.87(b)(2) of our existing regulations provides that a 
specific medical service or technology will be considered new for 
purposes of new medical service or technology add-on payments after the 
point at which data begin to become available reflecting the ICD-9-CM 
code assigned to the new service or technology. The point at which 
these data become available typically begins when the new medical 
service or technology is first introduced on the market, generally on 
the date that the medical service or technology receives FDA approval. 
Accordingly, for purposes of the new medical service or technology add-
on payment, a medical service or technology cannot be considered new 
prior to the date on which FDA approval is granted.
    In addition, as stated in section III.J.1. of the preamble of this 
proposed rule, Sec.  412.87(b)(3) of our existing regulations provides 
that, to be eligible for the add-on payment for new medical services or 
technologies, the DRG prospective payment rate otherwise applicable to 
the discharge involving the new medical service or technology must be 
assessed for adequacy. Under the cost criterion, to assess the adequacy 
of payment for a new medical service or technology paid under the 
applicable DRG prospective payment rate, we evaluate whether the 
charges for cases involving the new medical service or technology 
exceed certain threshold amounts.
    Section 412.87(b)(1) of our existing regulations provides that, to 
be eligible for the add-on payment for new medical services or 
technologies, the new medical service or technology must represent an 
advance that substantially improves, relative to technologies 
previously available, the diagnosis or treatment of Medicare 
beneficiaries. In addition, Sec.  412.87(b)(1) states that CMS will 
announce its determination as to whether a new medical service or 
technology meets the substantial clinical improvement criteria in the 
Federal Register as part of the annual updates and changes to the IPPS.
    Since the implementation of the policy on add-on payments for new 
medical services and technologies, we accept applications for add-on 
payments for new medical services and technologies on an annual basis 
by a specified deadline. For example, applications for FY 2009 were 
submitted in November 2007. After accepting applications, CMS then 
evaluates them in the annual IPPS proposed and final rules to determine 
whether the medical service or technology is eligible for the new 
medical service or technology add-on payment. If an application meets 
each of the eligibility criteria, the medical service or technology is 
eligible for new medical service or technology add-on payments 
beginning on the first day of the new fiscal year (that is, October 1).
    We have advised prior and potential applicants that we evaluate 
whether a medical service or technology is eligible for the new medical 
service or technology add-on payments prior to publication of the final 
rule setting forth the annual updates and changes to the IPPS, with the 
results of our determination announced in the final rule. We announce 
our results in the final rule for each fiscal year because we believe 
predictability is an important aspect of the IPPS and that it is 
important to apply a consistent payment methodology for new medical 
services or technologies throughout the entire fiscal year. For 
example, hospitals must train their billing and other staff after 
publication of the final rule to properly implement the coding and 
payment changes for the upcoming fiscal year set forth in the final 
rule. In addition, hospitals' budgetary process and clinical decisions 
regarding whether to utilize new technologies are based in part on the 
applicable payment rates under the IPPS for the upcoming fiscal year, 
including whether the new medical services or technologies qualify for 
the new medical service or technology add-on payment. If CMS were to 
make multiple payment changes under the IPPS during a fiscal year, 
these changes could adversely affect the decisions hospitals implement 
at the beginning of the fiscal year. For these reasons, we believe 
applications for new medical service or technology add-on payments 
should be evaluated prior to publication of the final IPPS rule for 
each fiscal year. Therefore, if an application does not meet the new 
medical service or technology add-on payment criteria prior to 
publication of the final rule, it will not be eligible for the new 
medical service or technology add-on payments for the fiscal year for 
which it applied for the add-on payments.
    Because we make our determination regarding whether a medical 
service or technology meets the eligibility criteria for the new 
medical service or technology add-on payments prior to publication of 
the final rule, we have advised both past and potential applicants that 
their medical service or technology must receive FDA approval early 
enough in the IPPS rulemaking cycle to allow CMS enough time to fully 
evaluate the application prior to the publication of the IPPS final 
rule. Moreover, because new medical services or technologies that have 
not received FDA approval do not meet the newness criterion, it would 
not be necessary or prudent for us to make a final determination 
regarding whether a new

[[Page 23617]]

medical service or technology meets the cost threshold and substantial 
clinical improvement criteria prior to the medical service or 
technology receiving FDA approval. In addition, we do not believe it is 
appropriate for CMS to determine whether a medical service or 
technology represents a substantial clinical improvement over existing 
technologies before the FDA makes a determination as to whether the 
medical service or technology is safe and effective. For these reasons, 
we first determine whether a medical service or technology meets the 
newness criteria, and only if so, do we then make a determination as to 
whether the technology meets the cost threshold and represents a 
substantial clinical improvement over existing medical services or 
technologies. For example, even if an application has FDA approval, if 
the medical service or technology is beyond the timeline of 2-3 years 
to be considered new, in the past we have not made a determination on 
the cost threshold and substantial clinical improvement. Further, as we 
have discussed in prior final rules (69 FR 49018-49019 and 70 FR 
47344), it is our past and present practice to analyze the new medical 
service or technology add-on payment criteria in the following 
sequence: Newness, cost threshold, and finally substantial clinical 
improvement. Under our proposal in this proposed rule, we would 
continue this practice of analyzing the eligibility criteria in this 
sequence and announce in the annual Federal Register as part of the 
annual updates and changes to the IPPS our determination on whether a 
medical service or technology meets the eligibility criteria in Sec.  
412.87(b).
    In the interest of more clearly defining the parameters under which 
CMS can fully and completely evaluate new medical service or technology 
add-on payment applications, we are proposing to amend the regulations 
at Sec.  412.87 by adding a new paragraph (c) to codify our current 
policy and specify that CMS will consider whether a new medical service 
or technology meets the eligibility criteria in Sec.  412.87(b) and 
announce the results in the Federal Register as part of the annual 
updates and changes to the IPPS. As a result, we are proposing to 
remove the duplicative text in Sec.  412.87(b)(1) that specifies that 
CMS will determine whether a new medical service or technology meets 
the substantial clinical improvement criteria and announce the results 
of its determination in the Federal Register as part of the annual 
updates and changes to the IPPS. We note that this proposal is not a 
change to our current policy, as we have always given consideration to 
whether an application meets the new medical service or technology 
eligibility criteria in the annual IPPS proposed and final rules. 
Rather, this proposal simply codifies our current practice of fully 
evaluating new medical service or technology add-on payment 
applications prior to publication of the final rule in order to 
maintain predictability within the IPPS for the upcoming fiscal year.
    In addition, we are proposing in new paragraph (c) of Sec.  412.87 
to set July 1 of each year as the deadline by which IPPS new medical 
service or technology add-on payment applications must receive FDA 
approval. This proposed deadline should provide us with enough time to 
fully consider all of the new medical service or technology add-on 
payment criteria for each application and maintain predictability in 
the IPPS for the coming fiscal year.
    Finally, under this proposal, applications that have not received 
FDA approval by July 1 would not be considered in the final rule, even 
if they were summarized in the corresponding IPPS proposed rule. 
However, applications that receive FDA approval of the medical service 
or technology after July 1 would be able to reapply for the new medical 
service or technology add-on payment the following year (at which time 
they would be given full consideration in both the IPPS proposed and 
final rules).
    In summary, for the reasons cited above, we are proposing to revise 
Sec.  412.87 to remove the second sentence of (b)(1) and add a new 
paragraph (c) to codify our current practice of how CMS evaluates new 
medical service or technology add-on payment applications and establish 
in paragraph (c) a deadline of July 1 of each year as the deadline by 
which IPPS new medical service or technology add-on payment 
applications must receive FDA approval in order to be fully evaluated 
in the applicable IPPS final rule each year.

III. Proposed Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of statistical areas established by the Office of Management and Budget 
(OMB). A discussion of the proposed FY 2009 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 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 2009 is 
discussed in section II.B. of the Addendum to this proposed rule.
    As discussed below in section III.I. of this preamble, we also take 
into account the geographic reclassification of hospitals in accordance 
with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating 
IPPS payment amounts. Under section 1886(d)(8)(D) of the Act, the 
Secretary is required to adjust the standardized amounts so as to 
ensure that aggregate payments under the IPPS after implementation of 
the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the 
Act are equal to the aggregate prospective payments that would have 
been made absent these provisions. The proposed budget neutrality 
adjustment for FY 2009 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, 2008 (the FY 2009 wage index) appears under 
section III.D. of this preamble.

B. Requirements of Section 106 of the MIEA-TRHCA

1. Wage Index Study Required Under the MIEA-TRHCA
    Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) required

[[Page 23618]]

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 this FY 2009 IPPS proposed rule one or more proposals to 
revise the wage index adjustment applied under section 1886(d)(3)(E) of 
the Act for purposes of the IPPS. The proposal (or proposals) must 
consider each of the following:
    <bullet> Problems associated with the definition of labor markets 
for the wage index adjustment.
    <bullet> The modification or elimination of geographic 
reclassifications and other adjustments.
    <bullet> The use of Bureau of Labor of Statistics data or other 
data or methodologies to calculate relative wages for each geographic 
area.
    <bullet> Minimizing variations in wage index adjustments between 
and within MSAs and statewide rural areas.
    <bullet> The feasibility of applying all components of CMS' 
proposal to other settings.
    <bullet> Methods to minimize the volatility of wage index 
adjustments while maintaining the principle of budget neutrality.
    <bullet> The effect that the implementation of the proposal would 
have on health care providers on each region of the country.
    <bullet> Methods for implementing the proposal(s) including methods 
to phase in such implementations.
    <bullet> 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 its June 2007 Report to Congress, ``Report to the Congress: 
Promoting Greater Efficiency in Medicare'' (Chapter 6 with Appendix), 
MedPAC made three broad recommendations regarding the wage index:
    (1) Congress should repeal the existing hospital wage index 
statute, including reclassifications and exceptions, and give the 
Secretary authority to establish a new wage index system;
    (2) The Secretary should establish a hospital compensation index 
that--
    <bullet> Uses wage data from all employers and industry-specific 
occupational weights;
    <bullet> Is adjusted for geographic differences in the ratio of 
benefits to wages;
    <bullet> Is adjusted at the county level and smoothes large 
differences between counties; and
    <bullet> Is implemented so that large changes in wage index values 
are phased in over a transition period; and
    (3) The Secretary should use the hospital compensation index for 
the home health and skilled nursing facility prospective payment 
systems and evaluate its use in the other Medicare fee-for-service 
prospective payment systems.
    The full June 2007 Report to Congress is available at the Web site: 
http://www.medpac.gov/documents/Jun07_EntireReport.pdf).
    In the presentation and analysis of its alternative wage index 
system, MedPAC addressed almost all of the nine points for 
consideration under section 106(b)(2) of Pub. L. 109-432. Following are 
the highlights of the alternative wage index system recommended by 
MedPAC:
    <bullet> Although the MedPAC recommended wage index generally 
retains the current labor market definitions, it supplements the 
metropolitan areas with county-level adjustments and eliminates single 
wage index values for rural areas.
    <bullet> In the MedPAC recommended wage index, the county-level 
adjustments, together with a smoothing process that constrains the 
magnitude of differences between and within contiguous wage areas, 
serve as a replacement for geographical reclassifications.
    <bullet> The MedPAC recommended wage index uses BLS data instead of 
the CMS hospital wage data collected on the Medicare cost report. 
MedPAC adjusts the BLS data for geographic differences in the ratio of 
benefits to wages using Medicare cost report data.
    <bullet> The BLS data are collected from a sample of all types of 
employers, not just hospitals. The MedPAC recommended wage index could 
be adapted to other providers such as HHAs and SNFs by replacing 
hospital occupational weights with occupational weights appropriate for 
other types of providers.
    <bullet> In the MedPAC recommended wage index, volatility over time 
is addressed by the use of BLS data, which is based on a 3-year rolling 
sample design.
    <bullet> MedPAC recommends a phased implementation for its 
recommended wage index in order to cushion the effect of large wage 
index changes on individual hospitals.
    <bullet> MedPAC suggests that using BLS data automatically 
addresses occupational mix differences, because the BLS data are 
specific to health care occupations, and national industry-wide 
occupational weights are applied to all geographic areas.
    <bullet> The MedPAC report does not provide any evidence of the 
impact of its wage index on staffing practices or the quality of care 
and patient safety.
    To assist CMS in meeting the requirements of section 106(b)(2) of 
Pub. L. 109-432, in February 2008, CMS awarded a Task Order under its 
Expedited Research and Demonstration Contract, to Acumen, LLC. The two 
general responsibilities of the Task Order are to (1) conduct a 
detailed impact analysis that compares the effects of MedPAC's wage and 
hospital compensation indexes with the CMS wage index and (2) assist 
CMS in developing a proposal (or proposals) that addresses the nine 
points for consideration under section 106(b)(2) of Pub. L. 109-432. 
Specifically, the tasks under the Task Order include, but are not 
limited to, an evaluation of whether differences between the two types 
of wage data (that is, CMS cost report and occupational mix data and 
BLS data) produce significant differences in wage index values among 
labor market areas, a consideration of alternative methods of 
incorporating benefit costs into the construction of the wage index, a 
review of past and current research on alternative labor market area 
definitions, and a consideration of how aspects of the MedPAC 
recommended wage index can be applied to the CMS wage data in 
constructing a new methodology for the wage index. We will present any 
analyses and proposals resulting from this Task Order in the FY 2009 
IPPS final rule or in a special Federal Register notice issued after 
the final rule is published.
2. CMS Proposals in Response to Requirements Under Section 106(b) of 
the MIEA-TRHCA
    As discussed in section III.A. of this preamble, the purpose of the 
hospital wage index is to adjust the IPPS standardized payment to 
reflect labor market area differences in wage levels. The geographic 
reclassification system exists in order to assist ``hospitals which are 
disadvantaged by their current geographic classification because they 
compete with hospitals that are located in the geographic area to which 
they seek to be reclassified'' (56 FR 25469). Geographic 
reclassification is

[[Page 23619]]

established under section 1886(d)(10) of the Act and is implemented 
through 42 CFR Part 412, Subpart L. (We refer readers to section III.I. 
of this preamble for a detailed discussion of the geographic 
reclassification system and other area wage index exceptions.)
    In its June 2007 Report to Congress, MedPAC discussed its findings 
that geographic reclassification, and numerous other area wage index 
exceptions added to the system over the years, have created major 
complexities and ``troubling anomalies'' in the hospital wage index. A 
review of the IPPS final rules reveals a long history of legislative 
changes that have permitted certain hospitals, that otherwise would not 
be able to reclassify under section 1886(d)(10) of the Act, to receive 
a higher wage index than calculated for their geographic area. MedPAC 
reports that more than one-third of hospitals now receive a higher wage 
index due to geographic reclassification or other wage index 
exceptions. We are concerned about the integrity of the current system, 
and agree with MedPAC that the process has become burdensome.
    As noted above, MedPAC recommended the elimination of geographic 
reclassification and other wage index exceptions. In addition, the 
President's FY 2009 Budget included a proposal to apply the geographic 
reclassification budget neutrality requirement at the State level 
rather than by adjusting the standardized rate for hospitals 
nationwide. Given the language in section 1886(d)(10) of the Act 
establishing the MGCRB, we believe a statutory change would be required 
to make these changes. However, we do have the authority to make some 
regulatory changes to the reclassification system as discussed below. 
We note that these proposals do not preclude future consideration of 
MedPAC's recommendations that could be implemented through additional 
changes to our regulations, once our analysis of those recommendations 
is complete (after the publication of the FY 2009 IPPS proposed rule).
a. Proposed Revision of the Reclassification Average Hourly Wage 
Comparison Criteria
    Regulations at 42 CFR 413.230(d)(1) set forth the average hourly 
wage comparison criteria that an individual hospital must meet in order 
for the MGCRB to approve a geographic reclassification application. Our 
current criteria (requiring an urban hospital to demonstrate that its 
average hourly wage is at least 108 percent of the average hourly wage 
of hospitals in the area in which the hospital is located and at least 
84 percent of the average hourly wage of hospitals in the area to which 
it seeks redesignation) were adopted in the FY 1993 IPPS final rule (57 
FR 39825). In that final rule, we explained that the 108 percent 
threshold ``is based on the national average hospital wage as a 
percentage of its area wage (96 percent) plus one standard deviation 
(12 percent).'' We also explained that we would use the 84-percent 
threshold to reflect the average hospital wage of the hospital as a 
percentage of its area wage less one standard deviation. We stated that 
``to qualify for a wage index reclassification, a hospital must have an 
average hourly wage that is more than one national standard deviation 
above its original labor market area and not less than one national 
standard deviation below its new labor market area'' (57 FR 39770). In 
response to numerous public comments we received, we expressed our 
policy and legal justifications for adopting the specific thresholds. 
Among other things, we stated that geographic reclassifications must be 
viewed not just in terms of those hospitals that are reclassifying, but 
also in terms of the nonreclassifying hospitals that, through a budget 
neutrality adjustment, are required to bear a financial burden 
associated with the higher wage indices received by those hospitals 
that reclassify. We also indicated that the Secretary has ample legal 
authority under section 1886(d)(10) of the Act to set the wage 
comparison thresholds and to revise such thresholds upon further 
review. We refer readers to that final rule for a full discussion of 
our justifications for the standards.
    In the FY 2000 IPPS final rule (65 FR 47089 through 47090), the 
wage comparison criteria for rural hospitals seeking individual 
hospital reclassifications were reduced to 82 percent and 106 percent 
to compensate for the historic economic underperformance of rural 
hospitals. The 2-percent drop in both thresholds was determined to 
allow a significant benefit to some hospitals that were close to 
meeting the existing criteria but would not make the reclassification 
standards overly liberal for rural hospitals.
    CMS has not evaluated or recalibrated the average hourly wage 
criteria for geographic reclassification since they were established in 
FY 1993. In consideration of the MIEA-TRHCA requirements and MedPAC's 
finding that over one-third of hospitals are receiving a reclassified 
wage index or other wage index adjustment, we decided to reevaluate the 
average hourly wage criteria for geographic reclassification. We ran 
simulations with more recent wage data to determine what would be the 
appropriate average hourly wage criteria. We found that the average 
hospital average hourly wage as a percentage of its area's wage has 
increased from approximately 96 percent in FY 1993 to closer to 98 
percent over FYs 2006, 2007, and 2008 (97.8, 98.2, and 98 percent, 
respectively). We also determined that the standard deviation has been 
reduced from approximately 12 percent in FY 1993 to closer to 10 
percent over the same 3-year period (10.7, 10.4, and 10.4 percent, 
respectively); that is, assuming normal distributions, approximately 68 
percent of all hospitals would have an average hourly wage that 
deviates less than 10 percentage points above or below the mean. This 
assessment indicates that the new baseline criteria for 
reclassification should be set to 88/108 percent. While the 108 
criterion appears not to require adjustment, the current 84 percent 
standard appears to be too low a threshold to serve the purpose of 
establishing wage comparability with a proximate labor market area.
    To assess the impact that these changes would have had on hospitals 
that reclassified in FY 2008, we ran models that set urban individual 
reclassification standards to 88/108 percent and the county group 
reclassification standard to 88 percent. We retained the 2-percent 
benefit for rural hospitals by setting an 86/106 percent standard. We 
used 3-year average hourly wage figures from the 2005, 2006, and 2007 
wage surveys and compared them to 3-year average hourly wage figures 
for CBSAs over the same 3-year period.
    Of the 295 hospitals that applied for and received individual 
reclassifications in FY 2008, 45 of them (15.3 percent) would not meet 
the proposed 88/86 percent threshold. Of the 66 hospitals that applied 
for and received county group reclassification in FY 2008, 6 hospitals 
(9.1 percent) in 3 groups would not have qualified with the new 
standards. We also ran comparisons for hospitals that reclassified in 
FY 2006 and FY 2007 to determine if they would have been able to 
reclassify in FY 2008, using 3-year averages available in FY 2008. We 
found that, of all hospitals that were reclassified in FY 2008 (that 
is, applications approved for FYs 2006 through 2008), 14.7 percent of 
individual reclassifications and 8.5 percent of county group 
reclassification would not have qualified to reclassify in FY 2008.

[[Page 23620]]

    Section 106 of MIEA-TRHCA requires us to propose revisions to the 
hospital wage index system after considering the recommendations of 
MedPAC. To address this requirement, we are proposing that the 84/108 
criteria for urban hospital reclassifications and the 82/106 criteria 
for rural hospital reclassifications be recalibrated using the 
methodology published in the FY 1993 final rule and more recent wage 
data (that is, data used in computing the FYs 2006, 2007, 2008 wage 
indices). We believe that hospitals that are seeking to reclassify to 
another area should be required to demonstrate more similarity to the 
area than the current criteria permit, and our recent analysis 
demonstrates that those criteria are no longer appropriate. Therefore, 
we are proposing to change the criterion for the comparison of a 
hospital's average hourly wage to that of the area to which the 
hospital seeks reclassification to 88 percent for urban hospitals and 
86 percent for rural hospitals for new reclassifications beginning with 
the FY 2010 wage index and, accordingly, revise our regulations at 42 
CFR 412.230 to reflect these changes. The criterion for the comparison 
of a hospital's average hourly wage to that of its geographic area 
would be unchanged (108 percent for urban hospitals and 106 percent for 
rural hospitals). We also are proposing that, when there are 
significant changes in labor market area definitions, such as CMS' 
adoption of new OMB CBSA definitions based upon the decennial census 
(69 FR 49027), we would again reevaluate and, if warranted, recalibrate 
these criteria. This would allow CMS to consider the effects of 
periodic changes in labor market boundaries and provide a regular 
timeline for updating and validating the reclassification criteria. 
Finally, we are proposing to adjust the 85 percent criterion for both 
urban and rural county group reclassifications to be equal to the 
proposed 88 percent standard for urban reclassifications, and to revise 
the regulations at 42 CFR 412.232 and 412.234 to reflect the change. 
The urban and rural county group average hourly wage standard has 
always been equivalent for both urban and rural county groups and has 
always been 1 percent higher than the 84 percent urban area individual 
reclassification standard. We would continue the policy of having an 
equivalent wage comparison criterion for both urban and rural county 
groups, as these groups have always used the same wage comparison 
criteria. We also would use the individual urban hospital 
reclassification standard of 88 percent because this threshold would 
ensure that the hospitals in the county group are at least as 
comparable to the proximate area as are individual hospitals within 
their own areas. Also, we do not believe it would be appropriate to 
have a group reclassification standard lower than the individual 
reclassification standards, thus potentially creating a situation where 
all of the hospitals in a county could reclassify, even though no 
single hospital within such county would be able to meet any average 
hourly wage-related comparisons for an individual reclassification.
    We considered raising the group reclassification criterion to 89 
percent in order to preserve the historical policy of the standard 
being set at 1 percent higher than the individual reclassification 
standard. However, we determined that making the group standard equal 
to the individual standard would adequately address our stated 
concerns.
    We note that the proposed changes in the reclassification criteria 
apply only to new reclassifications beginning with the FY 2010 wage 
index. Any hospital or county group that is in the midst of a 3-year 
reclassification in FY 2010 will not be affected by the proposed 
criteria change until they reapply for a geographic reclassification. 
Therefore, we are proposing the effective date for these changes would 
be September 1, 2008, the deadline for hospitals to submit applications 
for reclassification for the FY 2010 wage index.
b. Within-State Budget Neutrality Adjustment for the Rural and Imputed 
Floors
    Section 4410 of the Balanced Budget Act of 1997 (BBA) established 
the rural floor by requiring that the wage index for a hospital in an 
urban area of a State cannot be less than the area wage index 
determined for that State's rural area. Section 4410(b) of the BBA 
imposed the budget neutrality requirement and stated that the Secretary 
shall ``adjust the area wage index referred to in subsection (a) for 
hospitals not described in such subsection.'' Therefore, in order to 
compensate for the increased wage indices of urban hospitals receiving 
the rural floor, a nationwide budget neutrality adjustment is applied 
to the wage index to account for the additional payment to these 
hospitals. As a result, urban hospitals that qualify for their State's 
rural floor wage index receive enhanced payments at the expense of all 
rural hospitals nationwide and all other urban hospitals that do not 
receive their State's rural floor. In the FY 2009 proposed wage index, 
266 hospitals in 27 States benefit from the rural floor. The first 
chart below lists the percentage of total payments each State either 
received or contributed to fund the current rural floor and imputed 
floor provisions with national budget neutrality adjustments (as 
indicated in the discussion of the imputed floor below in this section 
III.B.2.b.). The second chart below provides a graphical depiction of 
the proposed FY 2009 impacts.

 FY 2009 IPPS Estimated Payments with Proposed Within-State Rural Floor
                   and Imputed Floor Budget Neutrality
------------------------------------------------------------------------
                                                        Proposed policy
                                      Current policy     application of
                                      application of    rural floor and
               State                  national rural     imputed floor
                                    floor and imputed        budget
                                       floor budget    neutrality within
                                        neutrality         each state
------------------------------------------------------------------------
Alabama...........................               -0.1                0.3
Alaska............................                0.0               -0.2
Arizona...........................               -0.2                0.3
Arkansas..........................               -0.1                0.3
California........................                0.7               -0.8
Colorado..........................                0.0               -0.1
Connecticut.......................                2.1               -2.2
Delaware..........................               -0.2                0.3
Washington, DC....................               -0.2                0.3

[[Page 23621]]

 
Florida...........................                0.0                0.0
Georgia...........................               -0.1                0.3
Hawaii............................               -0.1                0.3
Idaho.............................               -0.1                0.3
Illinois..........................               -0.2                0.1
Indiana...........................               -0.1                0.0
Iowa..............................                0.1               -0.1
Kansas............................               -0.1                0.3
Kentucky..........................               -0.1                0.3
Louisiana.........................               -0.1                0.0
Maine.............................               -0.1                0.3
Massachusetts.....................               -0.2                0.3
Michigan..........................               -0.2                0.3
Minnesota.........................               -0.2                0.3
Mississippi.......................               -0.1                0.3
Missouri..........................               -0.1                0.0
Montana...........................               -0.1                0.2
Nebraska..........................               -0.1                0.3
Nevada............................               -0.2                0.3
New Hampshire.....................                1.1               -1.2
New Jersey........................                0.7               -0.8
New Mexico........................               -0.1                0.0
New York..........................               -0.2                0.3
North Carolina....................               -0.1                0.1
North Dakota......................                0.1               -0.1
Ohio..............................               -0.1                0.1
Oklahoma..........................               -0.1                0.1
Oregon............................               -0.1                0.0
Pennsylvania......................               -0.1                0.1
Rhode Island......................               -0.2                0.3
South Carolina....................               -0.1                0.0
South Dakota......................               -0.1                0.3
Tennessee.........................                0.0                0.0
Texas.............................               -0.1                0.1
Utah..............................               -0.1                0.3
Vermont...........................                3.5               -3.4
Virginia..........................               -0.1                0.0
Washington........................               -0.1               -0.1
West Virginia.....................                0.0               -0.1
Wisconsin.........................               -0.1               -0.1
Wyoming...........................                0.0                0.1
------------------------------------------------------------------------


[[Page 23622]]

[GRAPHIC][TIFF OMITTED]TP30AP08.018

    The above charts demonstrate how, at a State-by-State level, the 
rural floor is creating a benefit for a minority of States that is then 
funded by a majority of States, including States that are 
overwhelmingly rural in character. The intent behind the rural floor 
seems to have been to address anomalous occurrences where certain urban 
areas in a State have unusually depressed wages when compared to the 
State's rural areas. However, because these comparisons occur at the 
State level, we believe it also would be sound policy to make the 
budget neutrality adjustment specific to the State, redistributing 
payments among hospitals within the State, rather than adjusting 
payments to hospitals in other States.
    In addition, a statewide budget neutrality adjustment would address 
the situation we discussed in the FY 2008 IPPS final rule with comment 
period (72 FR 47324) in which rural CAHs were converting to IPPS 
status, apparently to raise the State's rural wage index to a level 
whereby all urban hospitals in the State would receive the rural floor. 
Medicare payments to CAHs are based on 101 percent of reasonable costs 
while the IPPS pays hospitals a fixed rate per discharge. In addition, 
as a CAH, a hospital is guaranteed to recover its costs, while an IPPS 
hospital is provided with incentives to increase efficiency to cover 
its costs. Thus, we stated that the identified CAHs were converting 
back to IPPS, even though the conversion would not directly benefit 
them. Because these hospitals' wage levels are higher than most, if not 
all, of the urban hospitals in the State, the wage indices for most, if 
not all, of the State's urban hospitals would increase as a result of 
the rural floor provision if the CAHs convert to IPPS status. In 
simulating the effect of the hospitals setting the State's rural floor, 
we estimated that payment to hospitals in the State would increase in 
excess of $220 million in a single year. The MedPAC, in its June 2007 
Report to the Congress stated, ``The fact that the movement of one or 
two CAHs in or out of the [I]PPS system can increase (or decrease) 
Medicare payments by $220 million suggests there is a flaw in the 
design of the wage index system.'' (We refer readers to page 131 of the 
report.)
    For the above reasons, we are proposing to apply a State level 
rural floor budget neutrality adjustment to the wage index beginning in 
FY 2009. States that have no hospitals receiving a rural floor wage 
index would no longer have a negative budget neutrality adjustment 
applied to their wage indices. Conversely, hospitals in States with 
hospitals receiving a rural floor would

[[Page 23623]]

have their wage indices downwardly adjusted to achieve budget 
neutrality within the State. All hospitals within each State would, in 
effect, be responsible for funding the rural floor adjustment 
applicable within that specific State.
    In the FY 2005 IPPS final rule and the FY 2008 IPPS final rule with 
comment period (69 FR 49109 and 72 FR 47321, respectively), we 
temporarily adopted an ``imputed'' floor measure to address a concern 
by some individuals that hospitals in all-urban States were 
disadvantaged by the absence of rural hospitals. Because no rural wage 
index could be calculated, no rural floor could be applied within such 
States. We originally limited application of the policy to FYs 2005 
through 2007 and then extended it one additional year, through FY 2008. 
We are proposing to extend the imputed floor for 3 additional years, 
through FY 2011, and to revise the introductory text of Sec.  
412.64(h)(4) of our regulations to reflect this extension. For FY 2009, 
26 hospitals in New Jersey (33.8 percent) would receive the imputed 
floor. Rhode Island, the only other all-urban State, has no hospitals 
that would receive the imputed floor. In past years, we applied a 
national budget neutrality adjustment to the standardized amount to 
ensure that payments remained constant to payments that would have 
occurred in the absence of the imputed floor policy. As a result, 
payments to all other hospitals in the Nation were adjusted downward to 
subsidize the higher payments to New Jersey hospitals receiving the 
imputed floor. As the intent of the imputed floor is to create a 
protection to all-urban States similar to the protection offered to 
urban-rural mixed States by the rural floor, and the effect of the 
measure is also State-specific like the rural floor, we believe that 
the budget neutrality adjustments for the imputed floor and the rural 
floor should be applied in the same manner. Therefore, beginning with 
FY 2009, we are also proposing to apply the imputed floor budget 
neutrality adjustment to the wage index and at the State level.
    Based on our impact analysis of these proposals for FY 2009, of the 
49 States (Maryland is excluded because it is under a State waiver), 
the District of Columbia, and Puerto Rico, 39 would see either no 
change or an increase in total Medicare payments as a result of 
applying a budget neutrality adjustment to the wage index for the rural 
and imputed floors at the State level rather than the national level. 
The total payments of the remaining 12 States would decrease 0.1 
percent to 3.4 percent compared to continuing our prior national 
adjustment policy. The full impact analysis is reflected in the two 
charts presented earlier in this section III.B.2.b. of the preamble of 
this proposed rule. Tables 4D-1 and 4D-2 in the Addendum to this 
proposed rule reflect the proposed FY 2009 State level budget 
neutrality adjustments for the rural and imputed floors. We are 
specifically requesting public comments from national and State 
hospital associations regarding these proposals, particularly the 
national associations, as they represent member hospitals that are both 
positively and negatively affected by our proposed policies, and are, 
therefore, in the best position to comment on the policy merits of 
these proposals. We will view the absence of any comments from the 
national hospital associations as a sign that they do not object to our 
proposed policies.
c. Within-State Budget Neutrality Adjustment for Geographic 
Reclassification
    Currently, section 1886(d)(8)(D) of the Act requires us to adjust 
the standardized amount to ensure that the effects of geographic 
reclassification do not increase aggregate IPPS payments. This means 
that, in the case of a reclassification, budget neutrality is achieved 
by reducing the standardized amount for all hospitals nationwide. The 
FY 2009 President's Budget includes a legislative proposal to apply 
geographic reclassification budget neutrality at the State level 
(available at the Web site: www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf under FY 2009 Medicare Proposals, page 54). If 
this proposal is enacted by the Congress, budget neutrality would be 
achieved by adjusting the wage index for all hospitals within the State 
rather than reducing the standardized amount for all hospitals 
nationwide.
    As noted also in MedPAC's June 2007 Report to Congress, over the 
years, there have been many changes to the Medicare law that are 
intended to broaden the ability for a hospital to receive a wage index 
that is higher than the value that is calculated for its geographic 
area and not be subject to the proximity or wage level criteria for 
geographic reclassification established under section 1886(d)(10) of 
the Act. These more targeted geographic reclassification provisions are 
creating inequities in the wage index by sometimes allowing hospitals 
to be reclassified to areas where other hospitals that are closer in 
proximity are ineligible to reclassify. Applying budget neutrality at 
the State level would focus the costs of geographic reclassification 
closer to the areas where hospitals that benefit from the 
reclassification are located. We expect that a legislative provision on 
applying geographic reclassification budget neutrality at the State 
level would be applied to all reclassifications and wage index 
exceptions that are implemented through 42 CFR Part 412, Subpart L, and 
certain provisions of the Social Security Act that permit hospitals to 
receive a higher wage index than is calculated for their geographic 
area. (As discussed above, as a proposed regulatory matter, there also 
would be a separate within-State budget neutrality adjustment for the 
imputed and rural floors.) We expect that reclassification budget 
neutrality at the State level would operate through adjustments to the 
IPPS payments to hospitals in the State in which the reclassifying 
hospital is geographically located.
    We are seeking public comments regarding MedPAC's recommendations 
for reforming the wage index, our plan for our contractor's review of 
the wage index, and the regulatory proposals for modifying the current 
hospital wage index system. We also welcome additional suggestions for 
reforming the hospital wage index.

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 2008 final rule, for FY 2009 we are proposing to 
provide that hospitals receive 100 percent of their wage index based 
upon the CBSA configurations. Specifically, for each hospital, we will 
determine a wage index for FY 2009 employing wage index data from FY 
2005 hospital cost reports and using the CBSA labor market definitions. 
We consider CBSAs that are MSAs to be urban, and CBSAs that are 
Micropolitan Statistical Areas as well as areas outside of CBSAs to be 
rural. In addition, 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

[[Page 23624]]

wage index (69 FR 49029). We are proposing to codify this longstanding 
policy into our regulations at Sec.  412.64(b)(1)(ii)(A).
    On November 20, 2007, OMB announced the revision of titles for 
eight urban areas (OMB Bulletin No. 08-01). The revised titles are as 
follows:
    <bullet> Hammonton, New Jersey qualifies as a new principal city of 
the Atlantic City, New Jersey CBSA. The new title is Atlantic City-
Hammonton, New Jersey CBSA;
    <bullet> New Brunswick, New Jersey, located in the Edison, New 
Jersey Metropolitan Division, qualifies as a new principal city of the 
New York-Northern New Jersey-Long Island, New York, New Jersey, 
Pennsylvania CBSA. The new title for the Metropolitan Division is 
Edison-New Brunswick, New Jersey CBSA;
    <bullet> Summerville, South Carolina qualifies as a new principal 
city of the Charleston-North Charleston, South Carolina CBSA. The new 
title is Charleston-North Charleston-Summerville, South Carolina;
    <bullet> Winter Haven, Florida qualifies as a new principal city of 
the Lakeland, Florida CBSA. The new title is Lakeland-Winter Haven, 
Florida;
    <bullet> Bradenton, Florida replaces Sarasota, Florida as the most 
populous principal city of the Sarasota-Bradenton-Venice, Florida CBSA. 
The new title is Bradenton-Sarasota-Venice, Florida. The new CBSA code 
is 14600;
    <bullet> Frederick, Maryland replaces Gaithersburg, Maryland as the 
second most populous principal city in the Bethesda-Gaithersburg-
Frederick, Maryland CBSA. The new title is Bethesda-Frederick-
Gaithersburg, Maryland;
    <bullet> North Myrtle Beach, South Carolina replaces Conway, South 
Carolina as the second most populous principal city of the Myrtle 
Beach-Conway-North Myrtle Beach, South Carolina CBSA. The new title is 
Myrtle Beach-North Myrtle Beach-Conway, South Carolina;
    <bullet> Pasco, Washington replaces Richland, Washington as the 
second most populous principal city of the Kennewick-Richland-Pasco, 
Washington CBSA. The new title is Kennewick-Pasco-Richland, Washington.
    The OMB bulletin is available on the OMB Web site at https://www.whitehouse.gov/OMB-- go to ``Bulletins'' or ``Statistical Programs 
and Standards.'' CMS will apply these changes to the IPPS beginning 
October 1, 2008.

D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 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.
1. Development of Data for the Proposed FY 2009 Occupational Mix 
Adjustment
    On October 14, 2005, we published a notice in the Federal Register 
(70 FR 60092) proposing to use a new survey, the 2006 Medicare Wage 
Index Occupational Mix Survey (the 2006 survey) to apply an 
occupational mix adjustment to the FY 2008 wage index. In the proposed 
2006 survey, we included several modifications based on the comments 
and recommendations we received on the 2003 survey, including (1) 
allowing hospitals to report their own average hourly wage rather than 
using BLS data; (2) extending the prospective survey period; and (3) 
reducing the number of occupational categories but refining the 
subcategories for registered nurses.
    We made the changes to the occupational categories in response to 
MedPAC comments to the FY 2005 IPPS final rule (69 FR 49036). 
Specifically, MedPAC recommended that CMS assess whether including 
subcategories of registered nurses would result in a more accurate 
occupational mix adjustment. MedPAC believed that including all 
registered nurses in a single category may obscure significant wage 
differences among the subcategories of registered nurses, for example, 
the wages of surgical registered nurses and floor registered nurses may 
differ. Also, to offset additional reporting burden for hospitals, 
MedPAC recommended that CMS should combine the general service 
categories that account for only a small percentage of a hospital's 
total hours with the ``all other occupations'' category because most of 
the occupational mix adjustment is correlated with the nursing general 
service category.
    In addition, in response to the public comments on the October 14, 
2005 notice, we modified the 2006 survey. On February 10, 2006, we 
published a Federal Register notice (71 FR 7047) that solicited 
comments and announced our intent to seek OMB approval on the revised 
occupational mix survey (Form CMS-10079 (2006)). OMB approved the 
survey on April 25, 2006.
    The 2006 survey provides for the collection of hospital-specific 
wages and hours data, a 6-month prospective reporting period (that is, 
January 1, 2006, through June 30, 2006), the transfer of each general 
service category that comprised less than 4 percent of total hospital 
employees in the 2003 survey to the ``all other occupations'' category 
(the revised survey focuses only on the mix of nursing occupations), 
additional clarification of the definitions for the occupational 
categories, an expansion of the registered nurse category to include 
functional subcategories, and the exclusion of average hourly rate data 
associated with advance practice nurses.
    The 2006 survey included only two general occupational categories: 
nursing and ``all other occupations.'' The nursing category has four 
subcategories: Registered nurses, licensed practical nurses, aides, 
orderlies, attendants, and medical assistants. The registered nurse 
subcategory includes two functional subcategories: management personnel 
and staff nurses or clinicians. As indicated above, the 2006 survey 
provided for a 6-month data collection period, from January 1, 2006 
through June 30, 2006. However, we allowed flexibility for the 
reporting period beginning and ending dates to accommodate some 
hospitals' biweekly payroll and reporting systems. That is, the 6-month 
reporting period had to begin on or after December 25, 2005, and end 
before July 9, 2006.
    We are proposing to use the entire 6-month 2006 survey data to 
calculate the occupational mix adjustment for the FY 2009 wage index. 
The original timelines for the collection, review, and correction of 
the 2006 occupational mix data were discussed in detail in the FY 2007 
IPPS final rule (71 FR 48008). The revision and correction process for 
all of the data, including the 2006 occupational mix survey data to be 
used for computing the FY 2009 wage index, is discussed in detail in 
section III.K. of the preamble of this proposed rule.

[[Page 23625]]

2. Calculation of the Proposed Occupational Mix Adjustment for FY 2009
    For FY 2009 (as we did for FY 2008), we are proposing to calculate 
the occupational mix adjustment factor using the following steps:
    Step 1--For each hospital, determine the percentage of the total 
nursing category attributable to a nursing subcategory by dividing the 
nursing subcategory hours by the total nursing category's hours 
(registered nurse management personnel and registered nurse staff 
nurses or clinicians are treated as separate nursing subcategories). 
Repeat this computation for each of the five nursing subcategories: 
registered nurse management personnel; registered nurse staff nurses or 
clinicians; licensed practical nurses; nursing aides, orderlies, and 
attendants; and medical assistants.
    Step 2--Determine a national average hourly rate for each nursing 
subcategory by dividing a subcategory's total salaries for all 
hospitals in the occupational mix survey database by the subcategory's 
total hours for all hospitals in the occupational mix survey database.
    Step 3--For each hospital, determine an adjusted average hourly 
rate for each nursing subcategory by multiplying the percentage of the 
total nursing category (from Step 1) by the national average hourly 
rate for that nursing subcategory (from Step 2). Repeat this 
calculation for each of the five nursing subcategories.
    Step 4--For each hospital, determine the adjusted average hourly 
rate for the total nursing category by summing the adjusted average 
hourly rate (from Step 3) for each of the nursing subcategories.
    Step 5--Determine the national average hourly rate for the total 
nursing category by dividing total nursing category salaries for all 
hospitals in the occupational mix survey database by total nursing 
category hours for all hospitals in the occupational mix survey 
database.
    Step 6--For each hospital, compute the occupational mix adjustment 
factor for the total nursing category by dividing the national average 
hourly rate for the total nursing category (from Step 5) by the 
hospital's adjusted average hourly rate for the total nursing category 
(from Step 4).
    If the hospital's adjusted average hourly rate is less than the 
national average hourly rate (indicating the hospital employs a less 
costly mix of nursing employees), the occupational mix adjustment 
factor would be greater than 1.0000. If the hospital's adjusted average 
hourly rate is greater than the national average hourly rate, the 
occupational mix adjustment factor would be less than 1.0000.
    Step 7--For each hospital, calculate the occupational mix adjusted 
salaries and wage-related costs for the total nursing category by 
multiplying the hospital's total salaries and wage-related costs (from 
Step 5 of the unadjusted wage index calculation in section III.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).
    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 national hours. The 
proposed FY 2009 occupational mix adjusted national average hourly wage 
is $32.2252.
    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 
2009 occupational mix adjusted Puerto Rico specific average hourly wage 
is $13.7851.
    The table below is an illustrative example of the proposed 
occupational mix adjustment.
BILLING CODE 4120-01-P

[[Page 23626]]

[GRAPHIC][TIFF OMITTED]TP30AP08.019


[[Page 23627]]


[GRAPHIC][TIFF OMITTED]TP30AP08.020

BILLING CODE 4120-01-C

[[Page 23628]]

    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 
2009 wage index.
    For the FY 2008 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 (72 FR 47314). We believed this method had the least 
impact on the wage index for other hospitals in the area. For areas 
where no hospital submitted data for purposes of calculating the 
occupational mix adjustment, we applied the national occupational mix 
factor of 1.0000 in calculating the area's FY 2008 occupational mix 
adjusted wage index. We indicated in the FY 2008 IPPS final rule that 
we reserve the right to apply a different approach in future years, 
including potentially penalizing nonresponsive hospitals (72 FR 47314).
    For the FY 2009 wage index, we are proposing to handle the data for 
hospitals that did not respond to the occupational mix survey (neither 
the 1st quarter nor 2nd quarter data) in the same manner as discussed 
above for the FY 2008 wage index. In addition, if a hospital submits 
survey data for either the 1st quarter or 2nd quarter, but not for both 
quarters, we are proposing to use the data the hospital submitted for 
one quarter to calculate the hospital's proposed FY 2009 occupational 
mix adjustment factor. Lastly, if a hospital submits a survey(s), but 
that survey data can not be used because we determine it to be 
aberrant, we will also assign the hospital the average occupational mix 
adjustment for its labor market area. For example, if a hospital's 
individual nurse category average hourly wages are out of range (that 
is, unusually high or low), and the hospital does not provide 
sufficient documentation to explain the aberrancy, or the hospital does 
not submit any registered nurse staff salaries or hours data, we will 
assign the hospital the average occupational mix adjustment for the 
labor market area in which it is located.
    In calculating the average occupational mix adjustment factor for a 
labor market area, we replicated Steps 1 through 6 of the calculation 
for the occupational mix adjustment. However, instead of performing 
these steps at the hospital level, we aggregated the data at the labor 
market area level. In following these steps, for example, for CBSAs 
that contain providers that did not submit occupational mix survey 
data, the occupational mix adjustment factor ranged from a low of 
0.8968 (CBSA 39820, Redding, CA), to a high of 1.0775 (CBSA 43300, 
Sherman-Denison, TX). 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 2009, there was one CBSA for which we did not 
have occupational mix data for any of its providers (CBSA 12020, 
Athens-Clark County, GA). In the absence of any data in this labor 
market area, we applied an occupational mix adjustment factor of 1.0 to 
all provider(s).
    In the FY 2007 IPPS final rule, we also indicated that we would 
give serious consideration to applying a hospital-specific penalty if a 
hospital does not comply with regulations requiring submission of 
occupational mix survey data in future years. We stated that we believe 
that section 1886(d)(5)(I)(i) of the Act provides us with the authority 
to penalize hospitals that do not submit occupational mix survey data. 
That section authorizes us to provide for exceptions and adjustments to 
the payment amounts under IPPS as the Secretary deems appropriate. We 
also indicated that we would address this issue in the FY 2008 IPPS 
proposed rule.
    In the FY 2008 IPPS proposed rule, we solicited comments and 
suggestions for a hospital-specific penalty for hospitals that do not 
submit occupational mix survey data. In response to the FY 2008 IPPS 
proposed rule, some commenters suggested a 1-percent to 2-percent 
reduction in the hospital's wage index value or a set percentage of the 
standardized amount. We noted that any penalty that we would determine 
for nonresponsive hospitals would apply to a future wage index, not the 
FY 2008 wage index.
    In the FY 2008 final rule with comment period, we assigned 
nonresponsive hospitals the average occupational mix adjustment for the 
labor market area. For areas where no hospital submitted survey data, 
we applied the national occupational mix adjustment factor of 1.0000 in 
calculating the area's FY 2008 occupational mix adjusted wage index. We 
appreciate the suggestions we received regarding future penalties for 
hospitals that do not submit occupational mix survey data. We stated in 
the FY 2008 final rule with comment period that we may consider 
proposing a policy to penalize hospitals that do not submit 
occupational mix survey data for FY 2010, the first year of the 
application of the new 2007-2008 occupational mix survey, and that we 
expected that any such penalty would be proposed in the FY 2009 IPPS 
proposed rule so hospitals would be aware of the policy before the 
deadline for submitting the data to the fiscal intermediaries/MAC. At 
this time, however, we are not proposing a penalty for FY 2010. Rather, 
we are reserving the right to propose a penalty in the FY 2010 IPPS 
proposed rule, once we collect and analyze the FY 2007-2008 
occupational mix survey data. Hospitals are still on notice that any 
failure to submit occupational mix data for the FY 2007-2008 survey 
year may result in a penalty in FY 2010, thus achieving our policy goal 
of ensuring that hospitals are aware of the consequences of failure to 
submit data in response to the most recent survey.
3. 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index
    As stated earlier, section 304(c) of Pub. L. 106-554 amended 
section 1886(d)(3)(E) of the Act to require CMS to collect data every 3 
years on the occupational mix of employees for each short-term, acute 
care hospital participating in the Medicare program. We used 
occupational mix data collected on the 2006 survey to compute the 
proposed occupational mix adjustment for FY 2009. In the FY 2008 IPPS 
final rule with comment period (72 FR 47315), we discussed how we 
modified the occupational mix survey. The revised 2007-2008 
occupational mix survey provides for the collection of hospital-
specific wages and hours data for the 1-year period of July 1, 2007, 
through June 30, 2008, additional clarifications to the survey 
instructions, the elimination of the registered nurse subcategories, 
some refinements to the definitions of the occupational categories, and 
the inclusion of additional cost centers that typically provide nursing 
services. The revised 2007-2008 occupational mix survey will be applied 
beginning with the FY 2010 wage index.
    On February 2, 2007, we published in the Federal Register a notice 
soliciting comments on the proposed revisions to the occupational mix 
survey (72 FR 5055). The comment period for the notice ended on April 
3, 2007. After considering the comments we received, we made a few 
minor editorial changes

[[Page 23629]]

and published the final 2007-2008 occupational mix survey on September 
14, 2007 (72 FR 52568). OMB approved the survey without change on 
February 1, 2008 (OMB Control Number 0938 0907). The 2007-2008 Medicare 
occupational mix survey (Form CMS-10079 (2008)) is available on the CMS 
Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage, and through the fiscal intermediaries/MAC. 
Hospitals must submit their completed surveys to their fiscal 
intermediaries/MAC by September 1, 2008. The preliminary, unaudited 
2007-2008 occupational mix survey data will be released in early 
October 2008, along with the FY 2006 Worksheet S-3 wage data, for the 
FY 2010 wage index review and correction process.

E. Worksheet S-3 Wage Data for the Proposed FY 2009 Wage Index

    The proposed FY 2009 wage index values (to be effective for 
hospital discharges occurring on or after October 1, 2008, and before 
October 1, 2009) in section II.B. of the Addendum to this proposed rule 
are based on the data collected from the Medicare cost reports 
submitted by hospitals for cost reporting periods beginning in FY 2005 
(the FY 2008 wage index was based on FY 2004 wage data).
1. Included Categories of Costs
    The proposed FY 2009 wage index includes the following categories 
of data associated with costs paid under the IPPS (as well as 
outpatient costs):
    <bullet> Salaries and hours from short-term, acute care hospitals 
(including paid lunch hours and hours associated with military leave 
and jury duty).
    <bullet> Home office costs and hours.
    <bullet> 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).
    <bullet> Wage-related costs, including pensions and other deferred 
compensation costs. We note that, on March 28, 2008, CMS published a 
technical clarification to the cost reporting instructions for pension 
and deferred compensation costs (sections 2140 through 2142.7 of the 
Provider Reimbursement Manual, Part I). These instructions are used for 
developing pension and deferred compensation costs for purposes of the 
wage index, as discussed in the instructions for Worksheet S-3, Part 
II, Lines 13 through 20 and in the FY 2006 final rule (70 FR 47369).
2. Excluded Categories of Costs
    Consistent with the wage index methodology for FY 2008, the 
proposed wage index for FY 2009 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 2009 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, and hospices. In addition, they are used for 
prospective payments to IRFs, IPFs, and LTCHs, and for hospital 
outpatient services. We note that, in the IPPS rules, we do not address 
comments pertaining to the wage indices for non-IPPS providers. Such 
comments should be made in response to separate proposed rules for 
those providers.

F. Verification of Worksheet S-3 Wage Data

    The wage data for the proposed FY 2009 wage index were obtained 
from Worksheet S-3, Parts II and III of the FY 2005 Medicare cost 
reports. Instructions for completing Worksheet S-3, 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 proposed wage 
index includes FY 2005 data submitted to us as of February 29, 2008. 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/MAC to revise or verify data 
elements that resulted in specific edit failures. For the proposed FY 
2009 wage index, we identified and excluded 37 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 2009 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, 2008. 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 2009 IPPS final 
rule.
    In constructing the proposed FY 2009 wage index, we included the 
wage data for facilities that were IPPS hospitals in FY 2005; 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 20 hospitals that converted to CAH status between February 16, 
2007, the cut-off date for CAH exclusion from the FY 2008 wage index, 
and February 18, 2008, the cut-off date for CAH exclusion from the FY 
2009 wage index. After removing hospitals with aberrant data and 
hospitals that converted to CAH status, the proposed FY 2009 wage index 
is calculated based on 3,533 hospitals.
1. Wage Data for Multicampus Hospitals
    In the FY 2008 final rule with comment period (72 FR 47317), 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 2009 
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 allocation. The proposed FY 
2009 wage index in this proposed rule includes separate wage data for 
campuses of three multicampus hospitals.
    As with the FY 2008 wage index, we allowed hospitals the option of 
allocating their wages and hours for the FY 2009 wage index based on 
either FTE staff or discharge data. Again, we

[[Page 23630]]

are providing this option until a revised cost report is available that 
will allow a multicampus hospital to report the number of FTEs by 
location of its different campuses. Two of the three multicampus 
hospitals chose to have their wage data allocated by their Medicare 
discharge data. 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.
2. New Orleans' Post-Katrina Wage Index
    Since 2005 when Hurricane Katrina devastated the Gulf States, we 
have received numerous comments suggesting that current Medicare 
payments to hospitals in New Orleans, Louisiana are inadequate, and the 
wage index does not accurately reflect the increase in labor costs 
experienced by the city after the storm. The post-Katrina effects on 
the New Orleans wage index will not be realized in the wage index until 
FY 2010, when the wage index will be based on cost reporting periods 
beginning during FY 2006 (that is, beginning on or after October 1, 
2005 and before October 1, 2006).
    In responding to the health-related needs of people affected by the 
hurricane, the Federal Government, through the Deficit Reduction Act of 
2005 (DRA), appropriated $2 billion in FY 2006. These funds allowed the 
Secretary to make available $160 million in February 2007 to Louisiana, 
Mississippi, and Alabama for payments to hospitals and skilled nursing 
facilities facing financial stress because of changing wage rates not 
yet reflected in Medicare payment methodologies. In March and May 2007, 
the Department provided two additional DRA grants of $15 million and 
$35 million, respectively, to Louisiana for professional health care 
workforce recruitment and sustainability in the greater New Orleans 
area, namely the Orleans, Jefferson, St. Bernard, and Plaquemines 
Parishes. In addition, the Department issued a supplemental award of 
$60 million in provider stabilization grant funding to Louisiana, 
Mississippi, and Alabama to continue to help health care providers meet 
changing wage rates not yet reflected by Medicare's payment policies. 
On July 23, 2007, HHS awarded to Louisiana a new $100 million Primary 
Care Grant to help increase access to primary care in the Greater New 
Orleans area. The resulting stabilization and expansion of the 
community based primary care infrastructure, post Katrina, helps 
provide a viable alternative to local hospital emergency rooms for all 
citizens of New Orleans, especially those who are poor and uninsured. 
In other Department efforts, the OIG has performed an in-depth review 
of the post-Katrina infrastructure of five New Orleans hospitals, 
including the hospitals' staffing levels and wage costs. The OIG's 
final reports and recommendations are scheduled to be published in 
Spring 2008.

G. Method for Computing the Proposed FY 2009 Unadjusted Wage Index

    The method used to compute the proposed FY 2009 wage index without 
an occupational mix adjustment follows:
    Step 1--As noted above, we based the proposed FY 2009 wage index on 
wage data reported on the FY 2005 Medicare cost reports. We gathered 
data from each of the non-Federal, short-term, acute care hospitals for 
which data were reported on the Worksheet S-3, Parts II and III of the 
Medicare cost report for the hospital's cost reporting period beginning 
on or after October 1, 2004, and before October 1, 2005. In addition, 
we included data from some hospitals that had cost reporting periods 
beginning before October 2004 and reported a cost reporting period 
covering all of FY 2004. These data are included because no other data 
from these hospitals would be available for the cost reporting period 
described above, and because particular labor market areas might be 
affected due to the omission of these hospitals. However, we generally 
describe these wage data as FY 2005 data. We note that, if a hospital 
had more than one cost reporting period beginning during FY 2005 (for 
example, a hospital had two short cost reporting periods beginning on 
or after October 1, 2004, and before October 1, 2005), 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 2009 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 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 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

[[Page 23631]]

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, 
since 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 wage adjustment, we estimate the 
percentage change in the employment cost index (ECI) for compensation 
for each 30-day increment from October 14, 2003, through April 15, 
2005, for private industry hospital workers from the BLS' Compensation 
and Working Conditions. We use the ECI because it reflects the price 
increase associated with total compensation (salaries plus fringes) 
rather than just the increase in salaries. In addition, the ECI 
includes managers as well as other hospital workers. This methodology 
to compute the monthly update factors uses actual quarterly ECI data 
and assures that the update factors match the actual quarterly and 
annual percent changes. We also note that, since April 2006 with the 
publication of March 2006 data, the BLS' ECI uses a different 
classification system, the North American Industrial Classification 
System (NAICS), instead of the Standard Industrial Codes (SICs), which 
no longer exist. We have consistently used the ECI as the data source 
for our wages and salaries and other price proxies in the IPPS market 
basket and are not proposing to make any changes to the usage at this 
time. The factors used to adjust the hospital's data were based on the 
midpoint of the cost reporting period, as indicated below.

                    Midpoint of cost reporting period
------------------------------------------------------------------------
                                                              Adjustment
                     After                         Before       factor
------------------------------------------------------------------------
10/14/2004....................................   11/15/2004      1.05390
11/14/2004....................................   12/15/2004      1.05035
12/14/2004....................................   01/15/2005      1.04690
01/14/2005....................................   02/15/2005      1.04342
02/14/2005....................................   03/15/2005      1.03992
03/14/2005....................................   04/15/2005      1.03641
04/14/2005....................................   05/15/2005      1.03291
05/14/2005....................................   06/15/2005      1.02940
06/14/2005....................................   07/15/2005      1.02596
07/14/2005....................................   08/15/2005      1.02264
08/14/2005....................................   09/15/2005      1.01943
09/14/2005....................................   10/15/2005      1.01627
10/14/2005....................................   11/15/2005      1.01308
11/14/2005....................................   12/15/2005      1.00987
12/14/2005....................................   01/15/2006      1.00661
01/14/2006....................................   02/15/2006      1.00333
02/14/2006....................................   03/15/2006      1.00000
03/14/2006....................................   04/15/2006      0.99670
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 2005, and ending December 31, 2005, is June 30, 2005. An 
adjustment factor of 1.02596 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 2005 and covered a 
period of less than 360 days or more than 370 days, we annualize the 
data to reflect a 1-year cost report. Dividing the data by the number 
of days in the cost report and then multiplying the results by 365 
accomplishes annualization.
    Step 6--Each hospital is assigned to its appropriate urban or rural 
labor market area before any reclassifications under section 
1886(d)(8)(B), section 1886(d)(8)(E), or section 1886(d)(10) of the 
Act. Within each urban or rural labor market area, we add the total 
adjusted salaries plus wage-related costs obtained in Step 5 for all 
hospitals in that area to determine the total adjusted salaries plus 
wage-related costs for the labor market area.
    Step 7--We divide the total adjusted salaries plus wage-related 
costs obtained under both methods in Step 6 by the sum of the 
corresponding total hours (from Step 4) for all hospitals in each labor 
market area to determine an average hourly wage for the area.
    Step 8--We add the total adjusted salaries plus wage-related costs 
obtained in Step5 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 $32.2489.
    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 $13.7956 for Puerto Rico. For 
each labor market area in Puerto Rico, we calculate the Puerto Rico-
specific wage index value by dividing the area average hourly wage (as 
calculated in Step 7) by the overall Puerto Rico average hourly wage.
    Step 11--Section 4410 of Pub. L. 105-33 provides that, for 
discharges on or after October 1, 1997, the area wage index applicable 
to any hospital that is located in an urban area of a State may not be 
less than the area wage index applicable to hospitals located in rural 
areas in that State. For FY 2009, this proposed change would affect 266 
hospitals in 69 urban areas. The areas affected by this provision are 
identified by a footnote in Table 4A in the Addendum of 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 (72FR47321). As explained in section III.B.2.b. of the 
preamble of this proposed rule, we are proposing to extend 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 2009 Occupational Mix Adjusted Wage 
Index

    As discussed in section III.D. of this preamble, for FY 2009, we 
are proposing to apply the occupational mix adjustment to 100 percent 
of the FY

[[Page 23632]]

2009 wage index. We calculated the occupational mix adjustment using 
data from the 2006 occupational mix survey data, using the methodology 
described in section III.D.3. of this preamble.
    Using the 1st and 2nd quarter occupational mix survey data and 
applying the occupational mix adjustment to 100 percent of the proposed 
FY2009 wage index results in a proposed national average hourly wage of 
$32.2252 and a proposed Puerto-Rico specific average hourly wage of 
$13.7851. After excluding data of hospitals that either submitted 
aberrant data that failed critical edits, or that do not have FY 2005 
Worksheet S-3 cost report data for use in calculating the proposed 
FY2009 wage index, we calculated the proposed FY 2009 wage index using 
the occupational mix survey data from 3,364 hospitals. Using the 
Worksheet S-3 cost report data of 3,533 hospitals and occupational mix 
1st and/or 2nd quarter survey data from 3,364 hospitals represents a 
95.2 percent survey response rate. The proposed FY2009 national average 
hourly wages for each occupational mix nursing subcategory as 
calculated in Step 2 of the occupational mix calculation are as 
follows:

------------------------------------------------------------------------
                                                               Average
            Occupational mix nursing subcategory             hourly wage
------------------------------------------------------------------------
National RN Management.....................................     $38.6341
National RN Staff..........................................     $33.4795
National LPN...............................................     $19.2316
National Nurse Aides, Orderlies, and Attendants............     $13.6954
National Medical Assistants................................     $15.7714
National Nurse Category....................................     $28.7291
------------------------------------------------------------------------

    The proposed national average hourly wage for the entire nurse 
category as computed in Step 5 of the occupational mix calculation is 
$28.7291. Hospitals with a nurse category average hourly wage (as 
calculated in Step 4) of greater than the national nurse category 
average hourly wage receive an occupational mix adjustment factor (as 
calculated in Step 6) of less than 1.0. Hospitals with a nurse category 
average hourly wage (as calculated in Step 4) of less than the national 
nurse category average hourly wage receive an occupational mix 
adjustment factor (as calculated in Step 6) of greater than 1.0.
    Based on the January through June 2006 occupational mix survey 
data, we determined (in Step 7 of the occupational mix calculation) 
that the proposed national percentage of hospital employees in the 
Nurse category is 42.99 percent, and the proposed national percentage 
of hospital employees in the All Other Occupations category is 57.01 
percent. At the CBSA level, the percentage of hospital employees in the 
Nurse category ranged from a low of 27.26 percent in one CBSA, to a 
high of 85.30 percent in another CBSA.
    The proposed wage index values for FY 2009 (except those for 
hospitals receiving wage index adjustments under section 1886(d)(13) of 
the Act) are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this 
proposed rule.
    Tables 3A and 3B in the Addendum to this proposed rule list the 3-
year average hourly wage for each labor market area before the 
redesignation of hospitals based on FYs 2007, 2008, and 2009 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 2003 and FY 2004 cost reporting 
periods, as well as the FY 2005 period used to calculate the proposed 
FY 2009 wage index. The 3-year averages are calculated by dividing the 
sum of the dollars (adjusted to a common reporting period using the 
method described previously) across all 3 years, by the sum of the 
hours. If a hospital is missing data for any of the previous years, its 
average hourly wage for the 3-year period is calculated based on the 
data available during that period.
    The proposed wage index values in Tables 2, 4A, 4B, 4C, and 4F and 
the average hourly wages in Tables 2, 3A, and 3B in the Addendum to 
this proposed rule include the proposed occupational mix adjustment. 
The proposed wage index values in Tables 2, 4A, 4B, and 4C also include 
the proposed State-specific rural floor and imputed floor budget 
neutrality adjustments that are discussed in section III.B.2. of this 
preamble. The proposed State budget neutrality adjustments for the 
rural and imputed floors are included in Tables 4D-1 and 4D-2 in the 
Addendum to this proposed rule.

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

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.
    Section 1886(d)(8)(B) of the Act requires the Secretary to treat a 
hospital located in a rural county adjacent to one or more urban areas 
as being located in the MSA to which the greatest number of workers in 
the county commute, if the rural county would otherwise be considered 
part of an urban area under the standards for designating MSAs and if 
the commuting rates used in determining outlying counties were 
determined on the basis of the aggregate number of resident workers who 
commute to (and, if applicable under the standards, from) the central 
county or counties of all contiguous MSAs. In light of the 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

[[Page 23633]]

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:
    <bullet> If including the wage data for the redesignated hospitals 
would reduce the wage index value for the area to which the hospitals 
are redesignated by 1 percentage point or less, the area wage index 
value determined exclusive of the wage data for the redesignated 
hospitals applies to the redesignated hospitals.
    <bullet> 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.
    <bullet> If including the wage data for the redesignated hospitals 
increases the wage index value for the urban area to which the 
hospitals are redesignated, both the area and the redesignated 
hospitals receive the combined wage index value. Otherwise, the 
hospitals located in the urban area receive a wage index excluding the 
wage data of hospitals redesignated into the area.
    Rural areas whose wage index values would be reduced by excluding 
the wage data for hospitals that have been redesignated to another area 
continue to have their wage index values calculated as if no 
redesignation had occurred (otherwise, redesignated rural hospitals are 
excluded from the calculation of the rural wage index). The wage index 
value for a redesignated rural hospital cannot be reduced below the 
wage index value for the rural areas of the State in which the hospital 
is located.
    CMS has also adopted the following policies:
    <bullet> The wage data for a reclassified urban hospital is 
included in both the wage index calculation of the area to which the 
hospital is reclassified (subject to the rules described above) and the 
wage index calculation of the urban area where the hospital is 
physically located.
    <bullet> In cases where urban hospitals have reclassified to rural 
areas under 42 CFR 412.103, the urban hospital wage data are: (a) 
Included in the rural wage index calculation, unless doing so would 
reduce the rural wage index; and (b) included in the urban area where 
the hospital is physically located.
3. FY 2009 MGCRB Reclassifications
    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.
    At the time this proposed rule was constructed, the MGCRB had 
completed its review of FY 2009 reclassification requests. There were 
314 hospitals approved for wage index reclassifications by the MGCRB 
for FY 2009. Because MGCRB wage index reclassifications are effective 
for 3 years, hospitals reclassified during FY 2007 or FY 2008 are 
eligible to continue to be reclassified based on prior 
reclassifications to current MSAs during FY 2009. There were 175 
hospitals approved for wage index reclassifications in FY 2007 and 324 
hospitals approved for wage index reclassifications in FY 2008. Of all 
of the hospitals approved for reclassification for FY 2007, FY 2008, 
and FY 2009, 813 hospitals are in a reclassification status for FY 
2009.
    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. The request for withdrawal of an 
application for reclassification or termination of an existing 3-year 
reclassification that would be effective in FY 2009 must be received by 
the MGCRB within 45 days of the publication of this proposed rule. If a 
hospital elects to withdraw its wage index application after the MGCRB 
has issued its decision, but within 45 days of publication of this 
proposed rule date, it may later cancel its withdrawal in a subsequent 
year and request the MGCRB to reinstate its wage index reclassification 
for the remaining fiscal year(s) of the 3-year period (42 CFR 
412.273(b)(2)(i)). The request to cancel a prior withdrawal or 
termination must be in writing to the MGCRB no later than the deadline 
for submitting reclassification applications for the following fiscal 
year (42 CFR 412.273(d)). For further information about withdrawing, 
terminating, or canceling a previous withdrawal or termination of a 3-
year reclassification for wage index purposes, we refer the reader to 
42 CFR 412.273, as well as the August 1, 2002 IPPS final rule (67 FR 
50065), and the August 1, 2001 IPPS final rule (66 FR 39887).
    Changes to the wage index that result from withdrawals of requests 
for reclassification, wage index corrections, appeals, and the 
Administrator's review process will be incorporated into the wage index 
values published in the FY 2009 final rule. These changes may affect 
not only the wage index value for specific geographic areas, but also 
the wage index value redesignated hospitals receive; that is, whether 
they receive the wage index that includes the data for both the 
hospitals already in the area and the redesignated hospitals. Further, 
the wage index value for the area from which the hospitals are 
redesignated may be affected.
    Applications for FY 2010 reclassifications are due to the MGCRB by 
September 2, 2008 (the first working day of September 2008). 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 2008, via the CMS Internet Web site at: 
http://cms.hhs.gov/providers/prrb/mgcinfo.asp, or by calling the MGCRB 
at (410) 786-1174. The mailing address of the MGCRB is: 2520 Lord 
Baltimore Drive, Suite L, Baltimore, MD 21244-2670.
4. FY 2008 Policy Clarifications and Revisions
    We note below several policies related to geographic 
reclassification that were clarified or revised in the FY 2008 IPPS 
final rule with comment period (72 FR 47333):
    <bullet> Reinstating Reclassifications--As provided for in 42 CFR 
412.273(b)(2), once a hospital (or hospital group) accepts a newly 
approved reclassification, any previous reclassification is permanently 
terminated.
    <bullet> Geographic Reclassification for Multicampus Hospitals--
Because campuses of a multicampus hospital can now have their wages and 
hours data allocated by FTEs or discharge data, a hospital campus 
located in a geographic area distinct from the geographic area 
associated with the provider number of the multicampus hospital will 
have official wage data to supplement an individual or group 
reclassification application (Sec.  412.230(d)(2)(v)).
    <bullet> New England Deemed Counties--Hospitals in New England 
deemed counties are treated the same as Lugar hospitals in calculating 
the wage index. That is, the area is considered rural, but the 
hospitals within the area are deemed to be urban (Sec.  
412.64(b)(3)(ii)).
    <bullet> ``Fallback'' Reclassifications--A hospital will 
automatically be given its most recently approved reclassification

[[Page 23634]]

(thereby permanently terminating any previously approved 
reclassifications) unless it provides written notice to the MGCRB 
within 45 days of publication of the notice of proposed rulemaking that 
it wishes to withdraw its most recently approved reclassification and 
``fall back'' to either its prior reclassification or its home area 
wage index for the following fiscal year.
5. 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 proposed FY 2009 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, 2008, 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
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
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, NC
Los Alamos, NM.........................  Santa Fe, NM
Lyon, NV...............................  Carson City, NV
Cayuga, NY.............................  Syracuse, NY
Columbia, NY...........................  Albany-Schenectady-Troy, NY
Genesee, NY............................  Rochester, NY

[[Page 23635]]

 
Greene, NY.............................  Albany-Schenectady-Troy, NY
Schuyler, NY...........................  Ithaca, NY
Sullivan, NY...........................  Poughkeepsie-Newburgh-Middletown, NY
Wyoming, NY............................  Buffalo-Niagara Falls, NY
Ashtabula, OH..........................  Cleveland-Elyria-Mentor, OH
Champaign, OH..........................  Springfield, OH
Columbiana, OH.........................  Youngstown-Warren-Boardman, OH-PA
Cotton, OK.............................  Lawton, OK
Linn, OR...............................  Corvallis, OR
Adams, PA..............................  York-Hanover, PA
Clinton, PA............................  Williamsport, PA
Greene, PA.............................  Pittsburgh, PA
Monroe, PA.............................  Allentown-Bethlehem-Easton, PA-NJ
Schuylkill, PA.........................  Reading, PA
Susquehanna, PA........................  Binghamton, NY
Clarendon, SC..........................  Sumter, SC
Lee, SC................................  Sumter, SC
Oconee, SC.............................  Greenville, SC
Union, SC..............................  Spartanburg, SC
Meigs, TN..............................  Cleveland, TN
Bosque, TX.............................  Waco, TX
Falls, TX..............................  Waco, TX
Fannin, TX.............................  Dallas-Plano-Irving, TX
Grimes, TX.............................  College Station-Bryan, TX
Harrison, TX...........................  Longview, TX
Henderson, TX..........................  Dallas-Plano-Irving, TX
Milam, TX..............................  Austin-Round Rock, TX
Van Zandt, TX..........................  Dallas-Plano-Irving, TX
Willacy, TX............................  Brownsville-Harlingen, TX
Buckingham, VA.........................  Charlottesville, VA
Floyd, VA..............................  Blacksburg-Christiansburg-Radford, VA
Middlesex, VA..........................  Virginia Beach-Norfolk-Newport News, VA
Page, VA...............................  Harrisonburg, VA
Shenandoah, VA.........................  Winchester, VA-WV
Island, WA.............................  Seattle-Bellevue-Everett, WA
Mason, WA..............................  Olympia, WA
Wahkiakum, WA..........................  Longview, WA
Jackson, WV............................  Charleston, WV
Roane, WV..............................  Charleston, WV
Green, WI..............................  Madison, WI
Green Lake, WI.........................  Fond du Lac, WI
Jefferson, WI..........................  Milwaukee-Waukesha-West Allis, WI
Walworth, WI...........................  Milwaukee-Waukesha-West Allis, WI
----------------------------------------------------------------------------------------------------------------

    As in the past, hospitals redesignated under section 1886(d)(8)(B) 
of the Act are also eligible to be reclassified to a different area by 
the MGCRB. Affected hospitals are permitted to compare the reclassified 
wage index for the labor market area in Table 4C in the Addendum to 
this proposed rule into which they have been reclassified by the MGCRB 
to the wage index for the area to which they are redesignated under 
section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MCGRB 
reclassification within 45 days of the publication of this proposed 
rule.
6. Reclassifications Under Section 1886(d)(8)(B) of the Act
    As discussed in last year's FY 2008 IPPS final rule with comment 
period (72 FR 47336-47337), Lugar hospitals are treated like 
reclassified hospitals for purposes of determining their applicable 
wage index and receive the reclassified wage index (Table 4C in the 
Addendum to this proposed rule) for the urban area to which they have 
been redesignated. Because Lugar hospitals are treated like 
reclassified hospitals, when they are seeking reclassification by the 
MCGRB, they are subject to the rural reclassification rules set forth 
at 42 CFR 412.230. The procedural rules set forth at Sec.  412.230 list 
the criteria that a hospital must meet in order to reclassify as a 
rural hospital. Lugar hospitals 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 (Sec.  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 (Sec.  412.230(d)(1)(iii)(C)). Under current rules, the 
hospital must also demonstrate that its average hourly wage is equal to 
at least 82 percent of the average hourly wage of hospitals in the area 
to which it seeks redesignation (Sec.  412.230(d)(1)(iv)(C)). However, 
we are proposing to increase this threshold to 86 percent (as discussed 
in section III.B.2.a. of this preamble).
    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

[[Page 23636]]

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. As discussed in the FY 2008 final rule with 
comment period, we treat New England deemed counties in a manner 
consistent with how we treat Lugar counties. (We refer readers to 72 FR 
47337 for a discussion of this policy.)

J. Proposed FY 2009 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 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 three 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 2009 wage index, we calculated the out-
migration 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:
    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 2008 will be eligible to retain the adjustment for 
FY 2009. 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, 2008.
    Hospitals receiving the wage index adjustment under section 
1886(d)(13)(F) of the Act are not eligible for reclassification under 
sections 1886(d)(8) or (d)(10) of the Act unless they waive the out-
migration adjustment. Consistent with our FY 2005, 2006, 2007, and 2008 
IPPS final rules, we are proposing that hospitals redesignated under 
section 1886(d)(8) of the Act or reclassified under section 1886(d)(10) 
of the Act will be deemed to have chosen to retain their redesignation 
or reclassification. Section 1886(d)(10) hospitals that wish to receive 
the out-migration adjustment, rather than their reclassification, 
should follow the termination/withdrawal procedures specified in 42 CFR 
412.273 and section III.I.3. of the preamble of this proposed rule. 
Otherwise, they will be deemed to have waived the out-migration 
adjustment. Hospitals redesignated under section 1886(d)(8) of the Act 
will be deemed to have waived the out-migration adjustment, unless they 
explicitly notify CMS 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 2009. 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 would be deemed to have waived the 
out-migration adjustment unless CMS is otherwise notified. Hospitals 
that are eligible to receive the out-migration wage index adjustment 
and that withdraw their application for reclassification would 
automatically receive the wage index adjustment listed in Table 4J in 
the Addendum to this proposed rule.

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 FY 2009 wage index were made available on 
October 5, 2007, 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 posted 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 encourage 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 5, 2007, we instructed all fiscal

[[Page 23637]]

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.
    If a hospital wished to request a change to its data as shown in 
the October 5, 2007 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, 2007. 
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 5, 2007 memorandum referenced above.
    In the October 5, 2007 memorandum, we also specified that a 
hospital requesting revisions to its 1st and/or 2nd quarter 
occupational mix survey data was to copy its record(s) from the CY 2006 
occupational mix preliminary files posted to our 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, 2007.
    The fiscal intermediaries (or, if applicable, the MACs) notified 
the hospitals by mid-February 2008 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 2008. CMS 
published the proposed wage index public use files that included 
hospitals' revised wage index data on February 25, 2008. In a 
memorandum also dated February 25, 2008, we instructed fiscal 
intermediaries/MACs to notify all hospitals regarding the availability 
of the proposed wage index public use files and the criteria and 
process for requesting corrections and revisions to the wage index 
data. Hospitals had until March 11, 2008 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 data. Hospitals 
were also 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, 2008. The 
deadline for a hospital to request CMS intervention in cases where the 
hospital disagreed with the fiscal intermediary's (or, if applicable, 
the MAC's) policy interpretations is April 21, 2008.
    Hospitals should also 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 2005 data used to 
construct the proposed FY 2009 wage index. We note that the hospital 
average hourly wages shown in Table 2 only reflect changes made to a 
hospital's data and transmitted to CMS by February 29, 2008.
    We will release the final wage index data public use files in early 
May 2008 on the Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage. The May 2008 public use files will be 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 result from the correction process described 
above (revisions submitted to CMS by the fiscal intermediaries/MACs by 
April 14, 2008). If, after reviewing the May 2008 final files, a 
hospital believes that its wage or occupational mix data are incorrect 
due to a fiscal intermediary or MAC or CMS error in the entry or 
tabulation of the final data, the hospital should send a letter to both 
its fiscal intermediary or MAC and CMS that outlines why the hospital 
believes an error exists and to provide all supporting information, 
including relevant dates (for example, when it first became aware of 
the error). CMS and the fiscal intermediaries (or, if applicable, the 
MACs) must receive these requests no later than June 9, 2008. Requests 
mailed to CMS should be sent to: Centers for Medicare & Medicaid 
Services, Center for Medicare Management, Attention: Wage Index Team, 
Division of Acute Care, C4-08-06, 7500 Security Boulevard, Baltimore, 
MD 21244-1850.
    Each request also must be sent to the fiscal intermediary or the 
MAC. The fiscal intermediary or the MAC will review requests upon 
receipt and contact CMS immediately to discuss its findings.
    At this point in the process, that is, after the release of the May 
2008 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 or the MAC or CMS that the hospital 
could not have known about before its review of the final wage index 
data files. Specifically, neither the fiscal intermediary or the MAC 
nor CMS will approve the following types of requests:
    <bullet> 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, 2008.
    <bullet> Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the February 25, 
2008 wage index public use files.
    <bullet> 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 9, 2008) 
will be incorporated into the final wage index in the FY 2009 IPPS 
final rule, which will be effective October 1, 2008.
    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 2009 payment rates. Accordingly, 
hospitals that do not meet the procedural deadlines set forth above 
will not be afforded a later opportunity to submit wage index data 
corrections or to dispute the fiscal intermediary's (or, if applicable 
the MAC's) decision with respect to requested changes. Specifically, 
our policy is that hospitals that do not meet the procedural deadlines 
set forth above will not be permitted to challenge later, before the 
Provider Reimbursement Review Board, the failure of CMS to make a 
requested data revision. (See W. A. Foote Memorial Hospital v. Shalala, 
No. 99-CV-75202-DT (E.D. Mich. 2001) and Palisades General Hospital v. 
Thompson, No. 99-1230 (D.D.C. 2003).) We refer the reader also to the 
FY 2000 final rule (64 FR 41513) for a discussion of the parameters for 
appealing to the PRRB for wage index data corrections.
    Again, we believe the wage index data correction process described 
above provides hospitals with sufficient opportunity to bring errors in 
their wage and occupational mix data to the fiscal intermediary's (or, 
if applicable, the MAC's) attention. Moreover, because

[[Page 23638]]

hospitals will have access to the final wage index data by early May 
2008, 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 2009 wage index by August 
1, 2008, and the implementation of the FY 2009 wage index on October 1, 
2008. 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 9, 2008, 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 deadline for making corrections to 
the wage data for the following fiscal year's wage index. This 
provision is not available to a hospital seeking to revise another 
hospital's data that may be affecting the requesting hospital's wage 
index for the labor market area. As indicated earlier, since CMS makes 
the wage index data available to hospitals on the CMS Web site prior to 
publishing both the proposed and final IPPS rules, and the fiscal 
intermediaries or the MAC notify hospitals directly of any wage index 
data changes after completing their desk reviews, we do not expect that 
midyear corrections will be necessary. However, under our current 
policy, if the correction of a data error changes the wage index value 
for an area, the revised wage index value will be effective 
prospectively from the date the correction is made.
    In the FY 2006 IPPS final rule (70 FR 47385), we revised 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 9, 
2008 deadline for the FY 2009 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 deadline), and CMS acknowledges that the error in the 
hospital's wage index data was caused by CMS's or the fiscal 
intermediary's (or, if applicable, the MAC's) mishandling of the data, 
we believe that the hospital should not be penalized by our delay in 
publishing or implementing the correction. As with our current policy, 
we indicated that the provision is not available to a hospital seeking 
to revise another hospital's data. In addition, the provision cannot be 
used to correct prior years' wage index data; it can only be used for 
the current Federal fiscal year. In other situations where our policies 
would allow midyear corrections, we continue to believe that it is 
appropriate to make prospective-only corrections to the wage index.
    We note that, as with prospective changes to the wage index, the 
final retroactive correction will be made irrespective of whether the 
change increases or decreases a hospital's payment rate. In addition, 
we note that the policy of retroactive adjustment will still apply in 
those instances where a judicial decision reverses a CMS denial of a 
hospital's wage index data revision request.

L. Labor-Related Share for the Proposed Wage Index for FY 2009

    Section 1886(d)(3)(E) of the Act directs the Secretary to adjust 
the proportion of the national prospective payment system base payment 
rates that are attributable to wages and wage-related costs by a factor 
that reflects the relative differences in labor costs among geographic 
areas. It also directs the Secretary to estimate from time to time the 
proportion of hospital costs that are labor-related: ``The Secretary 
shall adjust the proportion (as estimated by the Secretary from time to 
time) of hospitals' costs which are attributable to wages and wage-
related costs of the DRG prospective payment rates * * *'' We refer to 
the portion of hospital costs attributable to wages and wage-related 
costs as the labor-related share. The labor-related share of the 
prospective payment rate is adjusted by an index of relative labor 
costs, which is referred to as the wage index.
    Section 403 of Pub. L. 108-173 amended section 1886(d)(3)(E) of the 
Act to provide that the Secretary must employ 62 percent as the labor-
related share unless this ``would result in lower payments to a 
hospital than would otherwise be made.'' However, this provision of 
Pub. L. 108-173 did not change the legal requirement that the Secretary 
estimate ``from time to time'' the proportion of hospitals costs that 
are ``attributable to wages and wage-related costs.'' We interpret this 
to mean that hospitals receive payment based on either a 62-percent 
labor-related share, or the labor-related share estimated from time to 
time by the Secretary, depending on which labor-related share resulted 
in a higher payment.
    We have continued our research into the assumptions employed in 
calculating the labor-related share. Our research involves analyzing 
the compensation share separately for urban and rural hospitals, using 
regression analysis to determine the proportion of costs influenced by 
the area wage index, and exploring alternative methodologies to 
determine whether all or only a portion of professional fees and 
nonlabor intensive services should be considered labor-related.
    In the FY 2006 IPPS final rule (70 FR 47392), we presented our 
analysis and conclusions regarding the methodology for updating the 
labor-related share for FY 2006. We also recalculated a labor-related 
share of 69.731 percent, using the FY 2002-based PPS market basket for 
discharges occurring on or after October 1, 2005. In addition, we 
implemented this revised and rebased labor-related share in a budget 
neutral manner, but consistent with section 1886(d)(3)(E) of the Act, 
we did not take into account the additional payments that would be made 
as a result of hospitals with a wage index less than or equal to 1.0 
being paid using a labor-related share lower than the labor-related 
share of hospitals with a wage index greater than 1.0.
    The labor-related share is used to determine the proportion of the 
national PPS base payment rate to which the area wage index is applied. 
In this proposed rule, we are not proposing to make any changes to the 
national average proportion of operating costs that are attributable to 
wages and salaries, fringe benefits, professional fees, contract labor, 
and labor intensive services. Therefore, we are proposing to continue 
to use a labor-related share of 69.731

[[Page 23639]]

percent for discharges occurring on or after October 1, 2008. Tables 1A 
and 1B in the Addendum to this proposed rule reflect this proposed 
labor-related share. We note that section 403 of Pub. L. 108-173 
amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to 
provide that the Secretary must employ 62 percent as the labor-related 
share unless this employment ``would result in lower payments to a 
hospital than would otherwise be made.''
    We also are proposing to continue to use a labor-related share for 
the Puerto Rico-specific standardized amounts of 58.7 percent for 
discharges occurring on or after October 1, 2008. Consistent with our 
methodology for determining the national labor-related share, we added 
the Puerto Rico-specific relative weights for wages and salaries, 
fringe benefits, contract labor, nonmedical professional fees, and 
other labor-intensive services to determine the labor-related share. 
Puerto Rico hospitals are paid based on 75 percent of the national 
standardized amounts and 25 percent of the Puerto Rico-specific 
standardized amounts. For Puerto Rico hospitals, the national labor-
related share will always be 62 percent because the wage index for all 
Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage 
index is applied to the Puerto Rico-specific portion of payments to the 
hospitals. The labor-related share of a hospital's Puerto Rico-specific 
rate will be either 62 percent or the Puerto Rico-specific labor-
related share depending on which results in higher payments to the 
hospital. If the hospital has a Puerto Rico-specific wage index of 
greater than 1.0, we will set the hospital's rates using a labor-
related share of 62 percent for the 25 percent portion of the 
hospital's payment determined by the Puerto Rico standardized amounts 
because this amount will result in higher payments. Conversely, a 
hospital with a Puerto Rico-specific wage index of less than 1.0 will 
be paid using the Puerto Rico-specific labor-related share of 58.7 
percent of the Puerto Rico-specific rates because the lower labor-
related share will result in higher payments. The proposed Puerto Rico 
labor-related share of 58.7 percent for FY 2008 is reflected in the 
Table 1C of the Addendum to this proposed rule.

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

A. Proposed Changes to the Postacute Care Transfer Policy (Sec.  412.4)

1. Background
    Existing regulations at Sec.  412.4(a) define discharges under the 
IPPS as situations in which a patient is formally released from an 
acute care hospital or dies in the hospital. Section 412.4(b) defines 
transfers from one acute care hospital to another. Section 412.4(c) 
establishes the conditions under which we consider a discharge to be a 
transfer for purposes of our postacute care transfer policy. In 
transfer situations, the transferring hospital is paid based on a 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.
    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 (Sec.  412.4(f)(1)). Transfer cases are also 
eligible for outlier payments. The outlier threshold for transfer cases 
is equal to the fixed-loss outlier threshold for nontransfer cases 
(adjusted for geographic variations in costs), divided by the geometric 
mean length of stay for the MS-DRG, multiplied by the length of stay 
for the case plus one day. The purpose of the IPPS postacute care 
transfer payment policy is to avoid providing an incentive for a 
hospital to transfer patients to another hospital, a SNF, or home under 
a written plan of care for home health services early in the patients'' 
stay in order to minimize costs while still receiving the full MS-DRG 
payment. The transfer policy adjusts the payments to approximate the 
reduced costs of transfer cases.
    Beginning with the FY 2006 IPPS, the regulations at Sec.  412.4 
specified that, effective October 1, 2005, a DRG would be subject to 
the postacute care transfer policy if, based on Version 23.0 of the DRG 
Definitions Manual (FY 2006), using data from the March 2005 update of 
FY 2004 MedPAR file, the DRG meets the following criteria:
    <bullet> The DRG had a geometric mean length of stay of at least 3 
days;
    <bullet> The DRG had at least 2,050 postacute care transfer cases; 
and
    <bullet> At least 5.5 percent of the cases in the DRG were 
discharged to postacute care prior to the geometric mean length of stay 
for the DRG.
    In addition, if the DRG was one of a paired set of DRGs based on 
the presence or absence of a CC or major cardiovascular condition 
(MCV), both paired DRGs would be included if either one met the three 
criteria above.
    If a DRG met the above criteria based on the Version 23.0 DRG 
Definitions Manual and FY 2004 MedPAR data, we made the DRG subject to 
the postacute care transfer policy. We noted in the FY 2006 final rule 
that we would not revise the list of DRGs subject to the postacute care 
transfer policy annually unless we made a change to a specific CMS DRG. 
We established this policy to promote certainty and stability in the 
postacute care transfer payment policy. Annual reviews of the list of 
CMS DRGs subject to the policy would likely lead to great volatility in 
the payment methodology with certain DRGs qualifying for the policy in 
one year, deleted the next year, only to be reinstated the following 
year. However, we noted that, over time, as treatment practices change, 
it was possible that some CMS DRGs that qualified for the policy will 
no longer be discharged with great frequency to postacute care. 
Similarly, we explained that there may be other CMS DRGs that at that 
time had a low rate of discharges to postacute care, but which might 
have very high rates in the future.
    The regulations at Sec.  412.4 further specify that if a DRG did 
not exist in Version 23.0 of the DRG Definitions Manual or a DRG 
included in Version 23.0 of the DRG Definitions Manual is revised, the 
DRG will be a qualifying DRG if it meets the following criteria based 
on the version of the DRG Definitions Manual in use when the new or 
revised DRG first became effective, using the most recent complete year 
of MedPAR data:
    <bullet> The total number of discharges to postacute care in the 
DRG must equal or exceed the 55th percentile for all DRGs; and
    <bullet> The proportion of short-stay discharges to postacute care 
to total discharges in the DRG exceeds the 55th percentile for all 
DRGs. A short-stay discharge is a discharge before the geometric mean 
length of stay for the DRG.
    A DRG also is a qualifying DRG if it is paired with another DRG 
based on the presence or absence of a CC or MCV that meets either of 
the above two criteria.
    The MS-DRGs that we adopted for FY 2008 were a significant revision 
to the CMS DRG system (72 FR 47141). Because the MS-DRGs were not 
reflected in Version 23.0 of the DRG Definitions Manual, consistent 
with Sec.  412.4, we established policy to recalculate the 55th 
percentile thresholds in order to determine which MS-DRGs would be 
subject to the postacute care transfer policy (72 FR 47186 through 
47188). Further, under

[[Page 23640]]

the MS-DRGs, the subdivisions within the base DRGs are different than 
those under the previous CMS DRGs. Unlike the CMS DRGs, the MS-DRGs are 
not divided based on the presence or absence of a CC or MCV. Rather, 
the MS-DRGs have up to three subdivisions based on: (1) The presence of 
a MCC; (2) the presence of a CC; or (3) the absence of either an MCC or 
CC. Consistent with our previous policy under which both CMS DRGs in a 
CC/non-CC pair were qualifying DRGs if one of the pair qualified, we 
established that each MS-DRG that shared a base MS-DRG will be a 
qualifying DRG if one of the MS-DRGs that shared the base DRG 
qualifies. We revised Sec.  412.4(d)(3)(ii) to codify this policy.
    Similarly, the adoption of the MS-DRGs also necessitated a revision 
to one of the criteria used in Sec.  412.4(f)(5) of the regulations to 
determine whether a DRG meets the criteria for payment under the 
``special payment methodology.'' Under the special payment methodology, 
a case subject to the special payment methodology that is transferred 
early to a postacute care setting will be paid 50 percent of the total 
IPPS payment plus the average per diem for the first day of the stay. 
In addition, the hospital will receive 50 percent of the per diem 
amount for each subsequent day of the stay, up to the full MS-DRG 
payment amount. A CMS DRG was subject to the special payment 
methodology if it met the criteria of Sec.  412.4(f)(5). Section 
412.4(f)(5)(iv) specifies that, for discharges occurring on or after 
October 1, 2005, and prior to October 1, 2007, if a DRG meets the 
criteria specified under Sec.  412.4(f)(5)(i) through (f)(5)(iii), any 
DRG that is paired with it based on the presence or absence of a CC or 
MCV is also subject to the special payment methodology. Given that this 
criterion was no longer applicable under the MS-DRG system, in the FY 
2008 final rule with comment period, we added a new Sec.  412.4(f)(6) 
(42 FR 47188 and 47410). Section 412.4(f)(6) provides that, for 
discharges on or after October 1, 2007, if an MS-DRG meets the criteria 
specified under Sec. Sec.  412.4(f)(6)(i) through (f)(6)(iii), any 
other MS-DRG that is part of the same MS-DRG group is also subject to 
the special payment methodology. We updated this criterion so that it 
conformed to the changes associated with adopting MS-DRGs for FY 2008. 
The revision makes an MS-DRG subject to the special payment methodology 
if it shares a base MS-DRG with an MS-DRG that meets the criteria for 
receiving the special payment methodology.
    Section 1886(d)(5)(J) of the Act provides that, effective for 
discharges on or after October 1, 1998, a ``qualified discharge'' from 
one of DRGs selected by the Secretary to a postacute care provider 
would be treated as a transfer case. This section required the 
Secretary to define and pay as transfers all cases assigned to one of 
the DRGs selected by the Secretary, if the individuals are discharged 
to one of the following postacute care settings:
    <bullet> A hospital or hospital unit that is not a subsection 
1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the 
hospitals and hospital units that are excluded from the term 
``subsection (d) hospital'' as psychiatric hospitals and units, 
rehabilitation hospitals and units, children's hospitals, long-term 
care hospitals, and cancer hospitals.)
    <bullet> A SNF (as defined at section1819(a) of the Act).
    <bullet> Home health services provided by a home health agency, if 
the services relate to the condition or diagnosis for which the 
individual received inpatient hospital services, and if the home health 
services are provided within an appropriate period (as determined by 
the Secretary). In the FY 1999 IPPS final rule (63 FR 40975 through 
40976 and 40979 through 40981), we specified that a patient discharged 
to home would be considered transferred to postacute care if the 
patient received home health services within 3 days after the date of 
discharge. In addition, in the FY 1999 IPPS final rule, we did not 
include patients transferred to a swing-bed for skilled nursing care in 
the definition of postacute care transfer cases (63 FR 40977).
2. Proposed Policy Change Relating to Transfers to Home with a Written 
Plan for the Provision of Home Health Services
    As noted above, in the FY 1999 IPPS final rule (63 FR 40975 through 
40976 and 40979 through 40981), we determined that 3 days is an 
appropriate period within which home health services should begin 
following a beneficiary's discharge to the home in order for the 
discharge to be considered a ``qualified discharge'' subject to the 
payment adjustment for postacute care transfer cases. In that same 
final rule, we noted that we would monitor whether 3 days would remain 
an appropriate timeframe.
    Section 1886(d)(5)(J)(ii)(III) of the Act provides that the 
discharge of an individual who receives home health services upon 
discharge will be treated as a transfer if ``such services are provided 
within an appropriate period as determined by the Secretary * * *''. 
The statute thus confers upon the Secretary the authority to determine 
an appropriate timeframe for the application of the postacute care 
transfer policy in cases where home health services commence subsequent 
to discharge from an acute care hospital. In the FY 1999 final IPPS 
rule, we established the policy that the postacute care transfer policy 
would apply to cases in which the home health care begins within 3 days 
of the discharge from an acute care policy. We noted in that rule that 
we did not believe that it was appropriate to limit the transfer 
definition to cases in which home health care begins on the same day as 
the patient is discharged from the hospital. We observed that data 
indicated that less than 8 percent of discharged patients who receive 
home health care begin receiving those services on the date of 
discharge. It is unreasonable to expect that patients who are 
discharged later in the day would receive a home health visit that same 
day. Furthermore, we believed that the financial incentive to delay 
needed home health care for only a matter of hours would be 
overwhelming if we limited the timeframe to one day. At the time of 
that final rule, we explained that we believed that 3 days would be a 
more appropriate timeframe because it would mitigate the incentive to 
delay home health services to avoid the application of the postacute 
care transfer policy, and because a 3-day timeframe was consistent with 
existing patterns of care.
    In that final rule, we also noted that a number of commenters had 
raised issues and questions concerning the proposal to adopt 3 days as 
the appropriate timeframe for the application of the postacute care 
transfer policy in these cases. While most of the commenters advocated 
shorter timeframes, on the grounds that postacute care beginning 3 days 
after a discharge should not be considered a substitute for inpatient 
hospital care, others suggested that a 3-day window might still allow 
for needlessly prolonged hospital care or delayed home health in order 
to avoid the application of the postacute care transfer policy. 
Although MedPAC agreed with the commenters who asserted that home 
health care services furnished after a delay of more than one day may 
not necessarily be regarded as substituting for inpatient acute care, 
they also noted that a 3-day window allows for the fact that most home 
health patients do not receive care every day, as well as for those 
occasions in which there may be a delay in arranging for the provision 
of planned care (for

[[Page 23641]]

example, an intervening weekend). The commission also stated that a 
shorter period may create a stronger incentive to delay the provision 
of necessary care beyond the window so that the hospital will receive 
the full DRG payment. In the light of these comments and, in 
particular, of the concern that a 3-day timeframe still allowed for 
some incentive to delay necessary home health services in order to 
avoid the application of the postacute care transfer policy, we 
indicated that we would continue to monitor this policy in order to 
track any changes in practices that may indicate the need for revising 
the window.
    Since the adoption of this policy in FY 1999, we have continued to 
receive reports that some providers discharge patients prior to the 
geometric mean length of stay but intentionally delay home health 
services beyond 3 days after the acute hospital discharge in order to 
avoid the postacute care transfer payment adjustment policy. These 
reports, and the concerns expressed by some commenters in FY 1999 about 
the adequacy of a 3-day window to reduce such incentives, have prompted 
us to examine the available data concerning the initiation and program 
payments for home health care subsequent to discharge from postacute 
care.
    We merged the FY 2004 MedPAR file with postacute care bill files 
matching beneficiary identification numbers and discharge and admission 
dates and looked at the 10 DRGs that were subject to the postacute care 
transfer policy from FYs 1999 through 2003 (DRG 14 (Intracranial 
Hemorrhage and Stroke with Infarction (formerly ``Specific 
Cerebrovascular Disorders Except Transient Ischemic Attack'')); DRG 113 
(Amputation for Circulatory System Disorders Except Upper Limb and 
Toe); DRG 209 (Major Joint Limb Reattachment Procedures of Lower 
Extremity); DRG 210 (Hip and Femur Procedures Except Major Joint 
Procedures <=17 with CC); DRG 211 (Hip and Femur Procedures Except 
Major Joint Procedures Age <=17 without CC); DRG 236 (Fractures of Hip 
and Pelvis); DRG 263 (Skin Graft and/or Debridement for Skin Ulcer or 
Cellulitis with CC); DRG 264 (Skin Graft and/or Debridement for Skin 
Ulcer or Cellulitis without CC); DRG 429 (Organic Disturbances and 
Mental Retardation); and DRG 483 (Tracheostomy with Mechanical 
Ventiliation 96+ Hours or Principal Diagnosis Except Face, Mouth, and 
Neck Diagnoses (formerly ``Tracheostomy Except for Face, Mouth, and 
Neck Diagnoses'')). We selected the original 10 ``qualified DRGs'' 
because they were the DRGs to which the postacute care transfer policy 
applied for FYs 1999 through 2003 and because we expect that trends 
that we found in the data with those DRGs would be likely to accurately 
reflect provider practices after the inception of the postacute care 
transfer policy. We expect that provider practices for the original 10 
DRGs would be consistent even with the expansion of the DRGs that are 
subject to the postacute care transfer policy. We note that providers 
may have even a greater incentive to delay the initiation of home 
health care in an effort to avoid the postacute care transfer policy 
now that there are more DRGs to which the policy applies. We compared 
data on home health services provided to patients who were discharged 
prior to the geometric mean length of stay to patients who were 
discharged at or beyond the geometric mean length of stay. For purposes 
of this analysis, we assumed that home health was the first discharge 
designation from the acute care hospital setting.
    The data showed that, on average, the Medicare payment per home 
health visit was higher for patients who were discharged prior to the 
geometric mean length of stay (as compared to patients who were 
discharged at or beyond the geometric mean length of stay). 
Additionally, we found some evidence in the data suggesting that, for 
patients discharged prior to the geometric mean length of stay for many 
DRGs, hospitals may indeed be discharging patients earlier than 
advisable, providing less than the optimal amount of acute inpatient 
care, and are instead substituting home health care for inpatient 
services, resulting in higher home health care payments under the 
Medicare program. One generally would expect that patients discharged 
prior to the geometric mean length of stay are genuinely less severely 
ill than patients discharged at or after the geometric mean length of 
stay because patients in the former group are judged to be appropriate 
for discharge after less acute inpatient care. However, our data paint 
a different picture. For example, the data on the average per day 
Medicare payments for home health care for those patients who are 
discharged from the hospital prior to the geometric mean length of stay 
in the DRGs to which the postacute care transfer policy applies, as 
compared to Medicare payments for patients discharged from the hospital 
at or after the geometric mean length of stay, show patterns other than 
what might be expected if hospitals are generally discharging patients 
for home health care only after the full amount of acute inpatient 
care. Specifically, average Medicare payments per home health care 
visit are consistently higher for patients discharged prior to the 
geometric mean length of stay than for patients discharged at or after 
the geometric mean length of stay. The average home health care per 
visit payments for patients treated for the relevant DRGs and 
discharged before the geometric mean length of stay are $204 when the 
initiation of home health care began on the second day after discharge, 
$199 on the third day, and $182 on the sixth day, compared to $177, 
$163, and $171, respectively for patients discharged on or after the 
geometric mean length of stay. Furthermore, the ratio of the payments 
for these two groups actually increases from 1.16 on the third day 
after discharge to 1.22 on the fourth day, before falling again to 
1.04, 1.07, and 1.08 on the fifth, sixth, and seventh days. This 
suggests the possibility that home health care for some relatively 
sicker patients is being delayed until just beyond the 3-day window 
during which the postacute care transfer policy applies. In the light 
of these data, we believe that it is appropriate to propose extending 
the applicable timeframe in order to reduce the incentive for providers 
to delay home health care when discharging patients from the acute care 
setting. Further examination of the data indicates that the average per 
day Medicare payments for home health care for those patients, in the 
DRGs to which the postacute care transfer policy applies, who are 
discharged from the hospital prior to the geometric mean length of 
stay, stabilizes at a somewhat lower amount when the initiation of home 
health visits begins on the seventh and subsequent days after 
discharge. Specifically, average payments per visit for this group fall 
from $182 when home health services began on the sixth day after the 
acute care hospital discharge to $174 on the seventh day, and then 
remain relatively steady at $171, $177, and $172 on the eighth, ninth, 
and tenth days. This suggests that a 7-day period would be an 
appropriate point at which to establish a new timeframe. The 
stabilization of average home health care visit payments at and after 
the seventh day suggests that this may be the point at which the 
incentives to delay the start of home health care in order to avoid the 
application of the postacute care transfer policy are reduced. As a 
consequence of this analysis, in this proposed rule, we are proposing 
to revise Sec.  412.4(c)(3) to extend the timeframe to within 7 days of 
discharge to home under a written

[[Page 23642]]

plan for the provision of home health services, effective October 1, 
2008. We believe that extending the applicable timeframe will lessen 
the incentive for providers to delay the start of home health care 
after discharging patients from the acute care hospital setting. During 
the comment period on this proposed rule, we plan to continue to search 
our data on postacute care discharges to home health services. We 
welcome comments and suggestions on other data analyses that can be 
performed to determine an appropriate timeframe for which the postacute 
care transfer policy would apply.
    In addition to the reasons noted above, we believe that 7 days is 
currently an appropriate timeframe because we believe that accommodates 
current practices and it is sufficiently long enough to lessen the 
likelihood that providers would delay the initiation of necessary home 
health services. At the same time, we believe that 7 days is narrow 
enough that we would still expect the majority of the home health 
services to be related to the condition to which the acute inpatient 
hospital stay was necessary. Further, we note that there may be some 
cases for which it is not clinically appropriate to begin home health 
services immediately following an acute care discharge, and that even 
when home health services are clinically appropriate sooner than within 
7 days of acute care discharge, home health services may not be 
immediately available.
    We note that, as we stated in the FY 2000 IPPS final rule (65 FR 
47081), if the hospital's continuing care plan for the patient is not 
related to the purpose of the inpatient hospital admission, a condition 
code 42 must be entered on the claim. If the continuing care plan is 
related to the purpose of the inpatient hospital admission but begins 
after 7 days (formerly after 3 days) of discharge, a condition code 43 
must be entered on the claim. The presence of either of these condition 
codes in conjunction with patient status discharge code 06 (Discharged/
Transferred to Home under Care of Organized Home Health Service 
Organization in Anticipation of Covered Skilled Care) will result in 
full payment rather than the transfer payment amount.
3. Evaluation of MS-DRGs Under Postacute Care Transfer Policy for FY 
2009
    For FY 2009, we are not proposing to make any changes to the 
criteria by which an MS-DRG would qualify for inclusion in the 
postacute care transfer policy. However, because we are proposing to 
revise some existing MS-DRGs and to add one new MS-DRG (discussed under 
section II.G. of this preamble), we are proposing to evaluate those MS-
DRGs under our existing postacute care transfer criteria in order to 
determine whether any of the revised or new MS-DRGs will meet the 
postacute care transfer criteria for FY 2009. Therefore, for 2009, we 
are evaluating MS-DRGs 001, 002, 215, 245, 901 through 909, 913 through 
923, 955 through 959, and 963 through 965. Any revisions made would not 
constitute a change to the application of the postacute care transfer 
policy. A list indicating which MS-DRGs would be subject to the 
postacute care transfer policy for FY 2009 can be found in Table 5 in 
the Addendum to this proposed rule.

B. Reporting of Hospital Quality Data for Annual Hospital Payment 
Update (Sec.  412.64(d)(2))

1. Background
a. Overview
    CMS is transforming the Medicare program from a passive payer to an 
active purchaser of higher quality, more efficient health care. Such 
care will contribute to the sustainability of the Medicare program, 
encourage the delivery of high quality care while avoiding unnecessary 
costs, and help ensure high value for beneficiaries. To support this 
transformation, CMS has worked with stakeholders to develop and 
implement quality measures, make provider and plan performance public, 
link payment incentives to reporting on measures, and ultimately is 
working to link payment to actual performance on these measures. 
Commonly referred to as value-based purchasing, this policy aligns 
payment incentives with the quality of care as well as the resources 
used to deliver care to encourage the delivery of high-value health 
care.
    The success of this transformation is supported by and dependent 
upon an increasing number of widely-agreed upon quality measures. The 
Medicare program has defined measures of quality in almost every 
setting and measures some aspect of care for almost all Medicare 
beneficiaries. These measures include clinical processes, patient 
perception of their care experience, and, increasingly, outcomes.
    The Medicare program has established mechanisms for collecting 
information on these measures, such as QualityNet, an Internet-based 
process that hospitals use to report all-payer information. Initial 
voluntary efforts were supplemented beginning in FY 2005 by a provision 
in the Medicare Prescription Drug Improvement and Modernization Act 
(MMA), which provided the full annual payment update only to 
``subsection (d) hospitals'' (that is, hospitals paid under the IPPS) 
that successfully reported on a set of widely-agreed upon quality 
measures. Since FY 2007, as required by subsequent legislation (the 
Deficit Reduction Act (DRA)) the number of quality measures and the 
amount of the financial incentive have increased.
    As a result, the great majority of hospitals now report on quality 
measures for heart failure, heart disease, pneumonia, and surgical 
infection and received the full annual update for FY 2008. The number 
of measures has continued to grow and the types of measures have grown 
as well, with the addition of outcomes measures, such as heart attack 
and heart failure mortality measures, and the HCAHPS measure of patient 
satisfaction. In section IV.B.2. of this preamble, we are seeking 
public comments on proposed additional quality measures.
    Reporting on these measures provides hospitals a greater awareness 
of the quality of care they provide and provides actionable information 
for consumers to make more informed decisions about their health care 
providers and treatments.
    Moving beyond reporting to performance, CMS has designed a Hospital 
Value-Based Purchasing Plan that would link hospital payments to their 
actual performance on quality measures. In accordance with the DRA, the 
Plan was submitted to Congress in November 2007. We discuss the Plan 
more fully in section IV.C. of this preamble.
    The ongoing CMS Premier Hospital Quality Incentive Demonstration 
project is another effort linking payments to quality performance. 
Launched in 2003, the Premier Hospital Quality Incentive Demonstration 
project promotes measurable improvements in the quality of care, 
examining whether economic incentives to hospitals are effective at 
improving the quality of care. Early evidence from the project 
indicates that linking payments to quality performance can be 
effective.
    As required by section 5001(c) the DRA, CMS also has implemented a 
program intended to encourage the prevention of certain avoidable or 
preventable hospital-acquired conditions (HACs), including infections, 
that may occur during a hospital stay. Beginning October 1, 2007, CMS 
required hospitals to begin reporting information on Medicare claims 
specifying whether certain diagnoses were present on admission (POA). 
Beginning October 1, 2008, CMS will no

[[Page 23643]]

longer pay hospitals for a DRG using the higher-paying CC or MCC 
associated with one or more of these conditions (if no other condition 
meeting the higher paying CC or MCC criteria is present) unless the 
condition was POA (that is, not acquired during the hospital stay). 
Linking a payment incentive to hospitals' prevention of avoidable or 
preventable HACs is a strong approach for encouraging high quality 
care. Combating these HACs can reduce morbidity and mortality as well 
as reducing unnecessary costs. In the FY 2008 IPPS final rule with 
comment period (72 FR 47217), CMS identified eight HACs. In section 
II.F. of this preamble, CMS is seeking comment on additional proposed 
conditions.
    CMS is committed to enhancing these value-based purchasing 
programs, in close collaboration with stakeholders, through the 
development and use of new measures for quality reporting, expanded 
public reporting, greater and more widespread incentives in the payment 
system for reporting on such measures, and ultimately performance on 
those measures. These initiatives hold the potential to transform the 
delivery of health care by rewarding quality of care and delivering 
higher value to Medicare beneficiaries.
    A critical element of value-based purchasing is well-accepted 
measures. Hospitals can then measure their performance relative to 
other hospitals. Further, this information can be posted for consumers 
to use to make more informed choices about their care. In this section 
IV.B. of this preamble, we describe past and current efforts to make 
this information available and proposals to expand these efforts and 
make even more useful hospital quality information available to the 
public.
b. Voluntary Hospital Quality Data Reporting
    In December 2002, the Secretary announced a partnership with 
several collaborators intended to promote hospital quality improvement 
and public reporting of hospital quality information. These 
collaborators included the American Hospital Association (AHA), the 
Federation of American Hospitals (FAH), the Association of American 
Medical Colleges (AAMC), the Joint Commission on Accreditation of 
Healthcare Organizations (the Joint Commission), the National Quality 
Forum (NQF), the American Medical Association (AMA), the Consumer-
Purchaser Disclosure Project, the American Association of Retired 
Persons (AARP), the American Federation of Labor-Congress of Industrial 
Organizations (AFL-CIO), the Agency for Healthcare Research and Quality 
(AHRQ), as well as CMS and others. In July 2003, CMS began the National 
Voluntary Hospital Reporting Initiative. This initiative is now known 
as the Hospital Quality Alliance: Improving Care through Information 
(HQA).
    We established the following ``starter set'' of 10 quality measures 
for voluntary reporting as of November 1, 2003:
Heart Attack (Acute Myocardial Infarction or AMI)
    <bullet> Was aspirin given to the patient upon arrival to the 
hospital?
    <bullet> Was aspirin prescribed when the patient was discharged?
    <bullet> Was a beta blocker given to the patient upon arrival to 
the hospital?
    <bullet> Was a beta blocker prescribed when the patient was 
discharged?
    <bullet> Was an Angiotensin Converting Enzyme (ACE) Inhibitor given 
for the patient with heart failure?
Heart Failure (HF)
    <bullet> Did the patient get an assessment of his or her heart 
function?
    <bullet> Was an Angiotensin Converting Enzyme (ACE) Inhibitor given 
to the patient?
Pneumonia (PN)
    <bullet> Was an antibiotic given to the patient in a timely way?
    <bullet> Had the patient received a pneumococcal vaccination?
    <bullet> Was the patient's oxygen level assessed?
    This starter set of 10 quality measures was endorsed by the NQF. 
The NQF is a voluntary consensus standard-setting organization 
established to standardize health care quality measurement and 
reporting through its consensus development process. In addition, this 
starter set is a subset of measures currently collected for the Joint 
Commission as part of its hospital inpatient certification program.
    We chose these 10 quality measures in order to collect data that 
would: (1) Provide useful and valid information about hospital quality 
to the public; (2) provide hospitals with a sense of predictability 
about public reporting expectations; (3) begin to standardize data and 
data collection mechanisms; and (4) foster hospital quality 
improvement.
    Hospitals submit quality data through the QualityNet secure Web 
site (formerly known as QualityNet Exchange) (www.qualitynet.org). This 
Web site meets or exceeds all current Health Insurance Portability and 
Accountability Act requirements for security of personal health 
information. Data from this initiative are used to populate the 
Hospital Compare Web site, www.hospitalcompare.hhs.gov. This Web site 
assists beneficiaries and the general public by providing information 
on hospital quality of care for consumers who need to select a 
hospital. It further serves to encourage consumers to work with their 
doctors and hospitals to discuss the quality of care hospitals provide 
to patients, thereby providing an additional incentive to improve the 
quality of care that they furnish.
c. Hospital Quality Data Reporting Under Section 501(b) of Pub. L. 108-
173
    Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) 
of Pub. L. 108-173, revised the mechanism used to update the 
standardized amount of payment for inpatient hospital operating costs. 
Specifically, the statute provided for a reduction of 0.4 percentage 
points to the update percentage increase (also known as the market 
basket update) for each of FYs 2005 through 2007 for any subsection (d) 
hospital that does not submit data on a set of 10 quality indicators 
established by the Secretary as of November 1, 2003. The statute also 
provided 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. This 
measure established an incentive for IPPS hospitals to submit data on 
the quality measures established by the Secretary.
    We initially implemented section 1886(b)(3)(B)(vii) of the Act in 
the FY 2005 IPPS final rule (69 FR 49078). In addition, we established 
the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) 
program and added 42 CFR 412.64(d)(2) to our regulations. We adopted 
additional requirements under the RHQDAPU program in the FY 2006 IPPS 
final rule (70 FR 47420).
d. Hospital Quality Data Reporting Under Section 5001(a) of Pub. L. 
109-171
    Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109-
171 (DRA), further amended section 1886(b)(3)(B) of the Act to revise 
the mechanism used to update the standardized amount for payment for 
hospital inpatient operating costs. Specifically, sections 
1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment 
update for FY 2007 and each subsequent fiscal year be reduced by 2.0 
percentage points for any subsection (d) hospital that does not

[[Page 23644]]

submit certain quality data in a form and manner, and at a time, 
specified by the Secretary. Section 1886(b)(3)(B)(viii)(III) of the Act 
requires that the Secretary expand the ``starter set'' of 10 quality 
measures that were 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 December 2005 report issued by the Institute of Medicine 
(IOM) of the National Academy of Sciences under section 238(b) of the 
MMA.\16\
---------------------------------------------------------------------------

    \16\ Institute of Medicine, ``Performance Measurement: 
Accelerating Improvement,'' December 1, 2005, available at: 
www.iom.edu/CMS/3809/19805/31310.aspx.
---------------------------------------------------------------------------

    The IOM measures include: 21 HQA quality measures (including the 
``starter set'' of 10 quality measures); the HCAHPS patient experience 
of care survey; and 3 structural measures. The structural measures are: 
(1) Implementation of computerized provider order entry for 
prescriptions; (2) staffing of intensive care units with intensivists; 
and (3) evidence-based hospital referrals. These structural measures 
constitute the Leapfrog Group's original ``three leaps,'' and are part 
of the NQF's 30 Safe Practices for Better Healthcare.
    Sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, 
effective for payments beginning with FY 2008, 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, and provide the Secretary with 
the discretion to replace any quality measures or indicators in 
appropriate cases, such as where all hospitals are effectively in 
compliance with a measure, or the measures or indicators have been 
subsequently shown to not represent the best clinical practice. Thus, 
the Secretary is granted broad discretion to replace measures that are 
no longer appropriate for the RHQDAPU program.
    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 would have the opportunity to 
review its data before these data are made public. In addition, this 
section requires that the Secretary report quality measures of process, 
structure, outcome, patients' perspective of care, efficiency, and 
costs of care that relate to services furnished in inpatient settings 
on the CMS Web site.
    Section 1886(b)(3)(B)(viii)(I) of the Act also provides that any 
reduction in a hospital's payment update will apply only with respect 
to the fiscal year involved, and will not be taken into account for 
computing the applicable percentage increase for a subsequent fiscal 
year.
    In the FY 2007 IPPS final rule (71 FR 48045), we amended our 
regulations at 42 CFR 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. In the FY 2007 IPPS final rule, we also 
added 11 additional quality measures to the 10-measure starter set to 
establish an expanded set of 21 quality measures (71 FR 48033 through 
48037).
    Commenters on the FY 2007 IPPS proposed rule requested that we 
notify the public as far in advance as possible of any proposed 
expansions of the measure set and program procedures in order to 
encourage broad collaboration and to give hospitals time to prepare for 
any anticipated change. Taking these concerns into account, in the CY 
2007 OPPS/ASC final rule with comment period (71 FR 68201), we adopted 
six additional quality measures for the FY 2008 IPPS update, for a 
total of 27 measures. The measure set that we adopted for the FY 2008 
payment determination was as follows:

------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial           <bullet> Aspirin at arrival.*
 Infarction)..
                                         <bullet> Aspirin prescribed at
                                          discharge.*
                                         <bullet> Angiotensin Converting
                                          Enzyme Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction.*
                                         <bullet> Beta blocker at
                                          arrival.*
                                         <bullet> Beta blocker
                                          prescribed at discharge.*
                                         <bullet> Fibrinolytic
                                          (thrombolytic) agent received
                                          within 30 minutes of hospital
                                          arrival.**
                                         <bullet> Percutaneous Coronary
                                          Intervention (PCI) received
                                          within 120 minutes of hospital
                                          arrival.**
                                         <bullet> Adult smoking
                                          cessation advice/counseling.**
------------------------------------------------------------------------
Heart Failure (HF).....................  <bullet> Left ventricular
                                          function assessment.*
                                         <bullet> Angiotensin Converting
                                          Enzyme Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction.
                                         <bullet> Discharge
                                          instructions.**
                                         <bullet> Adult smoking
                                          cessation advice/counseling.**
------------------------------------------------------------------------
Pneumonia (PN).........................  <bullet> Initial antibiotic
                                          received within 4 hours of
                                          hospital arrival *
                                         <bullet> Oxygenation
                                          assessment.*
                                         <bullet> Pneumococcal
                                          vaccination status.*
                                         <bullet> Blood culture
                                          performed before first
                                          antibiotic received in
                                          hospital.**
                                         <bullet> Adult smoking
                                          cessation advice/counseling.**
                                         <bullet> Appropriate initial
                                          antibiotic selection.**
                                         <bullet> Influenza vaccination
                                          status.**
------------------------------------------------------------------------
Surgical Care Improvement Project        <bullet> Prophylactic
 (SCIP)--named SIP for discharges prior   antibiotic received within 1
 to July 2006 (3Q06).                     hour prior to surgical
                                          incision.**
                                         <bullet> Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time.**

[[Page 23645]]

 
                                         <bullet> SCIP-VTE-1: Venous
                                          thromboembolism (VTE)
                                          prophylaxis ordered for
                                          surgery patients.***
                                         <bullet> SCIP-VTE-2: VTE
                                          prophylaxis within 24 hours
                                          pre/post surgery.***
                                         <bullet> SCIP Infection 2:
                                          Prophylactic antibiotic
                                          selection for surgical
                                          patients.***
------------------------------------------------------------------------
Mortality Measures (Medicare patients).  <bullet> Acute Myocardial
                                          Infarction 30-day mortality
                                          Medicare patients***
                                         <bullet> Heart Failure 30-day
                                          mortality Medicare
                                          patients.***
------------------------------------------------------------------------
Patients' Experience of Care...........  HCAHPS patient survey.***
------------------------------------------------------------------------
*Measure included in 10 measure starter set.
**Measure included in 21 measure expanded set.
***Measure added in CY 2007 OPPS/ASC final rule with comment period
  (data submission required as of January 2007 for three additional SCIP
  measures).

    For FY 2008, hospitals were required to submit data on 25 of the 27 
measures. No data submission was required for the two mortality outcome 
measures (30-Day Risk Standardized Mortality Rates for Heart Failure 
and AMI), because they were calculated using existing administrative 
Medicare claims data. The measures used for the payment determination 
included, for the first time, the HCAHPS patient experience of care 
survey as well as two outcome measures. These measures expanded the 
types of measures available for public reporting as required under 
section 1886(b)(3)(B)(viii) of the Act. In addition, the outcome 
measures, which are claims-based measures, did not increase the data 
submission requirements for hospitals, thereby reducing the burden 
associated with collection of data for quality reporting.
    In the FY 2008 IPPS proposed rule (72 FR 24805), we proposed to add 
1 outcome measure and 4 process measures to the existing 27-measure set 
to establish a new set of 32 quality measures to be used under the 
RHQDAPU program for the FY 2009 IPPS annual payment determination. We 
proposed to add the following five measures for the FY 2009 IPPS annual 
payment determination:
    <bullet> PN 30-day mortality measure (Medicare patients)
    <bullet> SCIP Infection 4: Cardiac Surgery Patients with Controlled 
6AM Postoperative
Serum Glucose
    <bullet> SCIP Infection 6: Surgery Patients with Appropriate Hair 
Removal
    <bullet> SCIP Infection 7: Colorectal Patients with Immediate 
Postoperative
Normothermia
    <bullet> SCIP Cardiovascular 2: Surgery Patients on a Beta Blocker 
Prior to Arrival Who Received a Beta Blocker During the Perioperative 
Period
    We stated that we planned to formally adopt these measures a year 
in advance in order to provide time for hospitals to prepare for 
changes related to the RHQDAPU program. We also stated that we 
anticipated that the proposed measures would be endorsed by the NQF, as 
a national consensus building entity. Finally, we stated that any 
proposed measure that was not endorsed by the NQF by the time that we 
published the FY 2008 IPPS final rule with comment period would not be 
finalized in that final rule.
    At the time we published the FY 2008 IPPS final rule with comment 
period, only the PN 30-day mortality measure had been endorsed by the 
NQF. Therefore, we finalized only that measure as part of the FY 2009 
IPPS measure set and stated that we would further address adding 
additional measures in the CY 2008 OPPS/ASC final rule and, if 
necessary, in the FY 2009 IPPS proposed and final rules. We also 
responded to comments we had received on the five proposed measures (72 
FR 47348 through 47351).
    In the CY 2008 OPPS/ASC final rule with comment period (72 FR 
66875), we noted that the NQF had endorsed the following additional 
process measures that we had proposed to include in the FY 2009 RHQDAPU 
program measure set:
    <bullet> SCIP Infection 4: Cardiac Surgery Patients with Controlled 
6AM Postoperative
Serum Glucose
    <bullet> SCIP Infection 6: Surgery Patients with Appropriate Hair 
Removal
    As we stated in the FY 2008 IPPS proposed rule (72 FR 24805), these 
measures reflect our continuing commitment to quality improvement in 
both clinical care and quality. These quality measures reflect 
consensus among affected parties as demonstrated by endorsement by a 
national consensus building entity. The addition of these two measures 
for the FY 2009 measure set bring the total number of measures in that 
measure set to 30 (72 FR 66876).
    The measure set to be used for FY 2009 annual payment determination 
is as follows:

------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial           <bullet> Aspirin at arrival*.
 Infarction).
                                         <bullet> Aspirin prescribed at
                                          discharge*.
                                         <bullet> Angiotensin Converting
                                          Enzyme Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction*.
                                         <bullet> Beta blocker at
                                          arrival*.
                                         <bullet> Beta blocker
                                          prescribed at discharge*.
                                         <bullet> Fibrinolytic
                                          (thrombolytic) agent received
                                          within 30 minutes of hospital
                                          arrival**.
                                         <bullet> Primary Percutaneous
                                          Coronary Intervention (PCI)
                                          received within 120 minutes of
                                          hospital arrival**.
                                         <bullet> Adult smoking
                                          cessation advice/counseling**.
------------------------------------------------------------------------
Heart Failure (HF).....................  <bullet> Left ventricular
                                          function assessment*.

[[Page 23646]]

 
                                         <bullet> Angiotensin Converting
                                          Enzyme Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction*.
                                         <bullet> Discharge
                                          instructions**.
                                         <bullet> Adult smoking
                                          cessation advice/counseling**.
------------------------------------------------------------------------
Pneumonia (PN).........................  <bullet> Initial antibiotic
                                          received within 4 hours of
                                          hospital arrival*.
                                         <bullet> Oxygenation
                                          assessment*.
                                         <bullet> Pneumococcal
                                          vaccination status*.
                                         <bullet> Blood culture
                                          performed before first
                                          antibiotic received in
                                          hospital**.
                                         <bullet> Adult smoking
                                          cessation advice/counseling**.
                                         <bullet> Appropriate initial
                                          antibiotic selection**.
                                         <bullet> Influenza vaccination
                                          status**.
------------------------------------------------------------------------
Surgical Care Improvement Project        <bullet> Prophylactic
 (SCIP)--named SIP for discharges prior   antibiotic received within 1
 to July 2006 (3Q06).                     hour prior to surgical
                                          incision**.
                                         <bullet> Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time**.
                                         <bullet> SCIP-VTE-1: Venous
                                          thromboembolism (VTE)
                                          prophylaxis ordered for
                                          surgery patients***.
                                         <bullet> SCIP-VTE-2: VTE
                                          prophylaxis within 24 hours
                                          pre/post surgery***.
                                         <bullet> SCIP Infection 2:
                                          Prophylactic antibiotic
                                          selection for surgical
                                          patients***.
                                         <bullet> SCIP-Infection 4:
                                          Cardiac Surgery Patients with
                                          Controlled 6AM Postoperative
                                          Serum Glucose*****.
                                         <bullet> SCIP Infection 6:
                                          Surgery Patients with
                                          Appropriate Hair Removal*****.
------------------------------------------------------------------------
Mortality Measures (Medicare patients).  <bullet> Acute Myocardial
                                          Infarction 30-day mortality
                                          Medicare patients***.
                                         <bullet> Heart Failure 30-day
                                          mortality Medicare
                                          patients***.
                                         <bullet> Pneumonia 30-day
                                          mortality Medicare
                                          patients****.
------------------------------------------------------------------------
Patients' Experience of Care...........  <bullet> HCAHPS patient
                                          survey***.
------------------------------------------------------------------------
* Measure included in 10 measure starter set.
** Measure included in 21 measure expanded set.
*** Measure added in CY 2007 OPPS/ASC final rule with comment period.
**** Measure added in FY 2008 IPPS final rule with comment period.
***** Measure added in CY 2008 OPPS/ASC final rule with comment period
  (data submission required effective with discharges starting January
  1, 2008).

    We also stated in the FY 2008 IPPS final rule with comment period 
and the CY 2008 OPPS/ASC final rule with comment period that the 
RHQDAPU program participation requirements for the FY 2009 program 
would apply to additional measures we adopt for the FY 2009 program (72 
FR 47361; 72 FR 66877).
    Therefore, hospitals are required to start submitting data for SCIP 
Infection 4 and SCIP Infection 6 starting with first quarter calendar 
year 2008 discharges and subsequent quarters until further notice. 
Hospitals must submit their aggregate population and sample size counts 
for Medicare and non-Medicare patients. These requirements are 
consistent with the requirements for the other AMI, HF, PN, and SCIP 
process measures included in the FY 2009 measure set. The complete list 
of procedures for participating in the RHQDAPU program for FY 2009 are 
provided in the FY 2008 IPPS final rule with comment period (72 FR 
47359 through 47361).
    Because SCIP Cardiovascular 2 and SCIP Infection 7 had not been 
endorsed by a national consensus building entity by the publishing 
deadline for the CY 2008 OPPS/ASC final rule with comment period, we 
did not adopt these measures as part of the FY 2009 IPPS measure set.
    In the FY 2008 IPPS proposed rule, we also solicited public 
comments on 18 measures and 8 measure sets that could be selected for 
future inclusion in the RHQDAPU program (72 FR 24805). These measures 
and measure sets highlight our interest in improving patient safety and 
outcomes of care, with a particular focus on the quality of surgical 
care and patient outcomes. In order to engender a broad review of 
potential performance measures, the list included measures that have 
not yet received endorsement by a national consensus review process for 
public reporting. The list also included measures developed by 
organizations other than CMS as well as measures that can be calculated 
using administrative data (such as claims).
    We solicited public comment not only on the measures and measure 
sets that were listed, but also on whether there were any critical gaps 
or ``missing'' measures or measure sets. We specifically requested 
input concerning the following issues:
    <bullet> Which of the measures or measure sets should be included 
in the FY 2009 RHQDAPU program or in subsequent years?
    <bullet> What challenges for data collection and reporting are 
posed by the identified measures and measure sets?
    <bullet> What improvements could be made to data collection or 
reporting that might offset or otherwise address those challenges?
    In the FY 2008 IPPS final rule with comment period (72 FR 47351), 
after consideration of the public comments received, we decided not to 
adopt any of these measures or measure sets for FY 2009. We indicated 
that we will continue to consider some of these measures and measure 
sets for subsequent years.
2. Proposed Quality Measures for FY 2010 and Subsequent Years
a. Proposed Quality Measures for FY 2010
    For FY 2010, we are proposing to require continued submission of 
data on 26 of the 30 existing AMI, Heart Failure,

[[Page 23647]]

Pneumonia, HCAHPS, and SCIP measures adopted for FY 2009. As noted 
above, the three outcome measures do not require hospitals to submit 
data. In addition, we are proposing to remove the Pneumonia Oxygenation 
Assessment measure from the RHQDAPU program measure set. We are 
proposing to discontinue requiring hospitals to submit data on the 
Pneumonia Oxygenation Assessment measure, effective with discharges 
beginning January 1, 2009. Section 1886(b)(3)(B)(viii)(VI) of the Act 
provides the Secretary with the discretion to replace any quality 
measures or indicators in appropriate cases, such as where all 
hospitals are effectively in compliance with a measure. We interpret 
this to authorize the Secretary to remove or retire measures from the 
RHQDAPU program.
    In the case of the Pneumonia Oxygenation Assessment measure, the 
vast majority of hospitals are performing near 100 percent. In 
addition, oxygenation assessment is routinely performed by hospitals 
for admitted patients without regard to the specific diagnosis. Thus, 
the measure is topped out so completely across virtually all hospitals 
as to provide no significant opportunity for improvement. We believe 
that the burden to hospitals to abstract and report these data 
outweighs the benefit in publicly reporting hospital level data with 
very little variation among hospitals. We do not expect that the 
retirement of the Pneumonia Oxygenation Assessment measure will result 
in the deterioration of care. However, if we determine otherwise, we 
may seek to reintroduce the measure.
    The proposed removal of the Pneumonia Oxygenation Assessment 
measure for FY 2010 represents the first instance of retiring a 
measure. We intend to review other existing chart-abstracted measures 
recognizing the significant burden to hospitals that chart abstraction 
requires. In this way, we seek to maximize the value of the RHQDAPU 
program to promote quality improvement by hospitals and to report 
information that the public will find beneficial in choosing inpatient 
hospital services. We invite comment on the retirement of the Pneumonia 
Oxygenation Assessment measure. In addition, we invite comment on other 
measures that may be suitable for retirement from the RHQDAPU program 
measure set. Finally, we invite comment on the following general 
considerations relevant to retiring measures:
    <bullet> Should CMS retire a RHQDAPU program measure when hospital 
performance on the measure has reached a high threshold (that is, 
performance on the measure has topped out) even if the measure still 
reflects best practice?
    <bullet> Are there reasons to consider retiring a measure other 
than high overall performance?
    <bullet> When a measure is retired on the basis of substantially 
complete compliance by hospitals, should data collection on the measure 
again be required after 1 or 2 years to assure that a high compliance 
level remains, or should some other way of monitoring continued 
hospital compliance be used?
    The specifications for two of the existing measures have been 
updated by the NQF, effective May 2007, with respect to the applicable 
timing interval. For the measures previously identified as:
    <bullet> AMI--Primary Percutaneous Coronary Intervention (PCI) 
received within 120 minutes of hospital arrival, the NQF has revised 
its endorsement of the specifications to reflect that the timing 
interval has been changed to PCI within 90 minutes of arrival.
    <bullet> Pneumonia--Initial antibiotic received within 4 hours of 
hospital arrival, the NQF has revised its endorsement of the 
specifications to reflect that the initial antibiotic must be received 
within 6 hours of arrival.
    In the FY 2008 IPPS final rule with comment period, one commenter 
``urged CMS to develop a policy to harmonize measures that related to 
payment, such as the NQF's move from a 4-hour timeframe for initial 
antibiotic administration for pneumonia patients to a 6-hour timeframe 
(72 FR 47357).'' Another commenter raised the issue of the timing for 
PCI in the AMI topic (72 FR 47347-8). In response to these comments, we 
responded that if we believe that a change is an appropriate change for 
the RHQDAPU program, we would expect to adopt it.
    Because the NQF is now endorsing different timing intervals with 
respect to these measures, we are proposing to also update these 
measures for the purposes of the FY 2010 RHQDAPU program. The updated 
measures are as follows:
    <bullet> AMI--Timing of Receipt of Primary Percutaneous Coronary 
Intervention (PCI); and
    <bullet> Pneumonia--Timing of receipt of initial antibiotic 
following hospital arrival.
    We note that the technical specifications for these measures will 
not change, and hospitals will continue to submit the same data that 
they currently submit. However, beginning with discharges on or after 
January 1, 2009, CMS will calculate the measures using the updated 
timing intervals.
    The NQF updated these two measures to reflect the most current 
consensus standards effective May 2007. Because this was after we 
issued the FY 2008 IPPS proposed rule, we could not adopt the updated 
measures in the FY 2008 IPPS final rule with comment period or CY 2008 
OPPS/ASC final rule with comment period. We also recognized that we did 
not have in place a subregulatory process that would have permitted us 
to update the measures. Therefore, we announced that hospitals could 
suppress the public reporting of the quality data for the two measures 
for hospital discharges starting with April 1, 2007 discharges. We did 
this because we believe that hospitals should not be held to out-of-
date consensus standards for public reporting pending the next 
regulatory cycle.
    We propose, in the future, to act on updates to existing RHQDAPU 
program measures made by a consensus building entity such as the NQF 
through a subregulatory process. This is necessary to be able to 
utilize the most up-to-date consensus standards in the RHQDAPU program, 
and recognizes that neither scientific advances nor consensus building 
entity standard updates are linked to the timing of regulatory actions. 
We propose to implement updates to existing RHQDAPU program measures 
and provide notification through the Qualitynet Web site, and 
additionally in the CMS/Joint Commission Specifications Manual for 
National Hospital Inpatient Quality Measures where data collection and 
measure specifications changes are necessary. We invite comment on this 
proposal.
    Under section 1886(b)(3)(B)(viii)(III) of the Act, the Secretary 
shall expand the RHQDAPU program measures beyond the measures specified 
as of November 1, 2003. Under section 1886(b)(3)(B)(viii)(V) of the 
Act, these measures, to the extent feasible and practicable, shall 
include measures set forth by one or more national consensus building 
entities.
    We are proposing to add the following 43 measures for the FY 2010 
payment determination: a SCIP measure that we proposed last year; 4 
nursing sensitive measures; 3 readmission measures; 6 Venous 
Thromboembolism measures; 5 stroke measures; 9 AHRQ measures; and 15 
cardiac surgery measures.
    We are proposing to add SCIP Cardiovascular 2, Surgery Patients on 
a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the 
Perioperative Period. This measure was initially proposed last year in 
the FY 2008 IPPS proposed rule, but because the NQF had not endorsed 
this measure

[[Page 23648]]

at the time we issued the FY 2008 IPPS final rule with comment period 
or the CY 2008 OPPS/ASC final rule with comment period, we did not 
adopt it. For the purposes of proposing the FY 2010 RHQDAPU program 
measure set, CMS believes that NQF endorsement of a measure represents 
a standard for consensus among affected parties as specified in section 
1886(b)(3)(B)(viii)(V) of the Act. The NQF is an independent health 
care quality endorsement organization with a diverse representation of 
consumer, purchaser, provider, academic, clinical, and other health 
care stakeholder organizations.
    In November 2007, the NQF endorsed SCIP Cardiovascular 2. CMS 
believes that this measure targets an important process of care, beta 
blocker administration for noncardiac surgery patients. Therefore, we 
are now proposing to add SCIP Cardiovascular 2 to the RHQDAPU program 
measures for FY 2010. The specifications and data collection tools are 
currently available through the Qualitynet Web site and in the CMS/
Joint Commission Specifications Manual for National Hospital Inpatient 
Quality Measures for hospitals to utilize and submit data for this 
measure. We are proposing that hospitals be required to submit data on 
this measure beginning with January 1, 2009 discharges.
    We also are proposing to add four nursing sensitive measures to the 
RHQDAPU program measure set for FY 2010. The four measures are:
    <bullet> Failure to Rescue
    <bullet> Pressure Ulcer Prevalence and Incidence by Severity (Joint 
Commission developed measure; all patient data from chart abstraction)
    <bullet> Patient Falls Prevalence
    <bullet> Patient Falls with Injury
    These measures broaden the ability of the RHQDAPU program measure 
set to assess care generally associated with nursing staff. In 
addition, these measures are directed toward outcomes that are 
underrepresented among the RHQDAPU program measures. These measures 
apply to the vast majority of inpatient stays and provide a great deal 
of critical information about hospital quality to consumers and 
stakeholders. The specifications and data collection tools are 
scheduled to be available in the specifications manual by December 2008 
for hospitals to utilize and submit data for these measures. We are 
proposing that hospitals be required to submit data on these four 
measures effective with discharges beginning April 1, 2009. While these 
measures are endorsed by NQF, the Joint Commission has initiated 
rigorous field testing of the measures, which may not be completed 
until late 2008. Therefore, it is possible that the endorsement status 
of these measures may change in the next several months. If this 
rigorous field testing results in uncertainty as to the NQF endorsement 
status at the time we issue the FY 2009 IPPS final rule, we will defer 
our final decision on whether to require these measures for the RHQDAPU 
program for FY 2010 until the time that we issue the CY 2009 OPPS/ASC 
final rule with comment period. This deferral is consistent with our 
measure expansion during the past 2 years, when we finalized some 
RHQDAPU program measures in the annual OPPS/ASC final rules.
    We are proposing to adopt three readmission measures for FY 2010 
that will be calculated using Medicare administrative claims data. The 
proposed measures are:
    <bullet> Pneumonia (PN) 30-Day Risk Standardized Readmission 
Measure (Medicare patients)
    <bullet> Heart Attack (AMI) 30-Day Risk Standardized Readmission 
Measure (Medicare patients)
    <bullet> Heart Failure (HF) 30-Day Risk Standardized Readmission 
Measure (Medicare patients)
    These readmission measures assess both quality of care and 
efficiency of care. They also promote coordination of care among 
hospitals and other providers. They compliment the existing 30-Day Risk 
Standardized Mortality Measures for Pneumonia, Heart Attack, and Heart 
Failure. These measures require no additional data collection from 
hospitals. The measures are risk adjusted to account for differences 
between hospitals in the characteristics of their patient populations.
    These three claims-based readmission measures are pending NQF 
endorsement. The NQF endorsement decision on these three measures is 
expected before we issue the FY 2009 IPPS final rule. We are proposing 
to add these three measures contingent upon NQF endorsement. We are 
also proposing to defer our decision on whether to include these 
measures until we issue the CY 2009 OPPS/ASC final rule, in the event 
that NQF endorsement status is still pending when we issue the FY 2009 
IPPS final rule. This deferral is consistent with our measure expansion 
during the past 2 years, when we finalized some RHQDAPU program 
measures in the annual OPPS/ASC final rules.
    We are also proposing to add six Venous Thromboembolism (VTE) 
measures. These measures comprehensively address a major cause of 
morbidity and mortality among hospitalized patients.
    <bullet> VTE-1: VTE Prophylaxis
    <bullet> VTE-2: VTE Prophylaxis in the ICU
    <bullet> VTE-4: Patients with overlap in anticoagulation therapy
    <bullet> VTE-5/6: (as combined measure) Patients with UFH dosages 
who have platelet count monitoring and adjustment of medication per 
protocol or nomogram
    <bullet> VTE-7: Discharge instructions to address: follow-up 
monitoring, compliance, dietary restrictions and adverse drug 
reactions/interactions
    <bullet> VTE-8: Incidence of preventable VTE
    These VTE measures are pending NQF endorsement. The NQF endorsement 
decision on these measures is expected before we issue the FY 2009 IPPS 
final rule. We are proposing to add these measures contingent upon NQF 
endorsement. We also are proposing to defer our decision on whether to 
include these measures until we issue the CY 2009 OPPS/ASC final rule 
with comment period, in the event that NQF endorsement status is still 
pending when we issue the FY 2009 IPPS final rule. This deferral is 
consistent with our measure expansion during the past 2 years, when we 
finalized some RHQDAPU program measures in the annual OPPS/ASC final 
rules. We are proposing that hospitals be required to submit data on 
these six measures effective with discharges beginning January 1, 2009.
    We also are proposing to add five Stroke measures that will apply 
only to certain identified groups under specific ICD-9-CM codes as 
specified in the specifications manual. These measures comprehensively 
address an important condition not currently covered by the RHQDAPU 
program that is associated with significant morbidity and mortality.
    <bullet> STK-1 DVT Prophylaxis
    <bullet> STK-2 Discharged on Antithrombotic Therapy
    <bullet> STK-3 Patients with Atrial Fibrillation Receiving 
Anticoagulation Therapy
    <bullet> STK-5 Antithrombotic Medication By End of Hospital Day Two
    <bullet> STK-7 Dysphasia Screening
    These Stroke measures are pending NQF endorsement. The NQF 
endorsement decision on these measures is expected before we issue the 
FY 2009 IPPS final rule. We are proposing to add these measures 
contingent upon NQF endorsement. We also are proposing to defer our 
adoption of these measures until we issue the CY 2009 OPPS/ASC final 
rule with comment period in the event that NQF

[[Page 23649]]

endorsement status is still pending as of the time we issue the FY 2009 
IPPS final rule. This approach is consistent with our measure expansion 
during the past 2 years, when CMS finalized some RHQDAPU program 
measures in the annual OPPS/ASC final rules. We are proposing that 
hospitals be required to submit data on these five measures effective 
with discharges beginning July 1, 2009.
    We also are proposing to add the following nine AHRQ Patient Safety 
Indicators (PSI) and Inpatient Quality Indicators (IQI) that have been 
endorsed by the NQF:
    <bullet> Patient Safety Indicator (PSI) 4--Death among surgical 
patients with treatable serious complications
    <bullet> PSI 6--Iatrogenic pneumothorax, adult
    <bullet> PSI 14--Postoperative wound dehiscence
    <bullet> PSI 15--Accidental puncture or laceration
    <bullet> Inpatient Quality Indicator (IQI) 4 and 11--Abdominal 
aortic aneurysm (AAA) mortality rate (with or without volume)
    <bullet> IQI 19--Hip fracture morality rate
    <bullet> IQI Mortality for selected medical conditions (composite)
    <bullet> IQI Mortality for selected surgical procedures (composite)
    <bullet> IQI Complication/patient safety for selected indicators 
(composite)
    These are claims-based outcome measures. They are important 
additional measures that can be calculated for hospital inpatients 
without the burden of additional chart abstraction. Hospitals currently 
collect and submit these data to CMS and other insurers for 
reimbursement. These measures will be calculated using all-payer claims 
data that hospitals currently collect with respect to each patient 
discharge. We are proposing to require hospitals to submit to CMS the 
all-payer claims data that we specify in the technical specifications 
manual as necessary to calculate the AHRQ PSI/IQI measures. We are 
proposing that hospitals begin submitting data on a quarterly basis on 
these measures to CMS by April 1, 2010 beginning with October 1, 2009 
discharges.
    However, we are aware that a large number of hospitals already 
submit these data on a voluntary basis to third party data aggregators 
such as State health agencies or State hospital associations. We seek 
comments on whether a hospital that already submits the data necessary 
to calculate these measures to such entities should be permitted to 
authorize such an entity to transmit these data to CMS, in accordance 
with applicable confidentiality laws, on their behalf. This would 
relieve the hospital of the burden of having to submit the same data 
directly to CMS via the QIO Clinical Warehouse.
    As an alternative to requiring that hospitals submit all-payer 
claims data for purposes of calculating the AHRQ PSI/IQI measures, CMS 
is considering whether it should initially calculate the AHRQ PSI/IQI 
measures using Medicare claims data only, and at a subsequent date 
require submission of all-payer claims data. We also seek comment on 
this alternative.
    We also are proposing to add 15 cardiac surgery measures. Cardiac 
surgical procedures carry a significant risk of morbidity and 
mortality. We believe that the nationwide public reporting of these 
cardiac surgery measures would provide highly meaningful information 
for the public.
    Currently, over 85 percent of hospitals with a cardiac surgery 
program submit data on the proposed cardiac surgery measures listed 
below to the Society of Thoracic Surgeons (STS) Cardiac Surgery 
Clinical Data Registry. We are proposing to accept these data from the 
STS registry beginning on July 1, 2009, on a quarterly basis for 
discharges on or after January 1, 2009. Hospitals that participate in 
the RHQDAPU program, but that do not submit data on the proposed 
cardiac surgery measures to the STS registry for discharges on or after 
January 1, 2009, would need to submit such data to CMS. Although we 
would accept cardiac surgery data from other clinical data registries, 
we are unaware of any other registries that collect all of the data 
necessary to support calculation of the proposed cardiac surgery 
measures. Hospitals and CMS would need to establish appropriate legal 
arrangements, to the extent such arrangements are necessary, to ensure 
that the transfer of these data from the STS registry to CMS complies 
with all applicable laws. By accepting these registry-based data, only 
those hospitals with cardiac surgery programs that do not already 
collect such data to submit to the STS registry will have any 
additional data submission burden. All of the proposed measures are 
currently NQF-endorsed. We are proposing that hospitals begin 
submitting data by July 1, 2009, on a quarterly basis on the following 
15 cardiac surgery measures to the STS data registry or CMS for 1st 
quarter calendar year 2009 discharges:
    <bullet> Participation in a Systematic Database for Cardiac Surgery
    <bullet> Pre-Operative Beta Blockade
    <bullet> Prolonged Intubation
    <bullet> Deep Sternal Wound Infection Rate
    <bullet> Stroke/CVA
    <bullet> Post-Operative Renal Insufficiency
    <bullet> Surgical Reexploration
    <bullet> Anti-Platelet Medication at Discharge
    <bullet> Beta Blockade Therapy at Discharge
    <bullet> Anti-Lipid Treatment at Discharge
    <bullet> Risk-Adjusted Operative Mortality for CABG
    <bullet> Risk-Adjusted Operative Mortality for Aortic Valve 
Replacement
    <bullet> Risk-Adjusted Operative Mortality for Mitral Valve 
Replacement/Repair
    <bullet> Risk-Adjusted Mortality for Mitral Valve Replacement and 
CABG Surgery
    <bullet> Risk-Adjusted Mortality for Aortic Valve Replacement and 
CABG Surgery
    The following table lists the 72 proposed measures for FY 2010:

------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial           <bullet> AMI-1 Aspirin at
 Infarction).                             arrival *.
                                         <bullet> AMI-2 Aspirin
                                          prescribed at discharge *.
                                         <bullet> AMI-3 Angiotensin
                                          Converting Enzyme Inhibitor
                                          (ACE-I) or Angiotensin II
                                          Receptor Blocker (ARB) for
                                          left ventricular systolic
                                          dysfunction *.
                                         <bullet> AMI 6 Beta blocker at
                                          arrival *.
                                         <bullet> AMI-5 Beta blocker
                                          prescribed at discharge *.
                                         <bullet> AMI-7a Fibrinolytic
                                          (thrombolytic) agent received
                                          within 30 minutes of hospital
                                          arrival**.
                                         <bullet> AMI-4 Adult smoking
                                          cessation advice/counseling**.
                                         <bullet> AMI-8a Timing of
                                          Receipt of Primary
                                          Percutaneous Coronary
                                          Intervention (PCI).
------------------------------------------------------------------------
Heart Failure (HF).....................  <bullet> HF-2 Left ventricular
                                          function assessment *.

[[Page 23650]]

 
                                         <bullet> HF-3 Angiotensin
                                          Converting Enzyme Inhibitor
                                          (ACE-I) or Angiotensin II
                                          Receptor Blocker (ARB) for
                                          left ventricular systolic
                                          dysfunction *.
                                         <bullet> HF-1 Discharge
                                          instructions**.
                                         <bullet> HF-4 Adult smoking
                                          cessation advice/counseling**.
------------------------------------------------------------------------
Pneumonia (PN).........................  <bullet> PN-2 Pneumococcal
                                          vaccination status *.
                                         <bullet> PN-3b Blood culture
                                          performed before first
                                          antibiotic received in
                                          hospital**.
                                         <bullet> PN-4 Adult smoking
                                          cessation advice/counseling**.
                                         <bullet> PN-6 Appropriate
                                          initial antibiotic
                                          selection**.
                                         <bullet> PN-7 Influenza
                                          vaccination status**.
                                         <bullet> PN-5c Timing of
                                          receipt of initial antibiotic
                                          following hospital
                                          arrival******.
------------------------------------------------------------------------
Surgical Care Improvement Project        <bullet> SCIP-1 Prophylactic
 (SCIP)--named SIP for discharges prior   antibiotic received within 1
 to July 2006 (3Q06).                     hour prior to surgical
                                          incision**.
                                         <bullet> SCIP-3 Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time**.
                                         <bullet> SCIP-VTE-1: Venous
                                          thromboembolism (VTE)
                                          prophylaxis ordered for
                                          surgery patients***.
                                         <bullet> SCIP-VTE-2: VTE
                                          prophylaxis within 24 hours
                                          pre/post surgery***.
                                         <bullet> SCIP Infection 2:
                                          Prophylactic antibiotic
                                          selection for surgical
                                          patients***.
                                         <bullet> SCIP-Infection 4:
                                          Cardiac Surgery Patients with
                                          Controlled 6AM Postoperative
                                          Serum Glucose*****.
                                         <bullet> SCIP Infection 6:
                                          Surgery Patients with
                                          Appropriate Hair Removal*****.
                                         <bullet> 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).  <bullet> MORT-30-AMI Acute
                                          Myocardial Infarction 30-day
                                          mortality Medicare
                                          patients***.
                                         <bullet> MORT-30-HF Heart
                                          Failure 30-day mortality
                                          Medicare patients***.
                                         <bullet> MORT-30-PN Pneumonia
                                          30-day mortality Medicare
                                          patients****.
------------------------------------------------------------------------
Patients' Experience of Care...........  <bullet> HCAHPS patient
                                          survey***.
------------------------------------------------------------------------
Readmission Measures (Medicare           <bullet> Heart Attack (AMI) 30-
 patients).                               Day Risk Standardized
                                          Readmission Measure (Medicare
                                          patients)******.
                                         <bullet> Heart Failure (HF) 30-
                                          Day Risk Standardized
                                          Readmission Measure (Medicare
                                          patients)******.
                                         <bullet> Pneumonia (PN) 30-Day
                                          Risk Standardized Readmission
                                          Measure (Medicare patients)
                                          ******.
------------------------------------------------------------------------
Inpatient Stroke Care..................  <bullet> STK-1 DVT
                                          Prophylaxis******.
                                         <bullet> STK-2 Discharged on
                                          Antithrombotic Therapy******.
                                         <bullet> STK-3 Patients with
                                          Atrial Fibrillation Receiving
                                          Anticoagulation Therapy******.
                                         <bullet> STK-5 Antithrombotic
                                          Medication By End of Hospital
                                          Day Two******.
                                         <bullet> STK-7 Dysphasia
                                          Screening******.
------------------------------------------------------------------------
Venous Thromboembolic Care.............  <bullet> VTE-1: VTE
                                          Prophylaxis******.
                                         <bullet> VTE-2: VTE Prophylaxis
                                          in the ICU******.
                                         <bullet> VTE-4: Patients with
                                          overlap in anticoagulation
                                          therapy******.
                                         <bullet> VTE-5/6: (as combined
                                          measure) patients with UFH
                                          dosages who have platelet
                                          count monitoring and
                                          adjustment of medication per
                                          protocol or nomagram******.
                                         <bullet> VTE-7: Discharge
                                          instructions to address:
                                          followup monitoring,
                                          compliance, dietary
                                          restrictions, and adverse drug
                                          reactions/interactions******.
                                         <bullet> VTE-8: Incidence of
                                          preventable VTE******.
------------------------------------------------------------------------
AHRQ Patient Safety Indicators.........  <bullet> Death among surgical
                                          patients with treatable
                                          serious complications******.
                                         <bullet> Iatrogenic
                                          pneumothorax, adult******.
                                         <bullet> Postoperative wound
                                          dehiscence******.
                                         <bullet> Accidental puncture or
                                          laceration******.
------------------------------------------------------------------------
AHRQ Inpatient Quality Indicators (IQI)  <bullet> Abdominal aortic
                                          aneurysm (AAA) mortality rate
                                          (with or without volume)
                                          ******.
                                         <bullet> Hip fracture morality
                                          rate******.
------------------------------------------------------------------------
AHRQ IQI Composite Measures............  <bullet> Mortality for selected
                                          surgical procedures
                                          (composite) ******.

[[Page 23651]]

 
                                         <bullet> Complication/patient
                                          safety for selected indicators
                                          (composite) ******.
                                         <bullet> Mortality for selected
                                          medical conditions (composite)
                                          ******.
------------------------------------------------------------------------
Nursing Sensitive Measures.............  <bullet> Failure to
                                          Rescue******.
                                         <bullet> Pressure Ulcer
                                          Prevalence and Incidence by
                                          Severity ******.
                                         <bullet> Patient Falls
                                          Prevalence******.
                                         <bullet> Patient Falls with
                                          Injury******.
------------------------------------------------------------------------
Cardiac Surgery Measures...............  <bullet> Participation in a
                                          Systematic Database for
                                          Cardiac Surgery ******.
                                         <bullet> Pre-operative Beta
                                          Blockade******.
                                         <bullet> Prolonged
                                          Intubation******.
                                         <bullet> Deep Sternal Wound
                                          Infection Rate******.
                                         <bullet> Stroke/CVA******.
                                         <bullet> Postoperative Renal
                                          Insufficiency******.
                                         <bullet> Surgical
                                          Reexploration******.
                                         <bullet> Anti-platelet
                                          Medication at Discharge******.
                                         <bullet> Beta Blockade Therapy
                                          at Discharge******.
                                         <bullet> Anti-lipid Treatment
                                          at Discharge******.
                                         <bullet> Risk-Adjusted
                                          Operative Mortality for
                                          CABG******.
                                         <bullet> Risk-Adjusted
                                          Operative Mortality for Aortic
                                          Valve Replacement******.
                                         <bullet> Risk-Adjusted
                                          Operative Mortality for Mitral
                                          Valve Replacement/
                                          Repair******.
                                         <bullet> Risk-Adjusted
                                          Mortality for Mitral Valve
                                          Replacement and CABG
                                          Surgery******.
                                         <bullet> Risk-Adjusted
                                          Mortality for Aortic Valve
                                          Replacement and CABG Surgery
                                          ******.
------------------------------------------------------------------------
*Measure included in 10 measure starter set.
**Measure included in 21 measure expanded set.
***Measure added in CY 2007 OPPS/ASC final rule with comment period.
****Measure added in FY 2008 IPPS final rule with comment period.
*****Measure added in CY 2008 OPPS/ASC final rule with comment period.
******Measure proposed in FY 2009 IPPS proposed rule.

    In summary, we are proposing to increase the RHQDAPU program 
measures from 30 measures for FY 2009 to a total of 72 measures for FY 
2010. The following table lists the increase in the RHQDAPU program 
measure set since the program's inception:

----------------------------------------------------------------------------------------------------------------
                                       Number of
                                        RHQDAPU
          IPPS payment year             program                            Topics covered
                                        quality
                                        measures
----------------------------------------------------------------------------------------------------------------
2005-2006...........................           10  AMI, HF, PN.
2007................................           21  AMI, HF, PN, SCIP.
2008................................           27  AMI, HF, PN, SCIP, Mortality, HCAHPS.
2009................................           30  AMI, HF, PN, SCIP, Mortality, HCAHPS.
2010................................           72  AMI, HF, PN, SCIP, Mortality, HCAHPS, Nursing Sensitive,
                                                    Readmission, VTE, Stroke, AHRQ IQI/PSI measures and
                                                    composites, Cardiac Surgery.
----------------------------------------------------------------------------------------------------------------

    The above measures reflect our continuing commitment to quality 
improvement in both clinical care and patient safety. These additional 
measures also demonstrate our commitment to include in the RHQDAPU 
program only those quality measures that reflect consensus among the 
affected parties and that have been reviewed by a consensus building 
process.
    To the extent that the proposed measures have not already been 
endorsed by a consensus building entity such as the NQF, we anticipate 
that they will be endorsed prior to the time that we issue the FY 2009 
IPPS final rule. We intend to finalize the FY 2010 RHQDAPU program 
measure set in the FY 2009 IPPS final rule, contingent on the 
endorsement status of the proposed measures. However, to the extent 
that a measure has not received NQF endorsement by the time we issue 
the FY 2009 IPPS final rule, we intend to finalize that measure for the 
FY 2010 RHQDAPU program measure set in the CY 2009 OPPS/ASC final rule 
with comment period if the measure is endorsed prior to the time we 
issue the CY-2009-OPPS/ASC final rule with comment period. We are 
requesting public comment on these measures.
b. Possible New Quality Measures, Measure Sets, and Program 
Requirements for FY 2011 and Subsequent Years
    The following table contains a list of 59 measures and 4 measure 
sets from which additional quality measures could be selected for 
inclusion in the RHQDAPU program. It includes measures and measure sets 
that highlight CMS' interest in improving patient safety and outcomes 
of care, with a particular focus on the quality of surgical care and 
patient outcomes. In order to engender a broad review of potential 
performance measures, the list includes measures that have not yet

[[Page 23652]]

been considered for approval by the HQA or endorsed by a consensus 
review process such as the NQF. It also includes measures developed by 
organizations other than CMS as well as measures that are to be derived 
from administrative data (such as claims) that may need to be modified 
for specific use by the Medicare program if implemented under the 
RHQDAPU program.
    We are seeking public comment on the measures and measure sets that 
are listed as well as any critical gaps or missing measures or measure 
sets. We specifically request input concerning the following:
    <bullet> Which of the measures or measure sets should be included 
in the RHQDAPU program for FY 2011 or in subsequent years?
    <bullet> What challenges for data collection and reporting are 
posed by the identified measures and measure sets? What improvements 
could be made to data collection or reporting that might offset or 
otherwise address those challenges?
    We are soliciting public comment on the following measure sets for 
consideration in FY 2011 and subsequent years:

 Possible Measures and Measure Sets for the RHQDAPU Program for FY 2011
                          and Subsequent Years
------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Chronic Pulmonary Obstructive Disease
 Measures:
    Complications of Vascular Surgery..  AAA stratified by open and
                                          endovascular methods.
                                         Carotid Endarterectomy.
                                         Lower extremity bypass.
------------------------------------------------------------------------
Inpatient Diabetes Care Measures:
    Healthcare Associated Infection....  Central Line-Associated Blood
                                          Stream Infections.
------------------------------------------------------------------------
                                         Surgical Site Infections.
Timeliness of Emergency Care Measures,   Median Time from ED Arrival to
 including Timeliness.                    ED Departure for Admitted ED
                                          Patients.
                                         Median Time from ED Arrival to
                                          ED Departure for Discharged ED
                                          Patients.
                                         Admit Decision Time to ED
                                          Departure Time for Admitted
                                          Patients.
------------------------------------------------------------------------
Surgical Care Improvement Project        SCIP Infection 8--Short Half-
 (SCIP)--named SIP for discharges prior   life Prophylactic Administered
 to July 2006 (3Q06).                     Preoperatively Redosed Within
                                          4 Hours After Preoperative
                                          Dose.
                                         SCIP Cardiovascular 3--Surgery
                                          Patients on a Beta Blocker
                                          Prior to Arrival Receiving a
                                          Beta Blocker on Postoperative
                                          Days 1 and 2.
------------------------------------------------------------------------
Complication Measures (Medicare
 patients):
    Healthcare Acquired Conditions.....  Serious reportable events in
                                          healthcare (never events).
                                         Pressure ulcer prevalence and
                                          incidence by severity.
                                         Catheter-associated UTI.
------------------------------------------------------------------------
Hospital Inpatient Cancer Care Measures  Patients with early stage
                                          breast cancer who have
                                          evaluation of the axilla.
                                         College of American
                                          Pathologists breast cancer
                                          protocol.
                                         Surgical resection includes at
                                          least 12 nodes.
                                         College of American
                                          Pathologists Colon and rectum
                                          protocol.
                                         Completeness of pathologic
                                          reporting.
------------------------------------------------------------------------
Serious Reportable Events in Healthcare  Surgery performed on the wrong
 (``Never Events'').                      body part.
                                         Surgery performed on the wrong
                                          patient.
                                         Wrong surgical procedure on a
                                          patient.
                                         Retention of a foreign object
                                          in a patient after surgery or
                                          other procedure.
                                         Intraoperative or immediately
                                          post-operative death in a
                                          normal health patient (defined
                                          as a Class 1 patient for
                                          purposes of the American
                                          Society of Anesthesiologists
                                          patient safety initiative).
                                         Patient death or serious
                                          disability associated with the
                                          use of contaminated drugs,
                                          devices, or biologics provided
                                          by the healthcare facility.
                                         Patient death or serious
                                          disability associated with the
                                          use or function of a device in
                                          patient care in which the
                                          device is used or functions
                                          other than as intended.
                                         Patient death or serious
                                          disability associated with
                                          intravascular air embolism
                                          that occurs while being cared
                                          for in a healthcare facility.
                                         Patient death or serious
                                          disability associated with
                                          patient elopement
                                          (disappearance) for more than
                                          four hours.
                                         Patient suicide, or attempted
                                          suicide resulting in serious
                                          disability, while being cared
                                          for in a healthcare facility.
                                         Patient death or serious
                                          disability associated with a
                                          medication error (e.g., error
                                          involving the wrong drug,
                                          wrong dose, wrong patient,
                                          wrong time, wrong rate, wrong
                                          preparation, or wrong route of
                                          administration).
                                         Patient death or serious
                                          disability associated with a
                                          hemolytic reaction due to the
                                          administration of ABO-
                                          incompatible blood or blood
                                          products.

[[Page 23653]]

 
                                         Patient death or serious
                                          disability associated with
                                          hypoglycemia, the onset of
                                          which occurs while the patient
                                          is being cared for in a health
                                          care facility.
                                         Stage 3 or 4 pressure ulcers
                                          acquired after admission to a
                                          health care facility.
                                         Patient death or serious
                                          disability due to spinal
                                          manipulative therapy.
                                         Patient death or serious
                                          disability associated with an
                                          electric shock while being
                                          cared for in a healthcare
                                          facility.
                                         Any incident in which a line
                                          designated for oxygen or other
                                          gas to be delivered to a
                                          patient contains the wrong gas
                                          or is contaminated by toxic
                                          substances.
                                         Patient death or serious
                                          disability associated with a
                                          burn incurred from any source
                                          while being cared for in a
                                          health care facility.
                                         Patient death associated with a
                                          fall while being cared for in
                                          a health care facility.
                                         Patient death or serious
                                          disability associated with the
                                          use of restraints or bedrails
                                          while being cared for in a
                                          health care facility.
                                         Any instance of care ordered by
                                          or provided by someone
                                          impersonating a physician,
                                          nurse, pharmacist, or other
                                          licensed health care provider.
                                         Abduction of a patient of any
                                          age.
                                         Sexual assault on a patient
                                          within or on the grounds of a
                                          health care facility.
                                         Death or significant injury of
                                          a patient or staff member
                                          resulting from a physical
                                          assault (i.e., battery) that
                                          occurs within or on the
                                          grounds of a health care
                                          facility.
------------------------------------------------------------------------
Average Length of Stay Coupled with
 Global Readmission Measure:
    Preventable Hospital-Acquired        Catheter-Associated Urinary
     Conditions (HACs).                   Tract Infection (UTI).
                                         Vascular Catheter-Associated
                                          Infection.
                                         Surgical Site Infections--
                                          Mediastinitis after Coronary
                                          Artery Bypass Graft (CABG).
                                         Surgical Site Infections
                                          following Elective Procedures--
                                          Total Knee Replacement,
                                          Laparoscopic Gastric Bypass,
                                          Litigation and Stripping of
                                          Varicose Veins.
                                         Legionnaires' Disease.
                                         Glycemic Control--Diabetic
                                          Ketoacidosis, Nonketotic
                                          Hypersmolar Coma, Hypoglycemic
                                          Coma.
                                         Iatrogenic pneumothorax.
                                         Delirium.
                                         Ventilator-Associated Pneumonia
                                          (VAP).
                                         Deep Vein Thrombosis (DVT)/
                                          Pulmonary Embolism (PE).
                                         Staphylococcus aureus
                                          Septicemia.
                                         Clostridium-Difficile
                                          Associated Disease (CDAD).
                                         Methicillin-Resistant
                                          Staphylococcus aureus (MRSA).
------------------------------------------------------------------------

c. Considerations in Expanding and Updating Quality Measures Under the 
RHQDAPU Program
    The RHQDAPU program has significantly expanded from an initial set 
of 10 measures to 30 measures for the FY 2009 payment determination. 
Initially, the conditions covered by the RHQDAPU program measures were 
limited to Acute Myocardial Infarction, Heart Failure, and Pneumonia, 
three high-cost and high-volume conditions. In expanding the process 
measures, Surgical Infection Prevention was the first additional focus, 
now supplemented by the two Venous Thromboembolism SCIP measures SCIP 
VTE-1 and SCIP VTE-2 for surgical patients. Of the 30 current measures, 
27 require data collection from chart abstraction and surveying 
patients and submission of detailed data elements.
    In looking forward to further expansion of the RHQDAPU program, we 
believe it is important to take several goals into consideration. These 
include: (a) Expanding the types of measures beyond process of care 
measures to include an increased number of outcome measures, efficiency 
measures, and 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 broadly reported by hospitals, such as clinical data 
registries or all-payer claims data bases; and (f) weighing the 
meaningfulness and utility of the measures compared to the burden on 
hospitals in submitting data under the RHQDAPU program.
    We request comments on how to reduce burden on the hospitals 
participating in the RHQDAPU program. We realize that our proposal to 
expand the RHQDAPU program measure set from submission of 30 measures 
in FY 2009 to 72 measures in FY 2010 is potentially burdensome. 
However, to minimize hospitals' burden, the proposed expansion uses 
many existing

[[Page 23654]]

data sources, including Medicare claims and registry data. We also 
request comment about which measures would be most useful while 
minimizing burden.
(1) Expanding the Types of Measures
    Section 1886(b)(3)(B)(viii)(III) of the Act requires the Secretary 
to add other quality measures that the Secretary determines to be 
appropriate for the measurement of the quality of care furnished by 
hospitals in inpatient settings. We intend to expand outcome measures 
such as mortality measures and measures of complications. For FY 2010, 
the proposed measure set includes:
    <bullet> Patient Experience of Care. HCAHPS collects data regarding 
a patient's experience of care in the hospital and provides a very 
meaningful perspective from the patient standpoint.
    <bullet> Efficiency. Efficiency is a Quality Domain, as defined by 
the IOM, that relates Quality and Cost. The three proposed readmission 
measures address hospital efficiency. These are considered efficiency 
measures because higher hospital readmission rates are linked to higher 
costs and also to lower quality of care received during hospitalization 
and after the initial hospital stay. We are also seeking additional 
ways in which to address efficiency.
    <bullet> Outcomes. The three 30-day mortality measures, the STS 
cardiac surgery measures, the AHRQ PSI/IQI measures, and the four 
outcome-related nursing sensitive measures represent significant 
expansion of the RHQDAPU program outcome measures. Additional outcome 
measures are provided in the list under consideration for inclusion in 
the RHQDAPU program for FY 2010 and beyond.
(2) Expanding the Scope of Hospital Services To Which Measures Apply
    Many of the most common and high-cost Medicare DRGs were posted on 
the Hospital Compare Web site in March 2008 as part of the President's 
transparency initiative. We have assessed these DRGs and have found 
that the FY 2009 RHQDAPU program measure set does not capture data 
regarding care in important areas such as Inpatient Diabetes Care, 
Chronic Obstructive Pulmonary Disease (COPD), and Chest Pain. These are 
areas for which we currently do not have quality measures but which 
constitute a significant portion of the top paying DRGs for Medicare 
beneficiaries. We intend to develop measures in these areas in order to 
provide additional quality information on the most common and high-cost 
conditions that affect Medicare beneficiaries. In the proposed FY 2010 
measure set, measures have been expanded to comprehensively address 
services related to preventing Venous Thromboembolism, treatment of 
stroke, and nursing services.
(3) Considering the Burden on Hospitals in Collecting Chart-Abstracted 
Data for Measures
    Although we are proposing to add additional chart-abstracted 
measures for FY 2010, we also are proposing to stagger the dates for 
which data collection for these measures must begin, which we believe 
will lessen the burden on hospitals as they incorporate these new 
measures into their systems. We also intend to work to simplify the 
data abstraction specifications that add to the burden of data 
collection.
(4) Harmonizing With Other CMS Programs
    We intend to harmonize measures across settings and other CMS 
programs as evidenced by the implementation of the readmission measures 
not only for the RHQDAPU program but also for the QIOs' 9th Scope of 
Work (SOW) Patient Pathways/Care Transitions Theme, which also uses the 
30-Day Readmission Measures and will provide assistance to engage 
hospitals in improving care. The 9th SOW also focuses on disparities in 
health care, which is another important area of interest for CMS. We 
plan to analyze current RHQDAPU measures to identify particular RHQDAPU 
program measures needed to evaluate the existence of health care 
disparities, to require data elements that would support better 
identification of health care disparities, and to find more efficient 
ways to ascertain this information from claims data. In addition, at 
least some of the CY 2008 Physician Quality Reporting Initiative (PQRI) 
measures align with the current RHQDAPU program AMI and SCIP measures 
reported starting with the FY 2007 RHQDAPU measure set. In other words, 
there are financial incentives that cover the same clinical processes 
of care across different providers and settings. For example, Aspirin 
for Heart Attack corresponds to PQRI measure number 28, and Surgical 
Infection Antibiotic Timing corresponds to PQRI measure number 20. 
Outpatient quality measures under the Hospital Outpatient Data Quality 
Data Reporting Program (HOP QDRP) are also aligned with the RHQDAPU 
program measures. For example, the HOP QDRP addresses Acute Myocardial 
Infarction treatment for transferred patients and surgical infection 
prevention for outpatient surgery.
(5) Using Alternative Data Sources Not Requiring Chart Abstraction
    We are actively pursuing alternative data sources, including data 
sources that are electronically maintained. Alternative data submission 
methodologies that we are proposing in this rule include:
    <bullet> Use of registry-collected clinical data for which there is 
broad existing hospital participation as previously described with the 
STS registry.
    <bullet> Use of data collected by State data organizations, State 
hospital associations, Federal entities such as AHRQ, and/or other data 
warehouses.
    In addition, we are considering adopting the following methods of 
data collection in the future and request comments on these methods:
    <bullet> Use of the CMS Continuity Assessment Record & Evaluation 
(CARE) tool, a standardized data collection instrument, which would 
allow data to be transmitted in ``real time.'' This recently developed, 
Internet-based, quality data collection tool was developed as a part of 
the Post Acute Care Reform Demonstration Program mandated by section 
5008 of the DRA. The CARE tool consists of a core set of assessment 
items, common to all patients and all care settings (meeting criteria 
of being predictive of cost, utilization, outcomes, among others), 
organized under five major domains: Medical, Functional, Social, 
Environmental, and Cognitive--Continuity of Care. The Internet-based 
CARE tool will communicate critical information across settings 
accurately, quickly, and efficiently with reduced time burden to 
providers and is intended to enhance beneficiaries' safe transitions 
between settings to prevent avoidable, costly events such as 
unnecessary rehospitalizations or medication errors. We believe that 
the CARE tool may provide a vehicle for collection of data elements to 
be used for calculating RHQDAPU program quality measures. CMS is 
considering utilizing the CARE tool in this manner. The Care tool is 
available at: www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/list.asp#TopOfPage. (Viewers should select ``Show only items with the 
word ``10243'', click on show items, select CMS-10243, click on 
downloads, and open Appendices A & B, pdf files.)
    We are particularly interested in receiving public comment on this 
tool. Our goal is to have a standardized, efficient, effective, 
interoperable, common assessment tool to capture key

[[Page 23655]]

patient characteristics that will help CMS capture information related 
to resource utilization; expected costs as well as clinical outcomes; 
and post-discharge disposition. The CARE tool will also be useful for 
guiding payment and quality policies.
    Specifically, we are interested in receiving public comments on how 
CARE might advance the use of health information technology in 
automating the process for collecting and submitting quality data.
    <bullet> Submission of data derived from electronic versions of 
laboratory test reports that are issued by the laboratory in accordance 
with CLIA to the ordering provider and maintained by the hospital as 
part of the patient's medical record during and after the patient's 
course of treatment at the hospital. We are considering using these 
data to support risk adjustment for claims-based outcome measures (for 
example, mortality measures) and to develop other outcomes measures. 
This would support use of electronically maintained data and our goal 
of reducing manual data collection burden on hospitals.
    <bullet> Submission of data currently being collected by clinical 
data registries in addition to the STS registry. This would support and 
leverage existing clinical data registries and existing voluntary 
clinical data collection efforts, such as:
    <bullet> American College of Cardiology (ACC) data registry for 
Cardiac Measures.
    <bullet> ACC data registry for ICD.
    <bullet> ACC data registry for Carotid Stents.
    <bullet> Vascular Surgery Registry for Vascular Surgical 
Procedures.
    <bullet> ACC-sponsored ``Get with the Guidelines'' registry for 
Stroke Care.
(6) Weighing the Meaningfulness and Utility of the Measures Compared to 
the Burden on Hospitals in Submitting Data Under the RHQDAPU Program
    We are proposing to retire one measure from the RHQDAPU program for 
FY 2010 because we have determined that the burden on hospitals in 
abstracting the data outweighs the meaningful benefit that we can 
ascertain from the measure. As we explained more fully above, we are 
seeking comments on the applicability to the RHQDAPU program of 
criteria currently described in the Hospital VBP Issues Paper for 
inclusion and retirement of measures. The Hospital VBP Issues Paper is 
located on the CMS Web site at the following location: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/hospital_VBP_plan_issues_paper.pdf.
3. Form and Manner and Timing of Quality Data Submission
    In the FY 2007 IPPS final rule (71 FR 48031 through 48045), we set 
out RHQDAPU program procedures for data submission, program withdrawal, 
data validation, attestation, public display of hospitals'' quality 
data, and reconsiderations. Section 1886(b)(3)(B)(viii)(I) of the Act 
requires that subsection (d) hospitals submit data on measures selected 
under that clause with respect to the applicable fiscal year. In 
addition, section 1886(b)(3)(B)(viii)(II) of the Act requires that each 
subsection (d) hospital submit data on measures selected under that 
clause to the Secretary in a form and manner, and at a time, specified 
by the Secretary. The technical specifications for each RHQDAPU program 
measure are listed in the CMS/Joint Commission Specifications Manual 
for National Inpatient Hospital Quality Measures (Specifications 
Manual). We update this manual semiannually or more frequently in 
unusual cases, and include detailed instructions and calculation 
algorithms for hospitals to collect and submit the data for the 
required measures.
    The maintenance of the specifications for the measures selected by 
the Secretary occurs through publication of the Specifications Manual. 
Thus, measure selection by the Secretary occurs through the rulemaking 
process; whereas the maintenance of the technical specifications for 
the selected measures occurs through a subregulatory process so as to 
best maintain the specifications consistent with current science and 
consensus. The data submission, Specifications Manual, and submission 
deadlines are posted on the QualityNet Web site at www.qualitynet.org. 
We require that hospitals submit data in accordance with the 
specifications for the appropriate discharge periods. When measure 
specifications are updated, we are proposing to require that hospitals 
submit all of the data required to calculate the required measures as 
outlined in the Specifications Manual current as of the patient 
discharge date.
4. Current and Proposed RHQDAPU Program Procedures
a. RHQDAPU Program Procedures for FY 2009
    In the FY 2008 IPPS final rule with comment period, we stated that 
the requirements for FY 2008 would continue to apply for FY 2009 (72 FR 
47361). The ``Reporting Hospital Quality Data for Annual Payment Update 
Reference Checklist'' section of the QualityNet Web site contains all 
of the forms to be completed by hospitals participating in the RHQDAPU 
program.
    Under these requirements hospitals must--
    <bullet> Register with QualityNet, before participating hospitals 
initially begin reporting data, regardless of the method used for 
submitting data.
    [dec221] Identify a QualityNet Administrator who follows the 
registration process located on the QualityNet Web site 
(www.qualitynet.org).
    [dec221] Complete the revised RHQDAPU program Notice of 
Participation form (only for hospitals that did not submit a form prior 
to August 15, 2007). For hospitals that share the same Medicare 
Provider Number (now CMS Certification Number (CCN)), report the name 
and address of each hospital on this form.
    [dec221] Collect and report data for each of the required measures 
except the Medicare mortality measures (AMI, HF, and PN 30-day 
Mortality for Medicare Patients). Hospitals must continuously report 
these data. Hospitals must submit the data to the QIO Clinical 
Warehouse using the CMS Abstraction & Reporting Tool (CART), The Joint 
Commission ORYX[supreg] Core Measures Performance Measurement System, 
or another third-party vendor tool that has met the measurement 
specification requirements for data transmission to QualityNet. All 
submissions will be executed through QualityNet. 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.
    <bullet> Submit complete data regarding the quality measures in 
accordance with the joint CMS/Joint Commission sampling requirements 
located on the QualityNet Web site for each quality measure that 
requires hospitals to collect and report data. 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.
    <bullet> Submit to CMS on a quarterly basis aggregate population 
and sample size counts for Medicare and non-Medicare discharges for the 
four topic areas (AMI, HF, PN, and SCIP).
    <bullet> Continuously collect and submit HCAHPS data in accordance 
with the HCAHPS Quality Assurance Guidelines, Version 3.0, located at 
the Web site: www.hcahpsonline.org. The QIO

[[Page 23656]]

Clinical Warehouse has been modified to accept zero HCAHPS-eligible 
discharges. We remind the public to refer to the QualityNet Web site 
for any questions about how to submit ``zero cases'' information.
    For the AMI 30-day, HF 30-day, and PN 30-day mortality measures, 
CMS uses Part A and Part B claims for Medicare fee-for-service patients 
to calculate the mortality measures. For FY 2009, hospital inpatient 
claims (Part A) from July 1, 2006 to June 30, 2007, will be used to 
identify the relevant patients and the index hospitalizations. 
Inpatient claims for the index hospitalizations and Part A and Part B 
claims for all inpatient, outpatient, and physician services received 
one year prior to the index hospitalizations are used to determine 
patient comorbidity, which is used in the risk adjustment calculation 
(see the Web site: www.qualitynet.org/dcs/ContentServer?cid=1163010398556&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page). No other hospital data submission is required to calculate the 
mortality rates.
b. Proposed RHQDAPU Program Procedures for FY 2010
    We are proposing to continue requiring the FY 2009 RHQDAPU program 
procedures for FY 2010 for hospitals participating in the RHQDAPU 
program, with the following modifications:
    <bullet> Notice of Participation. New subsection (d) hospitals and 
existing hospitals that wish to participate in RHQDAPU for the first 
time must complete a revised ``Reporting Hospital Quality Data for 
Annual Payment Update Notice of Participation'' that includes the name 
and address of each hospital that shares the same CCN.
    <bullet> Data Submission. In order to reduce the burden on 
hospitals that treat a low number of patients who are covered by the 
submission requirements, we are proposing the following:
    [dec221] AMI. We are proposing that a hospital that has five or 
fewer AMI discharges (both Medicare and non-Medicare combined) in a 
quarter will not be required to submit AMI patient level data for that 
quarter. We are proposing to begin implementing this requirement with 
discharges on or after January 1, 2009. However, the hospital must 
still submit its aggregate AMI population and sample size counts to CMS 
for that quarter as part of its quarterly RHQDAPU data submission.
    [dec221] HCAHPS. We are proposing that a hospital that has five or 
fewer HCAHPS-eligible discharges in any month will not be required to 
submit HCAHPS surveys for that month. However, the hospital must still 
submit its total number of HCAHPS-eligible cases for that month as part 
of its quarterly HCAHPS data submission. We are proposing to begin 
implementing this requirement with discharges on or after January 1, 
2009.
    [dec221] HF. We are proposing that a hospital that has five or 
fewer HF discharges (both Medicare and non-Medicare combined) in a 
quarter will not be required to submit HF patient level data for that 
quarter. However, the hospital must still submit its aggregate HF 
population and sample size counts to CMS for that quarter as part of 
its quarterly RHQDAPU data submission. We are proposing to begin 
implementing this requirement with discharges on or after January 1, 
2009.
    [dec221] PN. We are proposing that a hospital that has five or 
fewer PN discharges (both Medicare and non-Medicare combined) in a 
quarter will not be required to submit PN patient level data for that 
quarter. However, the hospital must still submit its aggregate PN 
population and sample size counts to CMS for that quarter as part of 
its quarterly RHQDAPU data submission. We are proposing to begin 
implementing this requirement with discharges on or after January 1, 
2009.
    [dec221] SCIP. We are proposing that a hospital that has five or 
fewer SCIP discharges (both Medicare and non-Medicare combined) in a 
quarter will not be required to submit SCIP patient level data for that 
quarter. However, the hospital must still submit its aggregate SCIP 
population and sample size counts to CMS for that quarter as part of 
its quarterly RHQDAPU data submission. We are proposing to begin 
implementing this requirement with discharges on or after January 1, 
2009.
    In addition, we are proposing the following quarterly deadlines for 
hospitals to submit the FY 2010 AMI, HF, SCIP, PN, Stroke, VTE, and 
nursing sensitive measure data:
    <bullet> The data submission deadline for hospitals to submit the 
patient level measure data for 1st calendar quarter of 2009 discharges 
would be August 15, 2009. Data must be submitted for each of these 
measures 4.5 months after the end of the preceding quarter. The 
specific deadlines will be listed on the QualityNet Web site.
    <bullet> Even though data on applicable measures will not be due 
until 4.5 months after the end of the preceding quarter, hospitals must 
submit their aggregate population and sample size counts no later than 
4 months after the end of the preceding quarter (the exact dates will 
be posted on the QualityNet Web site). This deadline falls 
approximately 15 days before the data submission deadline for the 
clinical process measures, and we are proposing it so that we can 
inform hospitals about their data submission status for the quarter 
before the 4.5 month clinical process measure deadline. We have found 
from past experience that hospitals need sufficient time to submit 
additional data when their counts differ from Medicare claims counts 
generated by CMS. We will provide hospitals with these Medicare claims 
counts and submitted patient level data counts on the QualityNet Web 
site approximately 2 weeks before the quarterly submission deadline. We 
plan to use the aggregate population and sample size data to assess 
submission completeness and adherence to sampling requirements for 
Medicare and non-Medicare patients.
    We propose the following quarterly deadlines for hospitals to 
submit cardiac surgery and the AHRQ PSI/IQI measure data to CMS or 
other entities:
    <bullet> The data submission deadline for hospitals to submit 
cardiac surgery patient level measure data to CMS or STS data registry 
for 1st calendar quarter of 2009 discharges would be June 1, 2009. Data 
must be submitted for each of these measures 2 months after the end of 
the preceding quarter. The specific deadlines will be listed on the 
QualityNet Web site.
    <bullet> The data submission deadline for hospitals to submit the 
AHRQ PSI/IQI measure data to CMS for 4th calendar quarter of 2009 
discharges would be April 1, 2010. Data must be submitted for each of 
these measures 3 months after the end of the preceding quarter. The 
specific deadlines will be listed on the QualityNet Web site.
    We are proposing these quarterly submission deadlines for cardiac 
surgery and AHRQ PSI/IQI measure data to coordinate submission 
deadlines with external data registries and provide more timely 
information to the consumers. We are proposing this quarterly 
submission deadline for cardiac surgery measure data to coincide with 
the STS quarterly submission deadline that is approximately 2 months 
following the discharge quarter. We also propose to shorten the time 
lag between the date of discharge and the public reporting of these 
quality measures to provide more timely consumer information.
5. Current and Proposed HCAHPS Requirements
a. FY 2009 HCAHPS Requirements
    For FY 2009, hospitals must continuously collect and submit HCAHPS 
data to the QIO Clinical

[[Page 23657]]

Warehouse by the data submission deadlines posted on the Web site at: 
www.hcahpsonline.org. The data submission deadline for first quarter CY 
2008 (January through March) discharges is July 9, 2008. To collect 
HCAHPS data, a hospital can either 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 a hospital can 
self-administer the survey without using a survey vendor, provided that 
the hospital meets Minimum Survey Requirements as specified on the Web 
site at: www.hcahpsonline.org. A current list of approved HCAHPS survey 
vendors can be found on the Web site at: www.hcahpsonline.org.
    Every hospital choosing to contract with a survey vendor should 
provide the sample frame of hospital-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 (see the Quality Assurance Guidelines for details about HCAHPS 
eligibility and sample frame creation) and must authorize the survey 
vendor to submit data via QualityNet on the hospital's behalf. CMS 
strongly recommends that the 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 after the survey vendor submits the data to the QIO Clinical 
Warehouse. These reports enable a hospital to ensure that its survey 
vendor has submitted the data on time and it has been accepted into the 
Warehouse.
    In the FY 2008 IPPS final rule with comment period (72 FR 47362), 
we stated that hospitals and survey vendors must participate in a 
quality oversight process conducted by the HCAHPS project team. 
Starting in July 2007, we began asking hospitals/survey vendors to 
correct any problems that were found and provide followup documentation 
of corrections for review within a defined time period. If the HCAHPS 
project team finds that the hospital has not made these corrections, 
CMS may determine that the hospital is not submitting HCAHPS data that 
meet the requirements for the RHQDAPU program. As part of these 
activities, HCAHPS project staff reviews and discusses with survey 
vendors and hospitals self-administering the survey their specific 
Quality Assurance Plans, survey management procedures, sampling and 
data collection protocols, and data preparation and submission 
procedures.
b. Proposed FY 2010 HCAHPS Requirements
    For FY 2010, we are proposing continuous collection of HCAHPS in 
accordance with the Quality Assurance Guidelines located at the Web 
site: www.hcahpsonline.org, by the quarterly data submission deadlines 
posted on the Web site: www.hcahpsonline.org. As stated above, starting 
with January 1, 2009 discharges, we are proposing that hospitals that 
have five or fewer HCAHPS-eligible discharges in a month would not be 
required to submit HCAHPS patient-level data for that month as part of 
the quarterly data submission that includes that month, but they would 
still be required to submit the number of HCAHPS-eligible cases for 
that month as part of their HCAHPS quarterly data submission.
    With respect to HCAHPS oversight, we are proposing that the HCAHPS 
Project Team will continue to conduct site visits and/or conference 
calls with hospitals/survey vendors to ensure the hospital's compliance 
with the HCAHPS requirements. During the onsite visit or conference 
call, the HCAHPS Project Team will review the hospital's/survey 
vendor's survey systems and will assess protocols based upon the most 
recent Quality Assurance Guidelines. All materials relevant to survey 
administration will be subject to review. The systems and program 
review includes, but it is not necessarily limited to: (a) survey 
management and data systems; (b) printing and mailing materials and 
facilities; (c) telephone/IVR materials and facilities; (d) data 
receipt, entry and storage facilities; and (e) written documentation of 
survey processes. Organizations will be given a defined time period in 
which to correct any problems and provide followup documentation of 
corrections for review. Hospitals/survey vendors will be subject to 
followup site visits and/or conference calls, as needed. If CMS 
determines that a hospital is noncompliant with HCAHPS program 
requirements, CMS may determine that the hospital is not submitting 
HCAHPS data that meet the requirements of the RHQDAPU program.
6. Current and Proposed Chart Validation Requirements
a. Chart Validation Requirements for FY 2009
    In the FY 2008 IPPS final rule with comment period (72 FR 47361), 
we stated that, until further notice, we would continue to require that 
hospitals meet the chart validation requirements that we implemented in 
the FY 2006 IPPS final rule (70 FR 47421 and 47422). These 
requirements, as well as additional information on validation 
requirements, continue and are being placed on the QualityNet Web site.
    We also stated in the FY 2008 IPPS final rule with comment period 
that, until further notice, hospitals must pass our validation 
requirement that requires a minimum of 80-percent reliability, based 
upon our chart-audit validation process (72 FR 47361).
    In the FY 2008 IPPS final rule with comment period (72 FR 47362), 
we indicated that, for the FY 2009 update, all FY 2008 validation 
requirements would apply, except for the following modifications. We 
would modify the validation requirement to pool the quarterly 
validation estimates for 4th quarter CY 2006 through 3rd quarter 2007 
discharges. We would also expand the list of validated measures in the 
FY 2009 update to add SCIP Infection-2, SCIP VTE-1, and SCIP VTE-2 
(starting with 4th quarter CY 2006 discharges). We would also drop the 
current two-step process to determine if the hospital is submitting 
validated data. For the FY 2009 update, we stated that we will pool 
validation estimates covering the four quarters (4th quarter CY 2006 
discharges through 3rd quarter 2007 discharges) in a similar manner to 
the current 3rd quarter pooled confidence interval.
    In summary, the following chart validation requirements apply for 
the FY 2009 RHQDAPU program:
    <bullet> The 21-measure expanded set will be validated using 4th 
quarter CY 2006 (4Q06) through 3rd quarter CY 2007 (3Q07) discharges.
    <bullet> SCIP VTE-1, VTE-2, and SCIP Infection 2 will be validated 
using 2nd quarter CY 2007 and 3rd quarter CY 2007 discharges.
    <bullet> SCIP Infection 4 and SCIP Infection 6 must be submitted 
starting with 1st quarter CY 2008 discharges but will not be validated.
    <bullet> HCAHPS data must continuously be submitted and will be 
reviewed as discussed above.
    <bullet> AMI, HF, and PN 30-day mortality measures will be 
calculated as discussed below.
    In the FY 2008 IPPS final rule with comment period (72 FR 47364), 
we stated that, for the FY 2008 update and in subsequent years, we 
would revise and post up-to-date confidence interval information on the 
QualityNet Web site explaining the application of the confidence 
interval to the overall validation results. The data are being 
validated at several levels. There are consistency and internal edit 
checks to

[[Page 23658]]

ensure the integrity of the submitted data; there are external edit 
checks to verify expectations about the volume of the data received.
b. Proposed Chart Validation Requirements for FY 2010
    For FY 2010, we are proposing the following chart validation 
requirements to reflect the proposed 72-measure set:
    <bullet> The following 21 measures from the FY 2009 RHQDAPU program 
measure set will be validated using data from 4th quarter 2007 through 
3rd quarter 2008 discharges.

------------------------------------------------------------------------
                                          Quality measure validated from
                 Topic                     4th quarter 2007 through 3rd
                                             quarter 2008 discharges
------------------------------------------------------------------------
Heart Attack (Acute Myocardial           Aspirin at arrival
 Infarction).
                                         Aspirin prescribed at discharge
                                         Angiotensin Converting Enzyme
                                          Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction
                                         Beta blocker at arrival
                                         Beta blocker prescribed at
                                          discharge
                                         Fibrinolytic (thrombolytic)
                                          agent received within 30
                                          minutes of hospital arrival
                                         Adult smoking cessation advice/
                                          counseling
------------------------------------------------------------------------
Heart Failure (HF).....................  Left ventricular function
                                          assessment
                                         Angiotensin Converting Enzyme
                                          Inhibitor (ACE-I) or
                                          Angiotensin II Receptor
                                          Blocker (ARB) for left
                                          ventricular systolic
                                          dysfunction
                                         Discharge instructions
                                         Adult smoking cessation advice/
                                          counseling
------------------------------------------------------------------------
Pneumonia (PN).........................  Pneumococcal vaccination status
                                         Blood culture performed before
                                          first antibiotic received in
                                          hospital
                                         Adult smoking cessation advice/
                                          counseling
                                         Appropriate initial antibiotic
                                          selection
                                         Influenza vaccination status
------------------------------------------------------------------------
Surgical Care Improvement Project        Prophylactic antibiotic
 (SCIP)--named SIP for discharges prior   received within 1 hour prior
 to July 2006 (3Q06).                     to surgical incision
                                         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 3: Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time
------------------------------------------------------------------------

    <bullet> SCIP Infection 4 and Infection 6 will be validated using 
data from 2nd and 3rd quarter CY 2008 discharges.
    In addition, we are proposing to include the following three 
measures in the FY 2010 RHQDAPU program validation process that are 
included the FY 2009 RHQDAPU program measure set but have been updated 
or deleted for the FY 2010 measure set:
    <bullet> Pneumonia antibiotic prophylaxis timing within 4 hours 
will be validated using data from 4th quarter 2007 through 3rd quarter 
2008 discharges.
    <bullet> Percutaneous Coronary Intervention (PCI) Timing within 120 
minutes will be validated using data from 4th quarter 2007 through 3rd 
quarter 2008 discharges.
    <bullet> Pneumonia Oxygenation Assessment will be validated using 
data from 4th quarter through 3rd quarter 2008 discharges.
    These measures will be submitted by hospitals during 2008 and early 
2009, and are available to be validated by CMS in time for the FY 2010 
RHQDAPU program payment eligibility determination.
    As explained above, will also revise and post up-to-date confidence 
interval information on the QualityNet Web site explaining the 
application of the confidence interval to the overall validation 
results.
c. Chart Validation Methods and Requirements Under Consideration for FY 
2011 and Subsequent Years
    Under the current and proposed RHQDAPU program chart validation 
process, we validate measures by reabstracting on a quarterly basis a 
random sample of five patient records for each hospital. This quarterly 
sample results in an annual combined sample of 20 patient records 
across 4 calendar quarters, but because the samples are random, they do 
not necessarily include patient records covering each of the clinical 
topics.
    We anticipate that the proposed expansion of the RHQDAPU program 
measure set to include additional clinical topics will decrease the 
percentage of RHQDAPU clinical topics, as well as the total number of 
measures, covered in many hospitals' annual chart validation. In 
addition to the measures for which hospitals must submit data for FY 
2009 (with the exception of the Pneumonia Oxygenation Assessment 
measure), we have proposed that hospitals will submit data on the 
proposed five stroke measures, six VTE measures, and four nursing 
sensitive measures for FY 2010 using chart abstraction. CMS is 
considering the addition of these measures to the current RHQDAPU 
program validation process for FY 2011 and future years.
    However, we are considering whether registries and other external 
parties that may be collecting data on proposed RHQDAPU program 
measures could validate the accuracy of those measures beginning in FY 
2011. In addition, we note that the proposed readmission measures are 
calculated using Medicare claims information and do not require chart 
validation.
    We are interested in receiving public comments from a broad set of 
stakeholders on the impact of adding measures to the validation 
process, as well as modifications to the current validation process 
that could improve

[[Page 23659]]

the reliability and validity of the methodology. We specifically 
request input concerning the following:
    <bullet> Which of the measures or measure sets should be included 
in the FY 2010 RHQDAPU program chart validation process or in the chart 
validation process for subsequent years?
    <bullet> What validation challenges are posed by the RHQDAPU 
program measures and measure sets? What improvements could be made to 
validation or reporting that might offset or otherwise address those 
challenges?
    <bullet> Should CMS switch from its current quarterly validation 
sample of five charts per hospital to randomly selecting a sample of 
hospitals, and selecting more charts on an annual basis to improve 
reliability of hospital level validation estimates?
    <bullet> Should CMS select the validation sample by clinical topic 
to ensure that all publicly reported measures are covered by the 
validation sample?
7. Data Attestation Requirements
a. Proposed Change to Requirements for FY 2009
    In the FY 2008 IPPS final rule with comment period (72 FR 47364), 
we stated that we would require for FY 2008 and subsequent years that 
hospitals attest each quarter to the completeness and accuracy of their 
data, including the volume of data, submitted to the QIO Clinical 
Warehouse in order to improve aspects of the validation checks. We 
stated that we would provide additional information to explain this 
attestation requirement, as well as provide the relevant form to be 
completed on the QualityNet Web site, at the same time as the 
publication of the FY 2008 IPPS final rule with comment period.
    We are now proposing to defer the requirement in FY 2009 for 
hospitals to separately attest to the accuracy and completeness of 
their submitted data due to the burden placed on hospitals to report 
paper attestation forms on a quarterly basis. We continue to expect 
that hospitals will submit quality data that are accurate to the best 
of their knowledge and ability.
b. Proposed Requirements for FY 2010
    For FY 2010 and subsequent years, we are soliciting public comment 
on the electronic implementation of the attestation requirement at the 
point of data submission to the QIO Clinical Warehouse. Hospitals would 
electronically pledge to CMS that their submitted data are accurate and 
complete to the best of their knowledge. Hospitals would be required to 
designate an authorized contact to CMS for attestation in their 
patient-level data submission.
    Resubmissions would continue to be allowed before the quarterly 
submission deadline, and hospitals would be required to electronically 
update their pledges about data accuracy at the time of resubmission. 
We welcome comments on this approach.
8. Public Display Requirements
    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. The RHQDAPU program 
quality measures are posted on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov). CMS requires that hospitals sign a 
``Reporting Hospital Quality Data for Annual Payment Update 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 as required in the applicable year's 
RHQDAPU program requirements.
    We are proposing to continue to display quality information for 
public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the 
Act. Before we display this information, hospitals will be permitted to 
review their information as recorded in the QIO Clinical Warehouse.
    Currently, hospitals that share the same CCN (formerly known as 
Medicare Provider Number (MPN)) must combine data collection and 
submission across their multiple campuses (for both clinical measures 
and for HCAHPS). These measures are then publicly reported as if they 
apply to a single hospital. We estimate that approximately 5 to 10 
percent of the hospitals reported on the Hospital Compare Web site 
share CCNs. Beginning with the FY 2008 RHQDAPU program, hospitals must 
report the name and address of each hospital that shares the same CCN. 
This information will be gathered through the RHQDAPU program Notice of 
Participation form for new hospitals participating in the RHQDAPU 
program. To increase transparency in public reporting and improve the 
usefulness of the Hospital Compare Web site, we will note on the Web 
site where publicly reported measures combine results from two or more 
hospitals.
9. Proposed Reconsideration and Appeal Procedures
    For FY 2009, we are proposing to continue the current RHQDAPU 
program reconsideration and appeal procedures finalized in the FY 2008 
IPPS final rule with comment period. The deadline for submitting a 
request for reconsideration in connection with the FY 2009 payment 
determination is November 1, 2008. We also are proposing to use the 
same procedural rules finalized in the FY 2008 IPPS final rule with 
comment period (72 FR 47365). We posted these rules on the QualityNet 
Web site for the FY 2008 RHQDAPU program reconsideration process.
    Under the procedural rules, in order to receive reconsideration for 
FY 2009, the hospital must--
    <bullet> Submit to CMS, via QualityNet, a Reconsideration Request 
form (available on the QualityNet Web site) containing the following 
information:
    [cir] Hospital Medicare ID number.
    [cir] Hospital Name.
    [cir] CMS-identified reason for failure (as provided in the CMS 
notification of failure letter to the hospital).
    [cir] 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 2009 IPPS 
annual payment update.)
    [cir] CEO contact information, including name, e-mail address, 
telephone number, and mailing address (must include physical address, 
not just the post office box).
    [cir] QualityNet System Administrator contact information, 
including name, e-mail address, telephone number, and mailing address 
(must include physical address, not just the post office box).
    <bullet> The request must be signed by the hospital's CEO.
    <bullet> Following receipt of a request for reconsideration, CMS 
will--
    <bullet> Provide an e-mail acknowledgement, using the contact 
information provided in the reconsideration request, to the CEO and the 
QualityNet Administrator that the letter has been received.
    <bullet> Provide a formal response to the hospital CEO, using the 
contact information provided in the reconsideration request, notifying 
the facility of the outcome of the reconsideration process. CMS expects 
the process to take 60 to 90 days from the due date of November 1, 
2008.
    If a hospital is dissatisfied with the result of a RHQDAPU program

[[Page 23660]]

reconsideration decision, the hospital may file a claim under 42 CFR 
part 405, subpart R (a Provider Reimbursement Review Board (PRRB) 
appeal).
10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 and 2010
    We propose to accept RHQDAPU program withdrawal forms for FY 2009 
from hospitals through August 15, 2008. We are proposing this deadline 
to provide CMS with sufficient time to update the RHQDAPU FY 2009 
payment to hospitals starting on October 1, 2008. If a hospital 
withdraws from the program for FY 2009, it will receive a 2.0 
percentage point reduction in its FY 2009 annual payment update.
    We also propose to accept RHQDAPU program withdrawal forms for FY 
2010 from hospitals through August 15, 2009. If a hospital withdraws 
from the program for FY 2010, it will receive a 2.0 percentage point 
reduction in its FY 2010 annual payment update.
11. Requirements for New Hospitals
    In the FY 2008 IPPS final rule with comment period (72 FR 47366), 
we stated that a new hospital that receives a provider number on or 
after October 1 of each year (beginning with October 1, 2007) will be 
required to report RHQDAPU program data beginning with the first day of 
the quarter following the date the hospital registers to participate in 
the RHQDAPU program. For example, a hospital that receives its CCN on 
October 2, 2008, and signs up to participate in the RHQDAPU program on 
November 1, 2007, will be expected to meet all of the data submission 
requirements for discharges on or after January 1, 2009.
    In addition, we 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. We refer readers to the Web site at www.hcahpsonline.org 
for a schedule of upcoming dry runs. 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 data and submit the data to QualityNet.
12. Electronic Medical Records
    In the FY 2006 IPPS final rule, we encouraged hospitals to take 
steps toward the adoption of electronic medical records (EMRs) that 
will allow for reporting of clinical quality data from the EMRs 
directly to a CMS data repository (70 FR 47420). We intend to begin 
working toward creating measures' specifications, and a system or 
mechanism, or both, that will accept the data directly without 
requiring the transfer of the raw data into an XML file as is currently 
done. The Department continues to work cooperatively with other Federal 
agencies in the establishment of Federal Health Architecture (FHA) data 
standards. We encouraged hospitals that are developing systems to 
conform them to industry standards, and in particular to FHA data 
standards, once identified, taking measures to ensure that the data 
necessary for quality measures are captured. Ideally, such systems will 
also provide point-of-care decision support that enables detection of 
high levels of performance on the measures. Hospitals using EMRs to 
produce data on quality measures will be held to the same performance 
expectations as hospitals not using EMRs.
    Due to the low volume of comments we received on this issue in 
response to the FY 2006 proposed IPPS rule, in the FY 2007 IPPS 
proposed (71 FR 24095), we again invited public comment on these 
requirements and related options. In the FY 2007 IPPS final rule (71 FR 
48045), we summarized and addressed the additional comments we 
received. In the FY 2008 IPPS proposed rule (72 FR 24809), we noted 
that we would welcome additional comments on this issue.
    In the FY 2008 IPPS final rule with comment period (72 FR 47366), 
we responded to the additional comments we received and noted that CMS 
plans to continue working with the American Health Information 
Community (AHIC) and other entities to explore processes through which 
an EMR could speed the collection and minimize the resources necessary 
for quality reporting. (The AHIC is a Federal advisory body, chartered 
in 2005 to make recommendations to the Secretary on how to accelerate 
the development and adoption of health information technology.) In 
addition, we noted that we will continue to participate in appropriate 
HHS studies and workgroups, as mentioned by a GAO report (GAO-07-320) 
about hospital quality data and their use of information technology. As 
appropriate, CMS will inform interested parties regarding progress in 
the implementation of HIT for the collection and submission of hospital 
quality data as specific steps, including timeframes and milestones, 
are identified. Current mechanisms include publication in the Federal 
Register as well as ongoing collaboration with external stakeholders 
such as the HQA, the AHA, the FAH, the AAMC, and the Joint Commission. 
We further anticipate that as HIT is implemented, a formal plan, 
including training, will be developed to assist providers in 
understanding and utilizing HIT in reporting quality data. In addition, 
we will assess the effectiveness of our communications with providers 
and stakeholders as it relates to all information dissemination 
pertinent to collecting hospital quality data as part of an independent 
and comprehensive external evaluation of the RHQDAPU program.
    We are again soliciting comments on the issues and challenges 
associated with EMRs. Specifically, we invite comment on our proposed 
changes to our data submission requirements to be more aligned with 
currently implemented HIT systems, including data collection from 
registries and laboratory data.
    We recognize the potential burden on hospitals of increased data 
reporting requirements for process measures that require chart 
abstraction. In FY 2007 IPPS rulemaking, we listed a variety of 
additional possible measures for future years. The measures included 
and emphasized additional outcomes measures. Additional measures were 
included for which the data sources are claims. For these, no 
additional data abstraction or submission would be required for 
reporting hospitals beyond the claims data. In proposing measures for 
FY 2010, we seek to emphasize outcome measures and to minimize any 
additional data collection burden. In addition, as provided in section 
1886(b)(3)(B)(viii)(VI) and discussed in section IV.B.2.a. of this 
proposed rule, we are proposing to retire one measure where there is no 
meaningful difference among hospitals as a means of reducing data 
collection burden.

C. Medicare Hospital Value-Based Purchasing (VBP)

1. Medicare Hospital VBP Plan Report to Congress
    Through section 5001(b) of the Deficit Reduction Act of 2005, 
Congress authorized the development of a plan to implement value-based 
purchasing (VBP) beginning FY 2009 for IPPS hospital services. By 
statute, the plan must address: (a) The ongoing development, selection, 
and modification process for measures of quality and efficiency in 
hospital inpatient settings; (b) reporting, collection, and validation 
of quality

[[Page 23661]]

data; (c) the structure, size, and source of value-based payment 
adjustments; and (d) public disclosure of hospital performance data.
    To develop the plan, CMS created a Hospital VBP Workgroup with 
members from various CMS components and the Office of the Assistant 
Secretary for Planning and Evaluation. The Workgroup completed an 
environmental scan of existing hospital VBP programs, an issue paper 
outlining the topics to be addressed in the plan, and an options paper 
presenting design alternatives for the plan.
    CMS hosted two public Listening Sessions in early 2007 to solicit 
comments from interested parties on outstanding design questions 
associated with development of the plan. The perspectives expressed by 
stakeholders (including hospitals, consumers, and purchasers) during 
these sessions and in writing assisted the Workgroup in creating the 
Medicare Hospital VBP Plan Report to Congress. The Report was submitted 
to Congress on November 21, 2007.
    The Medicare Hospital VBP Plan builds on the foundation of 
Medicare's current RHQDAPU program (discussed in section IV.B. of the 
preamble of this proposed rule), which, since FY 2005, has provided 
differential payments to hospitals that report their performance on a 
defined set of inpatient measures for public posting on the Hospital 
Compare Web site. If authorized by Congress, the VBP Plan would replace 
the current quality reporting program with a new program that would 
include both public reporting and financial incentives to drive 
improvements in clinical quality, patient-centeredness, and efficiency.
    The proposed plan contains the following key components: (a) A 
performance assessment model that incorporates measures from different 
quality domains (that is, clinical process of care, patient experience 
of care, outcomes, among others) to calculate a hospital's total 
performance score; (b) options for translating this score into an 
incentive payment that would make a portion of the hospital's base DRG 
payment contingent on its total performance score; (c) criteria for 
selecting performance measures for the financial incentive and 
candidate measures for FY 2009 and beyond; (d) a phased approach for 
transitioning from the RHQDAPU program to the VBP plan; (e) proposed 
enhancements to the current data transmission and validation 
infrastructure to support VBP program requirements; (f) refinements to 
the Hospital Compare Web site to support expanded public reporting; and 
(g) an approach to monitoring VBP impacts.
    The Medicare Hospital VBP Plan Report to Congress is available on 
the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf.
2. Testing and Further Development of the Medicare Hospital VBP Plan
    The Hospital VBP Workgroup has undertaken testing of the VBP Plan. 
This ``dry run'' or ``simulation'' of the Plan will use the most recent 
clinical process-of-care and HCAHPS measurement data available from the 
RHQDAPU program. New information generated by the VBP Plan testing will 
include: (a) Performance scores by domain; (b) total performance 
scores; and (c) financial impacts. Following a process similar to that 
used in developing the Plan, CMS will analyze this information by 
individual IPPS hospital, by segment of the hospital industry (that is, 
geographic location, size, teaching status, among others), and in 
aggregate for all IPPS hospitals.
    The results of VBP Plan testing will be used to further develop the 
Plan. Priorities for Plan completion include addressing the small 
numbers issue (described on pages 74 and 75 of the Hospital VBP Plan 
Report to Congress) and developing a scoring methodology for the 
outcomes domain (pages 57-58 of the Hospital VBP Plan Report to 
Congress), which will become an additional aspect of the performance 
model. After completion, the Plan will be retested.
    We are seeking public comments on how to take full advantage of the 
new information generated through this testing and further Plan 
development. For example: Should the testing and retesting results be 
publicly posted? If the testing results were to be posted, would the 
best location be the Hospital Compare Web site or the CMS Web site at: 
http://www.cms.hhs.gov? In what format would public posting be most 
useful to potential audiences? At what level would the data be posted--
individual hospital or some higher level? Which data elements from the 
testing results would be most useful to share?

D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural 
Hospitals (MDHs): Volume Decrease Adjustment (Sec. Sec.  412.92 and 
412.108)

1. Background
    Under the IPPS, special payment protections are provided to a sole 
community hospital (SCH). Section 1886(d)(5)(D)(iii) of the Act defines 
an SCH as a hospital that, by reason of factors such as isolated 
location, weather conditions, travel conditions, absence of other like 
hospitals (as determined by the Secretary), or historical designation 
by the Secretary as an essential access community hospital, is the sole 
source of inpatient hospital services reasonably available to Medicare 
beneficiaries. The regulations that set forth the criteria that a 
hospital must meet to be classified as an SCH are located in 42 CFR 
412.92 of the regulations.
    Under the IPPS, separate special payment protections also are 
provided to a Medicare-dependent, small rural hospital (MDH). Section 
1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is 
located in a rural area, has not more than 100 beds, is not an SCH, and 
has a high percentage of Medicare discharges (not less than 60 percent 
in its 1987 cost reporting year or in 2 of its most recent 3 audited 
and settled Medicare cost reporting years). The regulations that set 
forth the criteria that a hospital must meet to be classified as an MDH 
are located in 42 CFR 412.108.
    Although SCHs and MDHs are paid under special payment 
methodologies, they are hospitals that are paid under section 1886(d) 
of the Act. Like all IPPS hospitals paid under section 1886(d) of the 
Act, SCHs and MDHs are paid for their discharges based on the DRG 
weights calculated under section 1886(d)(4) of the Act.
    Effective with hospital cost reporting periods beginning on or 
after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended 
by section 6003(e) of Pub. L. 101-239) and section 1886(b)(3)(I) of the 
Act (as added by section 405 of Pub. L. 106-113 and further amended by 
section 213 of Pub. L. 106-554), provide that SCHs are paid based on 
whichever of the following rates yields the greatest aggregate payment 
to the hospital for the cost reporting period:
    <bullet> The Federal rate applicable to the hospital;
    <bullet> The updated hospital-specific rate based on FY 1982 costs 
per discharge;
    <bullet> The updated hospital-specific rate based on FY 1987 costs 
per discharge; or
    <bullet> The updated hospital-specific rate based on FY 1996 costs 
per discharge.
    For purposes of payment to SCHs for which the FY 1996 hospital-
specific rate yields the greatest aggregate payment, payments for 
discharges during FYs 2001, 2002, and 2003 were based on a blend of the 
FY 1996 hospital-specific rate and the greater of the Federal rate or 
the updated FY 1982 or FY 1987

[[Page 23662]]

hospital-specific rate. For discharges during FY 2004 and subsequent 
fiscal years, payments based on the FY 1996 hospital-specific rate are 
100 percent of the updated FY 1996 hospital-specific rate.
    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 difference between the Federal rate and the 
updated hospital-specific rate based on FY 1982 or FY 1987 costs per 
discharge, whichever is higher. However, section 5003 of Pub. L. 109-
171 (DRA) modified these rules for discharges occurring on or after 
October 1, 2006. Section 5003(c) changed the 50 percent adjustment to 
75 percent. Section 5003(b) requires that an MDH use the 2002 cost 
reporting year as its base year (that is, the FY 2002 updated hospital-
specific rate), if that use results in a higher payment. MDHs do not 
have the option to use their FY 1996 hospital-specific rate.
    For each cost reporting period, the fiscal intermediary/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/MAC makes the determination. However, it may not be 
possible for the fiscal intermediary/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/MAC makes a final adjustment at the close of 
the cost reporting period after it determines precisely which of the 
payment rates would yield the highest aggregate payment to the 
hospital.
    If a hospital disagrees with the fiscal intermediary's or MAC's 
determination regarding the final amount of program payment to which it 
is entitled, it has the right to appeal the fiscal intermediary's or 
MAC's decision in accordance with the procedures set forth in 42 CFR 
Part 405, Subpart R, which concern provider payment determinations and 
appeals.
2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources for 
Determining Core Staff Values
    Section 1886(d)(5)(D)(ii) of the Act requires that the Secretary 
make a payment adjustment to an SCH that experiences a decrease of more 
than 5 percent in its total number of inpatient discharges from one 
cost reporting period to the next, if the circumstances leading to the 
decline in discharges were beyond the SCH's control. Section 
1886(d)(5)(G)(iii) of the Act requires that the Secretary make a 
payment adjustment to an MDH that experiences a decrease of more than 5 
percent in its total number of inpatient discharges from one cost 
reporting period to the next, if the circumstances leading to the 
decline in discharges were beyond the MDH's control. These adjustments 
were designed to compensate an SCH or MDH for the fixed costs it incurs 
in the year in which the reduction in discharges occurred, which it may 
be unable to reduce. Such costs include the maintenance of necessary 
core staff and services. Our records indicate that less than 10 SCHs/
MDHs request and receive this payment adjustment each year.
    We believe that not all staff costs can be considered fixed costs. 
Using a standardized formula specified by us, the SCH or MDH must 
demonstrate that it appropriately adjusted the number of staff in 
inpatient areas of the hospital based on the decrease in the number of 
inpatient days. This formula examines nursing staff in particular. If 
an SCH or MDH has an excess number of nursing staff, the cost of 
maintaining those staff members is deducted from the total adjustment. 
One exception to this policy is that no SCH or MDH may reduce its 
number of staff to a level below what is required by State or local 
law. In other words, an SCH or MDH will not be penalized for 
maintaining a level of staff that is consistent with State or local 
requirements.
    The process for determining the amount of the volume decrease 
adjustment can be found in Section 2810.1 of the Provider Reimbursement 
Manual, Part 1 (PRM-1). Fiscal intermediaries/MACs are responsible for 
establishing whether an SCH or MDH is eligible for a volume decrease 
adjustment and, if so, the amount of the adjustment. To qualify for 
this adjustment, the SCH or MDH must demonstrate that: (a) a decrease 
of more than 5 percent in total number of inpatient discharges has 
occurred; and (b) the circumstance that caused the decrease in 
discharges was beyond the control of the hospital. Once the fiscal 
intermediary/MAC has established that the SCH or MDH satisfies these 
two requirements, it will calculate the adjustment. The adjustment 
amount is determined by subtracting the second year's DRG payment from 
the lesser of: (a) the second year's costs minus any adjustment for 
excess staff; or (b) the previous year's costs multiplied by the 
appropriate IPPS update factor minus any adjustment for excess staff. 
The SCH or MDH receives the difference in a lump-sum payment.
    In order to determine whether or not the hospital's nurse staffing 
level is appropriate, the fiscal intermediary/MAC compares the 
hospital's actual number of nursing staff in each area with the 
staffing of like-size hospitals in the same census region. If a 
hospital employs more than the reported average number of nurses for 
hospitals of its size and census region, the fiscal intermediary/MAC 
reduces the amount of the adjustment by the cost of maintaining the 
additional staff. The amount of the reduction is calculated by 
multiplying the actual number of nursing staff above the reported 
average by the average nurse salary for that hospital as reported on 
the Medicare cost report. The complete process for determining the 
amount of the adjustment can be found at Section 2810.1 of the PRM-1.
    Prior to FY 2007, our policy was for fiscal intermediaries/MACs to 
obtain average nurse staffing data from the AHA HAS/Monitrend Data 
Book. However, in light of concerns that the Data Book had been 
published in 1989 and is no longer updated, in the FY 2007 IPPS rule, 
we proposed and finalized our policy to update the data sources and 
methodology used to determine the core staffing factors (that is, the 
average nursing staff for similar bed size and census region) for 
purposes of calculating the volume decrease adjustment (71 FR 48056 
through 48060). We specified that for adjustment requests for decreases 
in discharges beginning with FY 2007 (that is, a decrease in discharges 
in 2007 as compared to 2006), an SCH or MDH could opt to use one of two 
data sources: the AHA Annual Survey or the Occupational Mix Survey, but 
could not use the HAS/Monitrend Data Book. (For any open adjustment 
requests prior to FY 2007, we allowed SCHs and MDHs the option of using 
the results of any of three sources: (1) The 2006 Occupational Mix 
Survey for cost reporting periods beginning in FY 2006; (2) the AHA 
Annual Survey (where available); or (3) the AHA HAS/Monitrend Data 
Book. We also specified a methodology for calculating those core 
staffing factors. For purposes of explaining the methodology, we 
applied it to the 2003 Occupational Mix Survey data. In our 
explanation, we recognized that some of the 2003 data seemed anomalous, 
and we solicited comments on a possible alternative methodology. 
However, there were no suggested alternative methodologies from the

[[Page 23663]]

commenters. We also explained that, while we used the 2003 Occupational 
Mix Survey data ``for purposes of describing how we would implement 
this methodology,'' the final policy was to use FY 2006 Occupational 
Mix Survey data going forward. At the time we published the proposed 
and final rules, however, we had not yet processed the FY 2006 data, 
and could not present the core staffing figures that resulted from such 
data.
    We have now processed the 2006 Occupational Mix Survey data using 
the methodology specified in the FY 2007 IPPS final rule and continue 
to see some results that cause us to believe that the methodology for 
calculating the core staffing factors should be slightly revised from 
the methodology discussed in the FY 2007 IPPS final rule (71 FR 48056 
through 48060). The new methodology uses a revised formula to remove 
outliers from the core staffing values.
a. Occupational Mix Survey
    In the FY 2007 IPPS final rule (71 FR 48055), we explained the 
methodology we would use for calculating core staffing values from the 
Occupational Mix Survey. We stated that we would calculate the nursing 
hours per patient day for each SCH or MDH by dividing the number of 
paid nursing hours (for registered nurses, licensed practical nurses 
and nursing aides) reported on the Occupational Mix Survey by the 
number of patients days reported on the Medicare cost report. The 
results would be grouped in the same bed-size groups and census regions 
as were used in the HAS/Monitrend Data Book.
    We indicated that we would publish the mean number of nursing hours 
per patient day, for each census region and bed-size group, in the 
Federal Register and on the CMS Web site. For purposes of the volume 
decrease adjustment, the published data would be utilized in the same 
way as the HAS/Monitrend data: The fiscal intermediary/MAC would 
multiply the SCH's and MDH's number of patient days by the applicable 
published hours per patient day. This figure would be divided by the 
average number of worked hours per year per nurse (for example, 2,080 
for a standard 40-hour week). The result would be the target number of 
core nursing staff for the particular SCH or MDH. If necessary, the 
cost of any excess staff (number of FTEs that exceed the published 
number) would be removed from the second year's costs or, if 
applicable, the previous year's costs multiplied by the IPPS update 
factor when determining the volume decrease adjustment.
    In the FY 2007 IPPS final rule (71 FY 48057), we stated that we 
would use the results of the FY 2006 Occupational Mix Survey and begin 
applying the methodology for adjustments resulting from a decrease in 
discharges in FY 2007. Because the occupational mix survey is conducted 
once every 3 years, we would update the data set every 3 years. 
However, at the time of the FY 2007 IPPS final rule, the FY 2006 
Occupational Mix Survey data were not available. In that final rule, we 
described our methodology using the FY 2003 occupational mix data and 
the FY 2003 Medicare cost report file. However, these data were used 
only in order to present an example of how our methodology would work. 
Our final policy was to use FY 2006 occupational mix and cost report 
data when actually processing adjustment requests.
    In the FY 2007 IPPS final rule, to illustrate how we would 
calculate the average number of nursing hours per patient day by bed 
size and region, we first merged the FY 2003 Occupational Mix Survey 
data with the FY 2003 Medicare cost report file. We eliminated all 
observations for non-IPPS providers, providers who failed to complete 
the occupational mix survey and the providers for which provider 
numbers, bed counts, and/or days counts were missing.
    For each provider in the pool, we calculated the number of nursing 
hours by adding the number of registered nurses, licensed practical 
nurses, and nursing aide hours reported on the Occupational Mix Survey. 
We divided the result of this calculation by the total number of 
inpatient days reported on the cost report to determine the number of 
nursing hours per patient day. For purposes of calculating the census 
regional averages for the various bed-size groups, we finalized our 
rule to only include observations that fell within three standard 
deviations of the mean of all observations, thus removing potential 
outliers in the data.
    When the FY 2006 Occupational Mix Survey data became available, our 
analysis of the results indicated that the methodology for computing 
core staffing factors should be further revised in order to further 
eliminate outlier data.
    After consulting with the Office of the Actuary on appropriate 
statistical methods to remove outlier data, we are proposing to modify 
our methodology for calculating the average nursing hours per patient 
day using the FY 2006 Occupational Mix Survey data and FY 2006 Medicare 
cost report data. Similar to what was finalized in the FY 2007 IPPS 
rule, we are proposing to merge the FY 2006 Occupational Mix Survey 
data with the FY 2006 Medicare cost report file. We would then 
eliminate all observations for non-IPPS providers, providers who failed 
to complete the occupational mix survey and the providers for which 
provider numbers, bed counts and/or days counts were missing. We would 
annualize the results so that the nursing hours from the Occupational 
Mix Survey and the patient days reported on the Medicare cost report is 
representative of one year.
    For each provider in the pool, we would calculate the number of 
nursing hours by adding the number of registered nurses, licensed 
practical nurses, and nursing aide hours reported on the Occupational 
Mix Survey. We would divide the result of this calculation by the total 
number of patient days reported on line 12 on Worksheet S-3, Part I, 
Column 6 of the Medicare cost report. This includes patient days in the 
general acute care area and the intensive care unit area. The result is 
the number of nursing hours per patient day.
    For purposes of calculating the census regional averages for the 
various bed-size groups, we are proposing a different method to remove 
outliers in the data. First, we would calculate the difference between 
the observations in the 75th percentile and the 25th percentile, which 
is the inter-quartile range. We would remove observations that are 
greater than the 75th percentile plus 1.5 times the inter-quartile 
range and less than the 25th percentile minus 1.5 times the inter-
quartile range. This methodology, known as the Tukey method, is a 
common statistical method used by the Office of the Actuary. Under the 
standard deviation method described in the FY 2007 IPPS final rule, the 
mean and standard deviation can be influenced by extreme values 
(because the standard deviation is increased by the very observations 
that would otherwise be discarded from the analysis). Our proposed 
methodology is a more robust technique because it uses the quartile 
values instead of variance to describe the spread of the data, and 
quartiles are less influenced by extreme outlier values that may be 
present in the data.
    Our proposed method would prevent the mean from being influenced by 
extreme observations and assumes that the middle 50 percent of the data 
has no outlier observations. The application of this methodology would 
result in a pool of approximately 2,578 providers. Each census region 
and bed group category required at least three providers in order for 
their average to be published. The results of the average nursing hours 
per patient day by bed size and region using

[[Page 23664]]

the FY 2006 Occupational Mix Survey Data and the FY 2006 hospital cost 
report data are shown in the table below. As stated in the FY 2007 IPPS 
final rule (71 FR 48059), the results of the FY 2006 Occupational Mix 
Survey may be used for the volume decrease adjustment calculations for 
decreases in discharges beginning with cost reporting periods beginning 
in FYs 2006, 2007, and 2008.

                                                           Paid Nursing Hours per Patient Day
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             Census Region
                                             -----------------------------------------------------------------------------------------------------------
               Number of beds                     New       Middle       South    East North  East South  West North  West South
                                                England    Atlantic    Atlantic     Central     Central     Central     Central    Mountain     Pacific
                                                     (1)         (2)         (3)         (4)         (5)         (6)         (7)         (8)         (9)
--------------------------------------------------------------------------------------------------------------------------------------------------------
0-49........................................       25.47       20.60       21.08       24.52       20.27       25.92       22.16       24.52       20.99
50-99.......................................       20.99       18.51       20.36       23.44       19.00       22.44       20.44       22.54       18.89
100-199.....................................       18.12       16.31       17.31       18.87       17.43       19.50       17.01       18.70       16.25
200-399.....................................       16.92       13.80       16.23       17.79       16.06       18.66       14.56       16.82       16.63
400+........................................       17.52       14.43       16.68       18.41       14.14       16.90       16.25       15.50       18.15
--------------------------------------------------------------------------------------------------------------------------------------------------------

b. AHA Annual Survey
    In the FY 2007 IPPS final rule (71 FR 48058), we also allowed SCHs 
or MDHs that experienced a greater than 5 percent reduction in the 
number of discharges in a cost reporting period the option of using the 
AHA Annual Survey results, where available, to compare the number of 
hospital's core staff with other like-sized hospitals in its geographic 
area. Our methodology for calculating the nursing hours per patient day 
using the AHA Annual Survey data and the Medicare hospital cost report 
was similar to the methodology using the Occupational Mix Survey data 
(eliminating outliers outside of three standard deviations from the 
mean). For this reason, as with the occupational mix data, both 
standard deviations and the mean could be influenced by extreme values. 
Therefore, we are proposing to refine our methodology to calculate the 
core staffing factors using the AHA Annual Survey data as well. The AHA 
Annual Survey contains FTE counts for registered nurses, practical and 
vocational nurses, nursing assistive personnel, and other personnel in 
both inpatient and outpatient areas of the hospital. This is consistent 
with the Occupational Mix Survey which collects data on both the 
inpatient and outpatient areas of the hospital.
    In the FY 2007 IPPS final rule, we stated we would calculate the 
nursing hours per patient day using the AHA Annual Survey data in a 
similar method to the Occupational Mix Survey. Consistent with the HAS/
Monitrend Data book, we would only calculate the average number of 
nursing staff for a bed-size/census group if there are data available 
for three or more hospitals. First, we would merge the AHA Annual 
Survey Data with the corresponding Medicare cost report. We would 
eliminate all observations for non-IPPS providers, providers with 
hospital-based SNFs, and the providers for which provider numbers, bed 
counts, and/or days counts were missing. We would multiply the number 
of nurse, licensed practical nurse, and nursing aide FTEs reported on 
the AHA Annual Survey by 2,080 hours to derive the number of nursing 
hours per year (based on a 40-hour work week). We would then divide 
this number by the total number of patient days reported on line 12 on 
Worksheet S-3, Part I, Column 6 of the Medicare cost report. In the FY 
2007 IPPS final rule (71 FR 48060), we had stated that we would 
eliminate all providers with results beyond three standard deviations 
from the mean. However, to be consistent with our methodology with the 
Occupational Mix Survey data, we are also proposing that we would 
remove outliers from the AHA Annual Survey data by calculating the 
difference between the observations in the 75th percentile and the 25th 
percentile, which is the inter-quartile range. Then, we are proposing 
to remove observations that are greater than the 75th percentile plus 
1.5 times the inter-quartile range and less than the 25th percentile 
minus 1.5 times the inter-quartile range. After removing the outliers, 
we would group the hospitals by bed size and census area to calculate 
the average number of nursing hours per patient day for each category. 
Using the 2006 AHA Annual Survey data as an example, this would result 
in a pool of approximately 1,205 providers. The results of the nursing 
hours per patient day using the 2006 AHA Annual Survey data and the 
Medicare cost report data are shown below. The 2006 Survey would be 
used for the volume decrease adjustment calculations for decreases in 
discharges occurring during cost reporting periods beginning in FY 
2006. As we stated in the FY 2007 IPPS final rule, for other years, the 
corresponding AHA Annual Survey would be used for the year in which the 
decreased occurred. For example, if a hospital experienced a decrease 
between its 2004 and 2005 cost reporting periods, the fiscal 
intermediary/MAC would compare the hospital's 2005 staffing with the 
results of the 2005 AHA Annual Survey, using the methodology discussed 
above.

                                                           Paid Nursing Hours per Patient Day
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             Census Region
                                             -----------------------------------------------------------------------------------------------------------
               Number of beds                     New       Middle       South    East North  East South  West North  West South
                                                England    Atlantic    Atlantic     Central     Central     Central     Central    Mountain     Pacific
                                                     (1)         (2)         (3)         (4)         (5)         (6)         (7)         (8)         (9)
--------------------------------------------------------------------------------------------------------------------------------------------------------
0-49........................................       25.82       23.48       21.77       26.12       17.25       24.75       23.66       25.44       24.50
50-99.......................................       23.42       19.40       20.69       23.47       22.06       23.28       20.55       19.28       19.91

[[Page 23665]]

 
100-199.....................................       18.89       17.46       18.43       20.08       19.64       20.23       19.02       18.80       18.71
200-399.....................................       18.89       14.96       15.75       17.02       15.07       19.81       15.85       18.17       18.01
400+........................................       18.98       16.66       17.39       21.59       16.47       17.71       15.06       17.76       21.11
--------------------------------------------------------------------------------------------------------------------------------------------------------

E. Rural Referral Centers (RRCs) (Sec.  412.96)

    Under the authority of section 1886(d)(5)(C)(i) of the Act, the 
regulations at Sec.  412.96 set forth the criteria that a hospital must 
meet in order to qualify under the IPPS as an RRC. For discharges 
occurring before October 1, 1994, RRCs received the benefit of payment 
based on the other urban standardized amount rather than the rural 
standardized amount. Although the other urban and rural standardized 
amounts are the same for discharges occurring on or after October 1, 
1994, RRCs continue to receive special treatment under both the DSH 
payment adjustment and the criteria for geographic reclassification.
    Section 402 of Pub. L. 108-173 raised the DSH adjustment for other 
rural hospitals with less than 500 beds and RRCs. Other rural hospitals 
with less than 500 beds are subject to a 12-percent cap on DSH 
payments. RRCs are not subject to the 12-percent cap on DSH payments 
that is applicable to other rural hospitals (with the exception of 
rural hospitals with 500 or more beds). RRCs are not subject to the 
proximity criteria when applying for geographic reclassification, and 
they do not have to meet the requirement that a hospital's average 
hourly wage must exceed the average hourly wage of the labor market 
area where the hospital is located by a certain percentage (106/108 
percent in FY 2008).
    Section 4202(b) of Pub. L. 105-33 states, in part, ``[a]ny hospital 
classified as an RRC by the Secretary * * * for fiscal year 1991 shall 
be classified as such an RRC for fiscal year 1998 and each subsequent 
year.'' In the August 29, 1997 final rule with comment period (62 FR 
45999), we reinstated RRC status for all hospitals that lost the status 
due to triennial review or MGCRB reclassification, but 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. However, subsequently, in the August 1, 2000 
final rule (65 FR 47089), we indicated that we were revisiting that 
decision. Specifically, we stated that we would permit hospitals that 
previously qualified as an RRC and lost their status due to OMB 
redesignation of the county in which they are located from rural to 
urban to be reinstated as an RRC. Otherwise, a hospital seeking RRC 
status must satisfy the applicable criteria. We used the definitions of 
``urban'' and ``rural'' specified in Subpart D of 42 CFR Part 412.
    One of the criteria under which a hospital may qualify as a RRC is 
to have 275 or more beds available for use (Sec.  412.96(b)(1)(ii)). A 
rural hospital that does not meet the bed size requirement can qualify 
as 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) (Sec.  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--
    <bullet> 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
    <bullet> The hospital's number of discharges is at least 5,000 per 
year, or, if fewer, the median number of discharges for urban hospitals 
in the census region in which the hospital is located. (The number of 
discharges criterion for an osteopathic hospital is at least 3,000 
discharges per year, as specified in section 1886(d)(5)(C)(i) of the 
Act.)
1. Case-Mix Index
    Section 412.96(c)(1) provides that CMS establish updated national 
and regional CMI values in each year's annual notice of prospective 
payment rates for purposes of determining RRC status. The methodology 
we used to determine the national and regional CMI values is set forth 
in the regulations at Sec.  412.96(c)(1)(ii). The proposed national 
median CMI value for FY 2009 includes all urban hospitals nationwide, 
and the proposed regional values for FY 2009 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 Sec.  413.75). 
These values are based on discharges occurring during FY 2007 (October 
1, 2006 through September 30, 2007), and include bills posted to CMS' 
records through December 2007.
    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, 
2008, they must have a CMI value for FY 2007 that is at least--
    <bullet> 1.4285; or
    <bullet> The median CMI value (not transfer-adjusted) for urban 
hospitals (excluding hospitals with approved teaching programs as 
identified in Sec.  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:

------------------------------------------------------------------------
                                                         Case-mix  index
                        Region                                value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)...............            1.2515
2. Middle Atlantic (PA, NJ, NY).......................            1.2691
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)            1.3589

[[Page 23666]]

 
4. East North Central (IL, IN, MI, OH, WI)............            1.3572
5. East South Central (AL, KY, MS, TN)................            1.3040
6. West North Central (IA, KS, MN, MO, NE, ND, SD)....            1.3557
7. West South Central (AR, LA, OK, TX)................            1.4405
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........            1.4692
9. Pacific (AK, CA, HI, OR, WA).......................            1.3872
------------------------------------------------------------------------

    The preceding numbers will be revised in the FY 2009 IPPS final 
rule to the extent required to reflect the updated FY 2007 MEDPAR file, 
which will contain data from additional bills received through March 
2008.
    Hospitals seeking to qualify as RRCs or those wishing to know how 
their CMI value compares to the criteria should obtain hospital-
specific CMI values (not transfer-adjusted) from their fiscal 
intermediaries. Data are available on the Provider Statistical and 
Reimbursement (PS&R) System. In keeping with our policy on discharges, 
these CMI values are computed based on all Medicare patient discharges 
subject to the IPPS DRG-based payment.
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 during FY 2006 (that is, October 1, 2005 
through September 30, 2006), which is 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, 2008, must have 
as the number of discharges for its cost reporting period that began 
during FY 2006 a figure that is at least--
    <bullet> 5,000 (3,000 for an osteopathic hospital); or
    <bullet> The median number of discharges for urban hospitals in the 
census region in which the hospital is located, as indicated in the 
following table.

------------------------------------------------------------------------
                                                            Number of
                        Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)...............             8,158
2. Middle Atlantic (PA, NJ, NY).......................            10,443
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)            10,344
4. East North Central (IL, IN, MI, OH, WI)............             8,900
5. East South Central (AL, KY, MS, TN)................             7,401
6. West North Central (IA, KS, MN, MO, NE, ND, SD)....             7,988
7. West South Central (AR, LA, OK, TX)................             5,816
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........             9,919
9. Pacific (AK, CA, HI, OR, WA).......................             8,600
------------------------------------------------------------------------

    These numbers will be revised in the FY 2009 IPPS final rule based 
on the latest available cost reports.
    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, 
2008, the hospital would be required to have at least 3,000 discharges 
for its cost reporting period that began during FY 2005.

F. Indirect Medical Education (IME) Adjustment (Sec.  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 Sec.  412.105.
    The Balanced Budget Act of 1997 (Pub. L. 105-33) established a 
limit on the number of allopathic and osteopathic residents that a 
hospital may include in its full-time equivalent (FTE) resident count 
for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of 
the Act, 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 the 
FTE resident count for IME purposes is effective for discharges 
occurring on or after October 1, 1997.
2. IME Adjustment Factor for FY 2009
    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{time}  <SUP>.405</SUP> - 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

[[Page 23667]]

regulations at Sec.  412.105(d)(3)(viii) through (d)(3)(xii). Section 
502(a) modifies the formula multiplier beginning midway through FY 2004 
and provides for a new schedule of formula multipliers for FYs 2005 and 
thereafter as follows:
    <bullet> For discharges occurring on or after April 1, 2004, and 
before October 1, 2004, the formula multiplier is 1.47.
    <bullet> For discharges occurring during FY 2005, the formula 
multiplier is 1.42.
    <bullet> For discharges occurring during FY 2006, the formula 
multiplier is 1.37.
    <bullet> For discharges occurring during FY 2007, the formula 
multiplier is 1.32.
    <bullet> For discharges occurring during FY 2008 and fiscal years 
thereafter, the formula multiplier is 1.35.
    Accordingly, for discharges occurring during FY 2009, the formula 
multiplier would be 1.35. We estimate that application of this formula 
multiplier for FY 2009 IME adjustment will result in an increase in IME 
payment of 5.5 percent for every approximately 10-percent increase in 
the hospital's resident-to-bed ratio.

G. Medicare GME Affiliation Provisions for Teaching Hospitals in 
Certain Emergency Situations; Technical Correction (Sec.  
413.79(f)(6)(iv))

1. Background
    Under section 1886(h) of the Act, as amended by section 9202 of the 
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 
99-272), the Secretary is authorized to make payments to hospitals for 
the direct costs of approved GME programs. Section 1886(d)(5)(B) of the 
Act provides that prospective payment acute care hospitals that have 
residents in an approved GME program receive an additional payment for 
a Medicare discharge to reflect the higher patient care costs of 
teaching hospitals, that is, IME costs. Sections 1886(h)(4)(F) and 
1886(d)(5)(B)(v) of the Act establish limits on the number of 
allopathic and osteopathic residents that hospitals may count for 
purposes of calculating direct GME payments and the IME adjustment, 
respectively, establishing hospital-specific direct GME and IME FTE 
resident caps. Under the authority granted by section 1886(h)(4)(H)(ii) 
of the Act, the Secretary issued rules to allow institutions that are 
members of the same affiliated group to apply their direct GME and IME 
FTE resident caps on an aggregate basis through a Medicare GME 
affiliation agreement. The Medicare regulations at Sec. Sec.  413.75 
and 413.76 permit hospitals, through a Medicare GME affiliation 
agreement, to adjust IME and direct GME FTE resident caps to reflect 
the rotation of residents among affiliated hospitals.
    In response to circumstances in the aftermath of Hurricanes Katrina 
and Rita, we supplemented regulations in the April 12, 2006 interim 
final rule with comment period published in the Federal Register (71 FR 
18654). The regulatory changes allowed certain hospitals to engage in 
emergency Medicare GME affiliations so that Medicare funding for GME is 
maintained while there are displaced residents training at various host 
hospitals even as the hurricane-affected hospitals are rebuilding their 
training programs. The modifications to the regulations at Sec.  
413.75(b) and Sec.  413.76(f) provided flexibility for home hospitals 
whose residency programs have been disrupted due to an emergency to 
enter into emergency Medicare GME affiliation agreements with host 
hospitals where the hospitals may not otherwise meet the regulatory 
requirements to form Medicare GME affiliations. (We note that on 
November 27, 2007, we issued a second interim final rule with comment 
period providing further flexibility relating to emergency Medicare GME 
affiliation agreements (72 FR 66893 through 66898). We expect to 
address the public comments received on both interim final rules with 
comment period and finalize our policies in the FY 2009 IPPS final rule 
scheduled to be published in August 2008.)
2. Technical Correction
    In the April 12, 2006 interim final rule, we revised Sec.  
413.79(f) by adding a new paragraph (6) to provide for more flexibility 
in Medicare GME affiliations for home hospitals located in section 1135 
emergency areas to allow the home hospitals to efficiently find 
training sites for displaced residents. We have discovered that, under 
Sec.  413.79(f)(6)(iv), in our provisions on the host hospital 
exception from the rolling average for the period from August 29, 2005 
to June 30, 2006, we included an incorrect cross-reference to the 
rolling average requirements for direct GME as ``Sec.  413.75(d).'' The 
correct citation to the rolling average requirements for direct GME is 
Sec.  413.79(d). We are proposing to correct the cross-reference under 
Sec.  413.79(f)(6)(iv) to read ``paragraph (d) of this section''.

H. Payments to Medicare Advantage Organizations: Collection of Risk 
Adjustment Data (Sec.  422.310)

    Section 1853 of the Act requires CMS to make advance monthly 
payments to a Medicare Advantage (MA) organization for each beneficiary 
enrolled in an MA plan offered by the organization for coverage of 
Medicare Part A and Part B benefits. Section 1853(a)(1)(C) of the Act 
requires CMS to adjust the monthly payment amount for each enrollee to 
take into account the health status of the MA plan's enrollees. Under 
the CMS-Hierarchical Condition Category (HCC) risk adjustment payment 
methodology, CMS determines risk scores for MA enrollees for a year and 
adjusts the monthly payment amount using the appropriate enrollee risk 
score.
    Under section 1853(a)(3)(B) of the Act, MA organizations are 
required to ``submit data regarding inpatient hospital services . . . 
and data regarding other services and other information as the 
Secretary deems necessary'' in order to implement a methodology for 
``risk adjusting'' payments made to MA organizations. Risk adjustments 
to payments are made in order to take into account ``variations in per 
capita costs based on [the] health status'' of the Medicare 
beneficiaries enrolled in an MA plan offered by the organization. 
Submission of data on inpatient hospital services has been required 
with respect to services beginning on or after July 1, 1997. Submission 
of data on other services has been required since July 1, 1998.
    While we initially required the submission of comprehensive data 
regarding services provided by MA organizations, including 
comprehensive inpatient hospital encounter data, we subsequently 
permitted MA organizations to submit an ``abbreviated'' set of data. 
Our regulations at 42 CFR 422.310(d)(1) currently explicitly provide MA 
organizations with the option of submitting an abbreviated data set. 
Under this provision, we currently collect limited risk adjustment data 
from MA organizations, primarily diagnosis data.
    From calendar years 2000 through 2006, application of risk 
adjustment to MA payments was ``phased in'' with an increasing 
percentage of the monthly capitation payment subjected to risk 
adjustment. Beginning with calendar year 2007, 100 percent of payments 
to MA organizations are risk-adjusted. Given the increased importance 
of the accuracy of our risk adjustment methodology, we are proposing to 
amend Sec.  422.310 to provide that CMS will collect data from MA 
organizations regarding each item and service provided to an MA plan 
enrollee. This will allow us to include utilization data and other 
factors that CMS can use in developing the CMS-HCC risk

[[Page 23668]]

adjustment models in order to reflect patterns of diagnoses and 
expenditures in the MA program.
    Specifically, we are proposing to revise Sec.  422.310(a) to 
clarify that risk adjustment data are data used not only in the 
application of risk adjustment to MA payments, but also in the 
development of risk adjustment models. For example, once encounter data 
for MA enrollees are available, CMS would have beneficiary-specific 
information on the utilization of services by MA plan enrollees. These 
data could be used to calibrate the CMS-HCC risk adjustment models 
using MA patterns of diagnoses and expenditures.
    We are proposing to revise Sec. Sec.  422.310(b), (c), (d)(3), and 
(g) to clarify that the term ``services'' includes items and services.
    We are proposing to revise Sec.  422.310(d) to clarify that CMS has 
the authority to require MA organizations to submit encounter data for 
each item and service provided to an MA plan enrollee. The proposed 
revision also would clarify that CMS will determine the formats for 
submitting encounter data, which may be more abbreviated than those 
used for the fee-for-service claims data submission process.
    We are proposing to revise Sec.  422.310(f) to clarify that one of 
the ``other'' purposes for which CMS may use risk adjustment data 
collected under this section would be to update risk adjustment models 
with data from MA enrollees. In addition, when providing that CMS may 
use risk adjustment data for purposes other than adjusting payments as 
described at Sec. Sec.  422.304(a) and (c), we are proposing to delete 
the phrase ``except for medical records data'' from paragraph (f). Any 
use of medical records data collected under paragraph (e) of Sec.  
422.310 is governed by the Privacy Act and the privacy provisions in 
the HIPAA. Furthermore, there may be occasions when we learn from 
analysis of medical record review data that some organizations have 
misunderstood our guidance on how to implement an operational 
instruction. We want to be able to provide improved guidance to MA 
organizations based on any insights that may emerge during analysis of 
the medical record review data.
    In addition, we are proposing a technical correction to Sec.  
422.310(f) to clarify that risk adjustment data are used not only to 
adjust payments to plans described at Sec. Sec.  422.301(a)(1), (a)(2), 
and (a)(3) (which refer to coordinated care plans and private fee-for-
service plans), but also to adjust payments for ESRD enrollees and 
payments to MSA plans and Religious Fraternal Benefit society plans, as 
described at Sec.  422.301(c).
    Under Sec.  422.310(g), we would continue to provide that data that 
CMS receives after the final deadline for a payment year will not be 
accepted for purposes of the reconciliation. However, we are proposing 
to revise paragraph (g)(2) of Sec.  422.310 to change the deadline from 
``December 31'' of the payment year to ``January 31'' of the year 
following the payment year. We are also proposing to add language to 
provide that CMS may adjust deadlines as appropriate.

I. Hospital Emergency Services under EMTALA (Sec.  489.24)

1. Background
    Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose 
specific obligations on certain Medicare-participating hospitals and 
CAHs. (Throughout this section of this proposed rule, when we reference 
the obligation of a ``hospital'' under these sections of the Act and in 
our regulations, we mean to include CAHs as well.) These obligations 
concern individuals who come to a hospital emergency department and 
request examination or treatment for a medical condition, and apply to 
all of these individuals, regardless of whether they are beneficiaries 
of any program under the Act.
    The statutory provisions cited above are frequently referred to as 
the Emergency Medical Treatment and Labor Act (EMTALA), also known as 
the patient antidumping statute. EMTALA was passed in 1986 as part of 
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), 
Pub. L. 99-272. Congress incorporated these antidumping provisions 
within the Social Security Act to ensure that individuals with 
emergency medical conditions are not denied essential lifesaving 
services. Under section 1866(a)(1)(I)(i) of the Act, a hospital that 
fails to fulfill its EMTALA obligations under these provisions may be 
subject to termination of its Medicare provider agreement, which would 
result in loss of all Medicare and Medicaid payments.
    Section 1867 of the Act sets forth requirements for medical 
screening examinations for individuals who come to the hospital and 
request examination or treatment for a medical condition. The section 
further provides that if a hospital finds that such an individual has 
an emergency medical condition, it is obligated to provide that 
individual with either necessary stabilizing treatment or an 
appropriate transfer to another medical facility where stabilization 
can occur.
    The EMTALA statute also outlines the obligation of hospitals to 
receive appropriate transfers from other hospitals. Section 1867(g) of 
the Act states that a participating hospital that has specialized 
capabilities or facilities (such as burn units, shock-trauma units, 
neonatal intensive care units, or, with respect to rural areas, 
regional referral centers as identified by the Secretary in regulation) 
shall not refuse to accept an appropriate transfer of an individual who 
requires these specialized capabilities or facilities if the hospital 
has the capacity to treat the individual. The regulations implementing 
section 1867 of the Act are found at 42 CFR 489.24. The regulations at 
42 CFR 489.20(l), (m), (q), and (r) also refer to certain EMTALA 
requirements. The Interpretive Guidelines concerning EMTALA are found 
at Appendix V of the CMS State Operations Manual.
    2. EMTALA Technical Advisory Group (TAG) Recommendations
    Section 945 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA), Pub. L. 108-173, required the 
Secretary to establish a Technical Advisory Group (TAG) to advise the 
Secretary on issues related to the regulations and implementation of 
EMTALA. The MMA specified that the EMTALA TAG be composed of 19 
members, including the Administrator of CMS, the Inspector General of 
HHS, hospital representatives and physicians representing specific 
specialties, patient representatives, and representatives of 
organizations involved in EMTALA enforcement.
    The EMTALA TAG's functions, as identified in the charter for the 
EMTALA TAG, were as follows: (1) Review EMTALA regulations; (2) provide 
advice and recommendations to the Secretary concerning these 
regulations and their application to hospitals and physicians; (3) 
solicit comments and recommendations from hospitals, physicians, and 
the public regarding the implementation of such regulations; and (4) 
disseminate information concerning the application of these regulations 
to hospitals, physicians, and the public. The TAG met 7 times during 
its 30-month term, which ended on September 30, 2007. At its meetings, 
the TAG heard testimony from representatives of physician groups, 
hospital associations, and others regarding EMTALA issues and concerns. 
During each meeting, the three subcommittees established by the TAG 
(the On-Call Subcommittee, the Action Subcommittee, and the Framework 
Subcommittee) developed

[[Page 23669]]

recommendations, which were then discussed and voted on by members of 
the TAG. In total, the TAG submitted 55 recommendations to the 
Secretary. If implemented, some of the recommendations would require 
regulatory changes. Of the 55 recommendations developed by the TAG, 5 
have already been implemented by CMS. A complete list of TAG 
recommendations will be available shortly in the Emergency Medical 
Treatment and Labor Act Technical Advisory Group final report available 
at the Web site: http://www.cms.hhs.gov/FACA/07_emtalatag.asp. The 
following recommendations have already been implemented by CMS:
    <bullet> That CMS revise, in the EMTALA regulations [42 CFR 
489.24(b)], the following sentence contained in the definition of 
``labor'': ``A woman experiencing contractions is in true labor unless 
a physician certifies that, after a reasonable time of observation, the 
woman is in false labor.''
    This recommendation was adopted with modification in the FY 2007 
IPPS final rule (71 FR 48143). We revised the definition of ``labor'' 
in the regulations at Sec.  489.24(b) to permit a physician, certified 
nurse-midwife, or other qualified medical person, acting within his or 
her scope of practice in accordance with State law and hospital bylaws, 
to certify that a woman is experiencing false labor. We issued Survey 
and Certification Letter S&C-06-32 on September 29, 2006, to clarify 
the regulation change. (The Survey and Certification Letter can be 
found at the following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp).
    <bullet> That hospitals with specialized capabilities (as defined 
in the EMTALA regulations) that do not have a dedicated emergency 
department be bound by the same responsibilities under EMTALA as 
hospitals with specialized capabilities that do have a dedicated 
emergency department.
    This recommendation was adopted in the FY 2007 IPPS final rule (71 
FR 48143). We added language at Sec.  489.24(f) that makes explicit the 
current policy that all Medicare-participating providers with 
specialized capabilities are required to accept an appropriate transfer 
if they have the capacity to treat the individual. We issued Survey and 
Certification Letter S&C-06-32 on September 29, 2006, to clarify the 
regulation change. (The Survey and Certification Letter can be found at 
the following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp).
    <bullet> That CMS clarify the intent of regulations regarding 
obligations under EMTALA to receive individuals who arrive by 
ambulance. Specifically, the TAG recommended that CMS revise a letter 
of guidance that had been issued by the agency to clarify its position 
on the practice of delaying the transfer of an individual from an 
emergency medical service provider's stretcher to a bed in a hospital's 
emergency department.
    This recommendation was adopted with modification by CMS in Survey 
and Certification Letter S&C-07-20, which was released on April 27, 
2007. (The Survey and Certification Letter can be found at the 
following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp).
    <bullet> That CMS clarify that a hospital may not refuse to accept 
an individual appropriately transferred under EMTALA on the grounds 
that it (the receiving hospital) does not approve the method of 
transfer arranged by the attending physician at the sending hospital 
(for example, a receiving hospital may not require the sending hospital 
to use an ambulance transport designated by the receiving hospital). In 
addition, CMS should improve its communication of such clarifications 
with its regional offices.
    This recommendation was adopted and implemented by CMS in Survey 
and Certification Letter S&C-07-20, which was released on April 27, 
2007. (The Survey and Certification Letter can be found at the 
following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp).
    <bullet> That CMS strike the language in the Interpretive 
Guidelines (CMS State Operations Manual, Appendix V) that addresses 
telehealth/telemedicine (relating to the regulations at Sec.  
489.24(j)(1)) and replace it with language that clarifies that the 
treating physician ultimately determines whether an on-call physician 
should come to the emergency department and that the treating physician 
may use a variety of methods to communicate with the on-call physician. 
A potential violation occurs only if the treating physician requests 
that the on-call physician come to the emergency department and the on-
call physician refuses.
    This recommendation was adopted and implemented by CMS in Survey 
and Certification Letter S&C-07-23, which was released on June 22, 
2007. (The Survey and Certification Letter can be found at the 
following Web site: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp).
    We are considering the remaining recommendations of the EMTALA TAG 
and may address them through future changes to or clarifications of the 
existing regulations or the Interpretive Guidelines, or both.
    At the end of its term, the EMTALA TAG compiled a final report to 
the Secretary. This report includes, among other materials, minutes 
from each TAG meeting as well as a comprehensive list of all of the 
TAG's recommendations. The final report will be available shortly at 
the following Web site: http://www.cms.hhs.gov/FACA/07_emtalatag.asp.
3. Proposed Changes Relating to Applicability of EMTALA Requirements to 
Hospital Inpatients
    While many issues pertaining to EMTALA involve individuals 
presenting to a hospital's dedicated emergency department, questions 
have been raised regarding the applicability of the EMTALA requirements 
to inpatients. We have previously discussed the applicability of the 
EMTALA requirements to hospital inpatients in both the May 9, 2002 IPPS 
proposed rule (67 FR 31475) and the September 9, 2003 stand alone final 
rule on EMTALA (68 FR 53243). As we stated in both of the 
aforementioned rules, in 1999, the United States Supreme Court 
considered a case (Roberts v. Galen of Virginia, 525 U.S. 249 (1999)) 
that involved, in part, the question of whether EMTALA applies to 
inpatients in a hospital. In the context of that case, the United 
States Solicitor General advised the Court that HHS would develop a 
regulation clarifying its position on that issue. In the 2003 final 
rule, CMS took the position that a hospital's obligation under EMTALA 
ends when that hospital, in good faith, admits an individual with an 
unstable emergency medical condition as an inpatient to that hospital. 
In that rule, CMS noted that other patient safeguards protected 
inpatients, including the CoPs as well as State malpractice law. 
However, in the 2003 final rule, CMS did not directly address the 
question of whether EMTALA's ``specialized care'' requirements (section 
1867(g) of the Act) applied to inpatients.
    As noted in section IV.I.2. of this preamble, the EMTALA TAG has 
developed a set of recommendations to the Secretary. One of those 
recommendations calls for CMS to revise its regulations to address the 
situation of an individual who: (1)

[[Page 23670]]

Presents to a hospital that has a dedicated emergency department and is 
determined to have an unstabilized emergency medical condition; (2) is 
admitted to the hospital as an inpatient; and (3) the hospital 
subsequently determines that stabilizing the individual's emergency 
medical condition requires specialized care only available at another 
hospital.
    We believe that the obligation of EMTALA does not end for all 
hospitals once an individual has been admitted as an inpatient to the 
hospital where the individual first presented with a medical condition 
that was determined to be an emergency medical condition. Rather, once 
the individual is admitted, admission only impacts on the EMTALA 
obligation of the hospital where the individual first presented. 
(Throughout this section of the preamble of this proposed rule, we will 
refer to the hospital where the individual first presented as the 
``admitting hospital.'') Section 1867(g) of the Act states: 
``Nondiscrimination--A participating hospital that has specialized 
capabilities or facilities (such as burn units, shock-trauma units, 
neonatal intensive care units, or (with respect to rural areas) 
regional referral centers as identified by the Secretary in regulation) 
shall not refuse to accept an appropriate transfer of an individual who 
requires such specialized capabilities or facilities if the hospital 
has the capacity to treat the individual.'' Section 1867(g) of the Act 
therefore requires a receiving hospital with specialized capabilities 
to accept a request to transfer an individual with an unstable 
emergency medical condition as long as the hospital has the capacity to 
treat that individual, regardless of whether the individual had been an 
inpatient at the admitting hospital. Furthermore, in the September 9, 
2003 final rule (68 FR 53263), we amended the regulations at Sec.  
489.24(d)(2)(i) to state: ``If a hospital has screened an individual 
under paragraph (a) of this section and found the individual to have an 
emergency medical condition, and admits that individual in good faith 
in order to stabilize the emergency medical condition, the hospital has 
satisfied its special responsibilities under this section with respect 
to that individual'' (emphasis added). We did not intend for the 
regulation to end the EMTALA obligation for any other hospital to which 
the individual may appropriately be transferred to stabilize his or her 
emergency medical condition. Permitting inpatient admission at the 
admitting hospital to end EMTALA obligations for another hospital to 
which an unstabilized individual is being appropriately transferred to 
receive specialized care would seemingly contradict the intent of 
section 1867(g) of the Act to ensure that hospitals with specialized 
capabilities provide medical treatment to individuals with emergency 
medical conditions to stabilize their conditions.
    We also note that, as we discussed in the preamble of the September 
9, 2003 stand alone final rule, once a hospital has admitted an 
individual as an inpatient, the individual is protected under the 
Medicare CoPs and may also have additional protections under State law. 
Accordingly, we believe it is consistent with the intent of EMTALA to 
limit its protections to individuals who need them most; for example, 
individuals who present to a hospital but may not have been formally 
admitted as patients and thus are not covered by other protections 
applicable to inpatients of the hospital. As noted above, once the 
individual is admitted, the CoPs apply to the admitting hospital's care 
of that individual. A hospital that fails to provide treatment to such 
individuals could face termination of its Medicare provider agreement 
for a violation of the CoPs. However, these CoPs do not, of course, 
apply to a hospital with specialized capabilities to which the 
individual might be transferred unless and until the individual is 
formally admitted as a patient at that hospital. Therefore, in order to 
ensure an individual the protections intended by the EMTALA statute, 
especially section 1867(g) of the Act (obligating a hospital with 
specialized capabilities to accept an appropriately transferred 
individual if it has the capacity to treat that individual), we believe 
it is appropriate to propose to clarify that section 1867(g) of the Act 
continues to apply so as to protect even an individual who has been 
admitted as an inpatient to the admitting hospital who has not been 
stable since becoming an inpatient. We believe that this proposed 
clarification is necessary to ensure that EMTALA protections are 
continued for individuals who are not otherwise protected by the 
hospital CoPs. (We note that this proposed clarification is consistent 
with the EMATLA TAG's recommendation that EMTALA does not apply when an 
individual is admitted to the hospital for an elective procedure and 
subsequently develops an emergency medical condition.)
    We recognize that this proposed clarification that EMTALA applies 
to a hospital with specialized capabilities when an inpatient (who 
presented to the admitting hospital under EMTALA) is in need of 
specialized care to stabilize his or her emergency medical condition 
may raise concerns among the provider community that such a 
clarification in policy could hypothetically result in an increase in 
the number of transfers. However, the intention of this proposed 
clarification is not to encourage patient dumping to hospitals with 
specialized capabilities. Rather, even if the hospital with specialized 
capabilities has an EMTALA obligation to accept an individual who was 
an inpatient at the admitting hospital, the admitting hospital 
transferring the individual should take all steps necessary to ensure 
that it is providing needed treatment within its capabilities prior to 
transferring the individual. This means that an individual with an 
unstabilized emergency medical condition should be transferred only 
when the capabilities of the admitting hospital have been exceeded.
    Accordingly, we are proposing to revise Sec.  489.24(f) by adding 
to the existing text a provision that specifies that paragraph (f) also 
applies to an individual who has been admitted under paragraph 
(d)(2)(i) of the section and who has not been stabilized.
    While we are not including the following in our proposed 
clarification, we are seeking public comments on whether the EMTALA 
obligation imposed on hospitals with specialized capabilities to accept 
appropriate transfers should apply to a hospital with specialized 
capabilities in the case of an individual who had a period of stability 
during his or her stay at the admitting hospital and is in need of 
specialized care available at the hospital with specialized 
capabilities. CMS takes seriously its duty to protect patients with 
emergency medical conditions as required by EMTALA. Thus, we are 
seeking public comments as to whether, with respect to the EMTALA 
obligation on the hospital with specialized capabilities, it should or 
should not matter if an individual who currently has an unstabilized 
emergency medical condition (which is beyond the capability of the 
admitting hospital) (1) remained unstable after coming to the hospital 
emergency department or (2) subsequently had a period of stability 
after coming to the hospital emergency department.
    In summary, to implement the recommendation by the EMTALA TAG and 
clarify our policy regarding the applicability of EMTALA to hospital 
inpatients, we are proposing to amend Sec.  489.24(f) to add a 
provision to state that when an individual covered by EMTALA was 
admitted as an inpatient and remains unstabilized with an

[[Page 23671]]

emergency medical condition, a receiving hospital with specialized 
capabilities has an EMTALA obligation to accept that individual, 
assuming that the transfer of the individual is an appropriate transfer 
and the participating hospital with specialized capabilities has the 
capacity to treat the individual.
4. Proposed Changes to the EMTALA Physician On-Call Requirements
a. Relocation of Regulatory Provisions
    During its term, the EMTALA TAG dedicated a significant portion of 
its discussion to a hospital's physician on-call obligations under 
EMTALA and made several recommendations to the Secretary regarding 
physician on-call requirements that are included in its final report 
(will be available shortly at the Web site: http://www.cms.hhs/gov/FACA/07_emtalatag.asp). The TAG recommended that CMS move the 
regulation discussing the obligation to maintain an on-call list from 
the EMTALA regulations at Sec.  489.24(j)(1) to the regulations 
implementing provider agreements at Sec.  489.20(r)(2). We agree with 
the TAG's recommendation. The requirement to maintain an on-call list 
is found at section 1866(a)(1)(I)(iii) of the Act, the section of the 
Act that refers to provider agreements. Section 1867 of the Act, which 
outlines the EMTALA requirements, makes no mention of the requirement 
to maintain an on-call list.
    To implement the EMTALA TAG's recommendation, we are proposing to 
delete the provision relating to maintaining a list of on-call 
physicians from Sec.  489.24(j)(1). We note that a provision for an on-
call physician list is already included in the regulations as a 
hospital provider agreement requirement at Sec.  489.20(r)(2). We are 
proposing to incorporate the language of Sec.  489.24(j)(1) as 
replacement language for the existing Sec.  489.20(r)(2) and amend the 
regulatory language to make it more consistent with the statutory 
language found at section 1866(a)(1)(I)(iii) of the Act. Proposed 
revised Sec.  489.20(r)(2) would read: ``An on-call list of physicians 
on its medical staff available to provide treatment necessary after the 
initial examination to stabilize individuals with emergency medical 
conditions who are receiving services required under Sec.  489.24 in 
accordance with the resources available to the hospital; and''. These 
proposed changes would make the regulations consistent with the 
statutory basis for maintaining an on-call list.
    The EMTALA TAG made additional recommendations regarding how a 
hospital would satisfy its on-call list obligations, including calling 
for an annual plan by the hospital and medical staff for on-call 
coverage that would include an assessment of factors such as the 
hospital's capabilities and services, community need for emergency 
department services as indicated by emergency department visits, 
emergent transfers, physician resources, and past performance of 
previous on-call plans. The TAG also recommended that a hospital have a 
backup plan for viable patient care options when an on-call physician 
is not available, including such factors as telemedicine, other staff 
physicians, transfer agreements, and regional or community call 
arrangements. While community call arrangements are discussed below, we 
intend to address the remainder of the TAG recommendations at a later 
date.
b. Shared/Community Call
    As noted in the previous section, section 1866(a)(1)(I)(iii) of the 
Act states, as a requirement for participation in the Medicare program, 
that a hospital must keep a list of physicians who are on call for duty 
after the initial examination to provide treatment necessary to 
stabilize an individual with an emergency medical condition. If a 
physician on the list is called by a hospital to provide stabilizing 
treatment and either fails or refuses to appear within a reasonable 
period of time, the hospital and that physician may be in violation of 
EMTALA as provided for under section 1867(d)(1)(C) of the Act. Thus, 
hospitals are required to maintain a list of on-call physicians, and 
physicians or hospitals, or both, may be held responsible under the 
EMTALA statute if a physician who is on call fails or refuses to appear 
within a reasonable period of time.
    In the May 9, 2002 proposed rule (67 FR 31471), we stated that we 
were aware of hospitals' increasing concerns regarding their physician 
on-call requirements. Specifically, we noted that we were aware of 
reports of physicians, particularly specialty physicians, severing 
their relationships with hospitals because of on-call obligations, 
especially when those physicians belong to more than one hospital 
medical staff. We further noted that physician attrition from these 
medical staffs could result in hospitals having no specialty physician 
service coverage for their patients. In the September 9, 2003 final 
rule (68 FR 53264), we clarified the regulations at Sec.  489.24(j) to 
permit on-call physicians to schedule elective surgery during the time 
that they are on call and to permit on-call physicians to have 
simultaneous on-call duties. We also specified that physicians, 
including specialists and subspecialists, are not required to be on 
call at all times, and that the hospital must have policies and 
procedures to be followed when a particular specialty is not available 
or the on-call physician cannot respond because of situations beyond 
his or her control. We expected these clarifications would help to 
improve access to physician services for all hospital patients by 
permitting hospitals flexibility to determine how best to maximize 
their available physician resources. Furthermore, we expected that 
these clarifications would permit hospitals to continue to attract 
physicians to serve on their medical staffs, thereby continuing to 
provide services to all patients, including those individuals who are 
covered by EMTALA.
    As part of its recommendations concerning physician on-call 
requirements, the EMTALA TAG recommended that hospitals be permitted to 
participate in ``community call.'' Specifically, the language of the 
recommendation states: ``The TAG recommends that CMS clarify its 
position regarding shared or community call: that such community call 
arrangements are acceptable if the hospitals involved have formal 
agreements recognized in their policies and procedures, as well as 
backup plans. It should also be clarified that a community call 
arrangement does not remove a hospital's obligation to perform an MSE 
[medical screening examination].'' The TAG also recommended in a 
subsequent recommendation that ``A hospital may satisfy its on-call 
coverage obligation by participation in an approved community/regional 
call coverage program. (CMS to determine appropriate approval 
process).''
    We believe that community call (as described below) would afford 
additional flexibility to hospitals providing on-call services and 
improve access to specialty physician services for individuals in an 
emergency department. Therefore, we are proposing to amend our 
regulations at Sec.  489.24(j) to provide that hospitals may comply 
with the on-call list requirement specified at Sec.  489.20(r)(2) 
(under our proposed revision), by participating in a formal community 
call plan so long as the plan meets the elements outlined below. We are 
further proposing to revise the regulations to state that, 
notwithstanding participation in a community call plan, hospitals are 
still required to perform medical screening examinations on individuals 
who present seeking treatment and to

[[Page 23672]]

provide for an appropriate transfer when appropriate.
    We propose ``community call,'' to be a formal on-call plan that 
permits a specific hospital in a region to be designated as the on-call 
facility for a specific time period, or for a specific service, or 
both. For example, if there are two hospitals that choose to 
participate in community call, Hospital A could be designated as the 
on-call facility for the first 15 days of each month and Hospital B 
could be designated as the on-call facility for the rest of each month. 
Alternatively, Hospital A could be designated as on-call for cases 
requiring specialized interventional cardiac care, while Hospital B 
could be designated as on-call for neurosurgical cases. We anticipate 
that hospitals and their communities would have the flexibility to 
develop a plan that reflects their local resources and needs. Such a 
community on-call plan will allow various physicians in a certain 
specialty in the aggregate to be on continuous call (24 hours a day, 7 
days a week), without putting a continuous call obligation on any one 
physician. We note that generally if an individual arrives at a 
hospital other than the designated on-call facility, is determined to 
have an unstabilized emergency medical condition, and requires the 
services of an on-call specialist, the individual would be transferred 
to the designated on-call facility in accordance with the community 
call plan.
    As noted above, we are proposing that a community call plan must be 
a formal plan among the participating hospitals. While we do not 
believe it is necessary for the formal community call plan to be 
subject to preapproval by CMS, if an EMTALA complaint investigation is 
initiated, the plan will be subject to review and enforcement by CMS. 
We are proposing that, at a minimum, hospitals must include the 
following elements when devising a formal community call plan:
    <bullet> The community call plan would include a clear delineation 
of on-call coverage responsibilities, that is, when each hospital 
participating in the plan is responsible for on-call coverage.
    <bullet> The community call plan would define the specific 
geographic area to which the plan applies.
    <bullet> The community call plan would be signed by an appropriate 
representative of each hospital participating in the plan.
    <bullet> The community call plan would ensure that any local and 
regional EMS system protocol formally includes information on community 
on-call arrangements.
    <bullet> Hospitals participating in the community call plan would 
engage in an analysis of the specialty on-call needs of the community 
for which the plan is effective.
    <bullet> The community call plan would include a statement 
specifying that even if an individual arrives at the hospital that is 
not designated as the on-call hospital, that hospital still has an 
EMTALA obligation to provide a medical screening examination and 
stabilizing treatment within its capability, and hospitals 
participating in community call must abide by the EMTALA regulations 
governing appropriate transfers.
    <bullet> There would be an annual reassessment of the community 
call plan by the participating hospitals.
    Proposed revised Sec.  489.24(j) would read ``Availability of on-
call physicians. In accordance with the on-call list requirements 
specified in Sec.  489.20(r)(2), a hospital must have written policies 
and procedures in place--(1) To respond to situations in which a 
particular specialty is not available or the on-call physician cannot 
respond because of circumstances beyond the physician's control; and 
(2) To provide that emergency services are available to meet the needs 
of individuals with emergency medical conditions if a hospital elects 
to--(i) Permit on-call physicians to schedule elective surgery during 
the time that they are on call; (ii) Permit on-call physicians to have 
simultaneous on-call duties; and (iii) Participate in a formal 
community call plan. Notwithstanding participation in a community call 
plan, hospitals are still required to perform medical screening 
examinations on individuals who present seeking treatment and to 
conduct appropriate transfers. The formal community call plan must 
include the following elements: [proposed elements noted above in the 
bullets are included in regulations text].''
    We welcome public comments on the proposed elements of the formal 
community call plan noted above. We are also soliciting public comments 
on whether individuals believe it is important that, in situations 
where there is a governing State or local agency that would have 
authority over the development of a formal community call plan, the 
plan be approved by that agency. In summary, we are proposing that, as 
part of the obligation to have an on-call list, hospitals may choose to 
participate in community call, provided that the formal community call 
plan includes, at a minimum, the elements noted in bullets above. 
Additionally, each hospital participating in the community call plan 
must have written policies and procedures in place to respond to 
situations in which the on-call physician is unable to respond due to 
situations beyond his or her control. We are further proposing that a 
hospital would still be responsible for performing medical screening 
examinations on individuals who present to the hospital seeking 
treatment and conducting appropriate transfers, regardless of which 
hospital has on-call responsibilities on a particular day.
5. Proposed Technical Change to Regulations
    In the FY 2008 IPPS final rule with comment period (72 FR 47413), 
we revised Sec.  489.24(a)(2) (which refers to the nonapplicability of 
the EMTALA provisions in an emergency area during an emergency period) 
to conform it to the changes made to section 1135 of the Act by the 
Pandemic and All-Hazards Preparedness Act. When we made the change to 
the regulations, we inadvertently left out language consistent with the 
following statutory language found in section 1135: ``pursuant to an 
appropriate State emergency preparedness plan; or in the case of a 
public health emergency described in subsection (g)(1)(B) that involves 
a pandemic infectious disease, pursuant to a State pandemic 
preparedness plan or a plan referred to in clause (i), whichever is 
applicable in the State.'' We also inadvertently left out the phrase in 
section 1135 ``during an emergency period'' when we state the 
nonapplicability of the sanctions in an emergency area. We are 
proposing to revise the language at Sec.  489.24(a)(2) to include the 
aforementioned language to conform the regulation text to the statutory 
language. Proposed revised Sec.  489.24(a)(2) would read as follows: 
``Nonapplicability of provisions of this section. Sanctions under this 
section for an inappropriate transfer during a national emergency or 
for the direction or relocation of an individual to receive medical 
screening at an alternate location pursuant to an appropriate State 
emergency preparedness plan or, in the case of a public health 
emergency that involves a pandemic infectious disease, pursuant to a 
State pandemic preparedness plan do not apply to a hospital with a 
dedicated emergency department located in an emergency area during an 
emergency period, as specified in section 1135(g)(1) of the Act. A 
waiver of these sanctions is limited to a 72-hour period beginning upon 
the implementation of a hospital disaster protocol, except that, if a 
public health emergency involves a pandemic infectious disease (such as 
pandemic

[[Page 23673]]

influenza), the waiver will continue in effect until the termination of 
the applicable declaration of a public health emergency, as provided 
for by section 1135(e)(1)(B) of the Act.''

J. Application of Incentives To Reduce Avoidable Readmissions to 
Hospitals

1. Introduction
    A significant portion of Medicare spending--$15 billion each year--
is related to hospital readmissions. According to a 2005 MedPAC 
analysis ,\17\ nearly 18 percent of beneficiaries who are discharged 
from the hospital are readmitted within 30 days, resulting in 
approximately 2 million readmissions. By MedPAC's method, over 13 
percent of 30-day hospital readmissions and an associated $12 billion 
in spending (\4/5\ of all Medicare spending for readmissions) were 
found to be potentially avoidable. Beyond cost considerations, 
readmissions may reflect poor quality of care and affect 
beneficiaries'' quality of life. Though not all readmissions are 
avoidable, hospitals should share accountability for readmission rates 
that could be much lower through the application of evidence-based best 
practices. Interventions that have been shown to reduce readmissions 
include better quality of care during the hospitalization, more 
complete care plans, emphasis on coordination of care at the point of 
transitions to home or postacute care, better use of after-hospital 
care, and more active involvement of patients and caregivers in 
decision making.
---------------------------------------------------------------------------

    \17\ Medicare Payment Advisory Commission: Report to Congress: 
Promoting Greater Efficiency in Medicare. June 2007, Chapter 5, page 
103.
---------------------------------------------------------------------------

    The application of incentives to reduce hospital readmissions, 
including payment and public reporting approaches, could promote the 
adoption and development of best practice interventions for averting 
avoidable readmissions, resulting in higher quality of care for 
Medicare beneficiaries and reduction in unnecessary costs for the 
program. Under the current payment system, readmissions are financially 
rewarding for hospitals. Application of payment incentives to encourage 
reduction of avoidable readmissions could help address unintended 
incentives in the current payment system.
    In this section, following discussion of readmission issues related 
to measurement, accountability, and interventions, we are presenting 
three approaches to applying incentives to reduce avoidable 
readmissions for public comment: (1) Direct adjustment to hospital DRG 
payments for avoidable readmissions, (2) adjustments to hospital DRG 
payments through a performance-based payment methodology, and (3) 
public reporting of readmission rates. We note that either type of 
adjustment to hospital payments for readmissions would likely require 
new statutory authority for the Medicare program. We are seeking public 
comments on all of the ideas presented in this section.
2. Measurement
    Routine, valid, and reliable measurement of hospital-specific rates 
of readmissions would be a prerequisite to any method of applying 
incentives for reducing hospital readmissions. Measurement data should 
be meaningful and actionable for hospitals and should be fair to 
encourage trust and engagement in the effort. Risk adjustment of 
measurement data is necessary to account for patient[pi]specific 
factors that influence the likelihood of readmission, such as age, 
disease severity, and comorbidities.
    Another important consideration in measurement of readmission rates 
is the time period from discharge to readmission (for example, 7, 15, 
30, or 90 days). In section IV.B. of the preamble of this proposed 
rule, measures of risk-adjusted 30-day readmission rates are proposed 
for the RHQDAPU program. The 9th Scope of Work for Medicare Quality 
Improvement Organizations (QIO 9th SOW) also includes 30-day 
readmission measures for communities.
    Measures should be aligned across settings of care. Hospitals are 
not the only providers that affect the occurrence of readmissions. For 
example, the care delivered by SNFs and HHAs also has an important 
impact on whether a beneficiary is readmitted. Data from aligned 
readmissions measures, applicable to various settings of care, would 
provide better information about care coordination problems within and 
between settings. Alignment of readmissions measures would also 
facilitate more powerful application of incentives across Medicare's 
payment systems.
    Another consideration is whether to focus on all readmissions or to 
focus on those that are known to be higher cost, more easily 
preventable, or most frequently occurring. For example, numerous 
hospitals have successfully implemented programs to reduce readmissions 
of heart failure patients, so more is known about the prevention of 
heart failure readmissions. Further, heart failure readmissions may be 
more costly than readmissions for other conditions. Another focus of 
efforts to prevent readmissions could be patients with multiple chronic 
conditions, who may be at the highest risk to experience readmissions.
3. Accountability
    In the assignment of accountability for readmissions, risk 
adjustment of measurement data is one consideration of fairness; 
however, other factors must also be considered, including avoidability 
and shared accountability. Most clinicians would agree that a goal of 
zero readmissions may not be appropriate, as an extremely low rate of 
readmissions could indicate restricted access to needed medical 
services, overuse of hospital resources during the initial 
hospitalization (for example, prolonged length of stay), or excessive 
intensity of post-acute care services. Adequate risk adjustment could 
help to elucidate the avoidability of readmissions by identifying an 
expected readmission rate for a given patient or patient population.
    Shared accountability is another important consideration. Hospitals 
are clearly accountable for the care provided during hospitalization 
and can also affect the quality of care provided after the 
hospitalization, but hospitals are not the only accountable entity. 
Both during and after hospitalization, physicians and other health 
professionals share accountability for the quality of care. Other 
provider entities, including skilled nursing facilities, rehabilitation 
facilities, home health agencies, and end-stage renal disease 
facilities, also share accountability for avoidable readmissions. 
Medicare beneficiaries themselves and their caregivers and social 
support systems play important roles in avoiding readmissions, 
particularly when beneficiaries have been discharged to home. 
    Assignment of accountability also requires consideration of 
situations where the patient presents for readmission with a different 
diagnosis or presents to a different hospital. If the

[[Page 23674]]

locus of accountability were at the hospital level, a second hospital 
should not be held accountable for a readmission resulting from a first 
hospital's lack of adherence to evidence-based best practices for 
averting readmissions. If the locus of accountability were at the 
community level, then shared accountability could encourage hospitals 
to work together to reduce readmissions. 
4. Interventions 
    A number of interventions have been identified as best practices 
for averting avoidable readmissions.\18,19,20,21,22,23,24,25,26\ Some 
of these evidence-based interventions are listed below:
---------------------------------------------------------------------------

    \18\ Coleman, E.A., C. Parry, S. Chalmers, et al. 2006. The care 
transitions intervention: Results of a randomized controlled trial. 
Archives of Internal Medicine, 166 (September 25): 1822-1828.
    \19\ Coleman, E.A., J.D. Smith, R. Devbani, et al. 2005. 
Posthospital medication discrepancies: Prevalence and contributing 
factors. Archives of Internal Medicine 165, (September 12): 1842-
1847.
    \20\ Coleman, E., and R. Berenson. 2004. Lost in transition: 
Challenges and opportunities for improving the quality of 
transitional care. Annals of Internal Medicine, 141, no. 7 (October 
5): 533-536.
    \21\ Institute for Healthcare Improvement. 2004a. Reducing 
readmissions for heart failure patients: Hackensack University 
Medical Center. Available at http://www.ihi.org.
    \22\ Institute for Healthcare Improvement. 2004b. The 
MedProvider inpatient care unit-congestive heart failure project. 
Available at: http://www.ihi.org.
    \23\ Lappe, J.M., J.B. Muhlestein, D.L. Lappe, et al. 2004. 
Improvements in 1-year cardiovascular clinical outcomes associated 
with a hospital-based discharge medication program. Annals of 
Internal Medicine, 141, no.6 (September 21): 446-453.
    \24\ Naylor, M.D., D. Brooton, R. Campbell, et al. 1999. 
Comprehensive discharge planning and home follow-up of hospitalized 
elders. Journal of the American Medical Association, 281, no.7 
(February 17): 613-620.
    \25\ VanSuch, M., J.M. Naessens, R.J. Stroebel, et al. 2006. 
Effect of discharge instructions on readmission of hospitalized 
patients with heart failure: Do all of the Joint Commission on 
Accreditation of Healthcare Organizations heart failure core 
measures reflect better care? Quality and Safety in Healthcare, 15: 
414-417.
    \26\ Weinberg D.B., J.H. Gittell, R.W. Lusenhop, et al. 2007. 
Beyond our walls: Impact of patient and provider coordination across 
the continuum on outcomes for surgical patients. Health Services 
Research, 42, no. 1, pt. 1 (February): 7-24.
---------------------------------------------------------------------------

    <bullet> Better, safer care during the hospitalization.
    <bullet> Improved communication among providers and with the 
patient and caregivers.
    <bullet> Care planning that begins with assessment at admission.
    <bullet> Clear discharge instructions, with specific attention to 
medication management.
    <bullet> Shared accountability for care coordination, with 
attention to transitions and hand-offs.
    <bullet> Discharge to a proper setting of care.
    <bullet> Better, safer care in the post-acute setting of care.
    <bullet> Appropriate use of palliative care and honest planning for 
the likely course.
    <bullet> Timely physician follow up visits.
    <bullet> Active involvement of patients and their caregivers.
    Interventions such as these have been employed by several 
participants in CMS Physician Group Practice Demonstration and have 
contributed to improvements in the quality and cost-efficiency of care 
provided to Medicare beneficiaries. For example, the University of 
Michigan Faculty Group Practice's transitional care call-back program 
contacts Medicare patients discharged from the emergency department and 
acute care hospital to address gaps in care during the transition 
between care settings. The program provides short-term care 
coordination with linkages to visiting nurse and community services, as 
well as coordination with primary care and specialty clinics. The 
Everett Clinic utilizes hospital coaches to guide patients and 
caregivers through complicated care processes during hospital stays and 
on discharge. The clinic proactively reaches out to recently 
hospitalized patients to assure that they have a physician followup 
visit within 10 days after discharge to address any unresolved or new 
health problems.
    CMS is considering strategies for distributing a discharge 
checklist that the agency developed to help beneficiaries and their 
caregivers prepare for discharge from a hospital or nursing home. The 
checklist includes a range of issues to consider and address with 
physicians and other health care providers to facilitate a smooth 
transition to home or postacute care setting. In addition, the 
checklist provides information about supportive home and community-
based services.
    The QIO 9th SOW includes a theme entitled Patient Pathways (Care 
Transitions). The goal of this theme is to measurably improve the 
quality of care for Medicare beneficiaries who transition among care 
settings, resulting in reduced readmissions and replicable strategies 
to sustain reduced readmission rates. The QIO 8th SOW included 
initiatives to reduce avoidable readmissions of home health patients.
5. Financial Incentive: Direct Payment Adjustment
    The first of three approaches presented for comment is direct 
adjustment to hospital DRG payments for readmissions. This approach 
would likely require new statutory authority for the Medicare program. 
In section II.F. of the preamble of this
proposed rule, we discuss direct adjustments to MS-DRG payment for 
selected preventable HACs. Similarly, a payment adjustment could be 
applied for readmissions determined to be avoidable because the 
hospital did not follow evidence-based best practices for averting 
readmissions. The magnitude of the payment adjustment could be based on 
patient-specific risk factors and on the apportionment of shared 
accountability among the involved entities.
    A variation of this approach could be adjustment of all hospital 
payments for readmissions, nationwide or by some regional designation, 
based on aggregate information about avoidable readmissions for the 
entire relevant Medicare population (national or regional) under 
typical circumstances. Under this approach, hospitals would receive 
less Medicare payment for readmissions for conditions with lower 
expected rates of readmission and less shared accountability.
    Potential unintended consequences resulting from a financial 
incentive to avert readmissions also need to be considered. For 
example, hospitals could begin discharging patients to settings that 
provide more intensive postacute care to avoid readmissions, thereby 
potentially driving up total costs for episodes of care and total 
Medicare spending. As another example of potential unintended 
consequences, hospitals could begin to resist medically necessary 
readmissions from postacute care providers, creating an access problem.
6. Financial Incentive: Performance-Based Payment Adjustment
    The second approach presented for comment is adjustment to hospital 
MS-DRG payments using a performance-based payment methodology, such as 
the Medicare Hospital VBP Plan referenced in section IV.C. of the 
preamble of this proposed rule and available at: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf. The intent of the VBP Plan 
methodology is to promote adherence to evidence-based best practices in 
the delivery of care and to provide rewards for those who are 
successful in improving their measured performance. Implementation of 
the VBP methodology would require new statutory authority for the 
Medicare program.
    Under the VBP Plan, measures of clinical processes of care, patient 
experience (HCAHPS), and outcomes (30-day mortality) would be scored 
and translated into an incentive payment. These measures of process, 
outcome, and patient-centeredness address areas of quality that are 
important to reducing readmissions; however, other measures could be 
added to more fully adjust payments for readmissions. Direct measures 
of hospital-specific, risk adjusted readmission rates could be included 
in the VBP Plan performance

[[Page 23675]]

assessment model. In addition, other measures of care coordination that 
indirectly address readmissions could also be included.
    The direct adjustment approach and the VBP Plan approaches for 
applying financial incentives to the reduction of avoidable 
readmissions could be implemented separately or in combination.
7. Nonfinancial Incentive: Public Reporting
    A third approach presented for comment is public reporting of 
hospital-specific, risk adjusted readmission rates. The 
Administration's Value-Driven Health Care initiative, which stems from 
the President's Executive Order Promoting Quality and Efficient Health 
Care in Federal Government Health Care Programs, calls for Federal 
agencies to make health care quality and cost information more 
transparent. Health care consumers, including Medicare beneficiaries, 
and their providers and caregivers need better information to support 
more informed decision making about their care. The public reporting of 
readmission rates would likely not require new statutory authority for 
the Medicare program.
    The Hospital Compare Web site could be used to report readmission 
rates along with the other quality and cost of care parameters 
displayed on that site. Public reporting has been demonstrated to be a 
strong non-financial incentive with a competitive effect, as hospitals 
appropriately focus on maintaining and enhancing their reputations as 
providers of high quality of care. The VBP Plan envisions public 
reporting in concert with the VBP financial incentive, but the public 
reporting incentive could be applied regardless of statutory authority 
to implement the VBP Plan.
8. Conclusion
    The purpose of this section is to solicit and encourage public 
comments on considerations and options for applying incentives to 
reduce avoidable hospital readmissions. We welcome public comments on 
readmission issues related to measurement, accountability, and 
interventions, as well as on potential approaches to applying financial 
and nonfinancial incentives to reduce avoidable readmissions.

K. Rural Community Hospital Demonstration Program

    In accordance with the requirements of section 410A(a) of Pub. L. 
108-173, the Secretary has established a 5-year demonstration program 
(beginning with selected hospitals' first cost reporting period 
beginning on or after October 1, 2004) to test the feasibility and 
advisability of establishing ``rural community hospitals'' for Medicare 
payment purposes for covered inpatient hospital services furnished to 
Medicare beneficiaries. A rural community hospital, as defined in 
section 410A(f)(1), is a hospital that--
    <bullet> 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;
    <bullet> Has fewer than 51 beds (excluding beds in a distinct part 
psychiatric or rehabilitation unit) as reported in its most recent cost 
report;
    <bullet> Provides 24-hour emergency care services; and
    <bullet> Is not designated or eligible for designation as a CAH.
    Section 410A(a)(4) of Pub. L. 108-173 states that no more than 15 
such hospitals may participate in the demonstration program.
    As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in 
accordance with sections 410A(a)(2) and (a)(4) of Pub. L. 108-173 and 
using 2002 data from the U.S. Census Bureau, we identified 10 States 
with the lowest population density from which to select hospitals: 
Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, 
South Dakota, Utah, and Wyoming (Source: U.S. Census Bureau Statistical 
Abstract of the United States: 2003). Nine rural community hospitals 
located within these States are currently participating in the 
demonstration program. (Of the 13 hospitals that participated in the 
first 2 years of the demonstration program, 4 hospitals located in 
Nebraska have become CAHs and have withdrawn from the program.)
    In a notice published in the Federal Register on February 6, 2008 
(73 FR 6971 through 6973), we announced a solicitation for up to six 
additional hospitals to participate in the demonstration program. 
Hospitals that enter the demonstration under this solicitation will be 
able to participate for no more than 2 years. The February 6, 2008 
notice specifies the eligibility requirements for the demonstration 
program.
    Under the demonstration program, participating hospitals are paid 
the reasonable costs of providing covered inpatient hospital services 
(other than services furnished by a psychiatric or rehabilitation unit 
of a hospital that is a distinct part), applicable for discharges 
occurring in the first cost reporting period beginning on or after the 
October 1, 2004 implementation date of the demonstration program. 
Payments to the participating hospitals will be the lesser amount of 
the reasonable cost or a target amount in subsequent cost reporting 
periods. The target amount in the second cost reporting period is 
defined as the reasonable costs of providing covered inpatient hospital 
services in the first cost reporting period, increased by the inpatient 
prospective payment update factor (as defined in section 1886(b)(3)(B) 
of the Act) for that particular cost reporting period. The target 
amount in subsequent cost reporting periods is defined as the preceding 
cost reporting period's target amount, increased by the inpatient 
prospective payment update factor (as defined in section 1886(b)(3)(B) 
of the Act) for that particular cost reporting period.
    Covered inpatient hospital services are inpatient hospital services 
(defined in section 1861(b) of the Act), and include extended care 
services furnished under an agreement under section 1883 of the Act.
    Section 410A of Pub. L. 108-173 requires that, ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration program 
under this section was not implemented.'' Generally, when CMS 
implements a demonstration program on a budget neutral basis, the 
demonstration program is budget neutral in its own terms; in other 
words, the aggregate payments to the participating providers do not 
exceed the amount that would be paid to those same providers in the 
absence of the demonstration program. This form of budget neutrality is 
viable when, by changing payments or aligning incentives to improve 
overall efficiency, or both, a demonstration program may reduce the use 
of some services or eliminate the need for others, resulting in reduced 
expenditures for the demonstration program's participants. These 
reduced expenditures offset increased payments elsewhere under the 
demonstration program, thus ensuring that the demonstration program as 
a whole is budget neutral or yields savings. However, the small scale 
of this demonstration program, in conjunction with the payment 
methodology, makes it extremely unlikely that this demonstration 
program could be viable under the usual form of budget neutrality. 
Specifically, cost-based payments to 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

[[Page 23676]]

participation in this demonstration program is unlikely to yield 
benefits to the participant if budget neutrality were to be implemented 
by reducing other payments for these providers.
    In order to achieve budget neutrality for this demonstration 
program for FY 2009, we are proposing to adjust the national inpatient 
PPS rates by an amount sufficient to account for the added costs of 
this demonstration program. We are proposing to apply budget neutrality 
across the payment system as a whole rather than merely across the 
participants in this demonstration program. As we discussed in the FY 
2005, FY 2006, FY 2007 and FY 2008 IPPS final rules (69 FR 49183; 70 FR 
47462; 71 FR 48100; and 72 FR 47392), we believe that the language of 
the statutory budget neutrality requirements permits the agency to 
implement the budget neutrality provision in this manner. For FY 2009, 
using data from the cost reports from each of the nine hospitals' first 
year of participation in the demonstration program, that is, cost 
reports for years beginning in CY 2005, and estimating the cost of six 
additional hospitals based on these data, we estimate that the 
additional cost would be $32,011,849. (In the final rule, we should 
know the exact number of hospitals participating in the demonstration 
program and would revise our estimates accordingly.) This estimated 
adjusted amount reflects the estimated difference between the 
participating hospitals costs and the IPPS payment based on data from 
the hospitals' cost reports. We discuss the payment rate adjustment 
that is required to ensure the budget neutrality of the demonstration 
program for FY 2009 in section II.A.4. of the Addendum to this proposed 
rule.

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

A. Background

    Section 1886(g) of the Act requires the Secretary to pay for the 
capital-related costs of inpatient acute hospital services ``in 
accordance with a prospective payment system established by the 
Secretary.'' Under the statute, the Secretary has broad authority in 
establishing and implementing the IPPS for acute care hospital 
inpatient capital-related costs. We initially implemented the IPPS for 
capital-related costs in the 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 most acute care 
hospitals (other than hospitals receiving certain exception payments 
and certain new hospitals). The basic methodology for determining 
capital prospective payments using the Federal rate is set forth in 
Sec.  412.312. For the purpose of calculating payments for each 
discharge, the standard Federal rate is adjusted as follows:
    (Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment 
Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA for 
hospitals located in Alaska and Hawaii) x (1 + Capital DSH Adjustment 
Factor + Capital IME Adjustment Factor, if applicable).
    Hospitals also may receive outlier payments for those cases that 
qualify under the threshold established for each fiscal year as 
specified in Sec.  412.312(c) of the regulations.
1. Exception Payments
    The regulations at Sec.  412.348(f) provide that a hospital may 
request an additional payment if the hospital incurs unanticipated 
capital expenditures in excess of $5 million due to extraordinary 
circumstances beyond the hospital's control. This policy was originally 
established for hospitals during the 10-year transition period, but as 
we discussed in the FY 2003 IPPS final rule (67 FR 50102), we revised 
the regulations at Sec.  412.312 to specify that payments for 
extraordinary circumstances are also made for cost reporting periods 
after the transition period (that is, cost reporting periods beginning 
on or after October 1, 2001). Additional information on the exception 
payment for extraordinary circumstances in Sec.  412.348(f) can be 
found in the FY 2005 IPPS final rule (69 FR 49185 and 49186).
    During the transition period, under Sec. Sec.  412.348(b) through 
(e), eligible hospitals could receive regular exception payments. These 
exception payments guaranteed a hospital a minimum payment percentage 
of its Medicare allowable capital-related costs depending on the class 
of the hospital (Sec.  412.348(c)), but were available only during the 
10-year transition period. After the end of the transition period, 
eligible hospitals can no longer receive this exception payment. 
However, even after the transition period, eligible hospitals receive 
additional payments under the special exceptions provisions at Sec.  
412.348(g), which guarantees all eligible hospitals a minimum payment 
of 70 percent of its Medicare allowable capital-related costs provided 
that special exceptions payments do not exceed 10 percent of total 
capital IPPS payments. Special exceptions payments may be made only for 
the 10 years from the cost reporting year in which the hospital 
completes its qualifying project, and the hospital must have completed 
the project no later than the hospital's cost reporting period 
beginning before October 1, 2001. Thus, an eligible hospital may 
receive special exceptions payments for up to 10 years beyond the end 
of the capital IPPS transition period. Hospitals eligible for special 
exceptions payments are required to submit documentation to the 
intermediary indicating the completion date of their project. (For more 
detailed information regarding the special exceptions policy under 
Sec.  412.348(g), 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).)
2. New Hospitals
    Under the IPPS for capital-related costs, Sec.  412.300(b) of the 
regulations defines a new hospital as a hospital that has operated 
(under current or previous ownership) for less than 2 years. (For more 
detailed information, we refer readers to the FY 1992 IPPS final rule 
(56 FR 43418).) During the 10-year transition period, a new hospital 
was exempt from the capital IPPS for its first 2 years of operation and 
was paid 85 percent of its reasonable costs during that period. 
Originally, this provision was effective only through the transition 
period and, therefore, ended with cost reporting periods beginning in 
FY 2002. Because, 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 Sec.  412.304(c)(2) to provide that, for cost reporting 
periods beginning on or after October 1, 2002, a new hospital (defined 
under Sec.  412.300(b)) is paid 85 percent of its Medicare allowable 
capital-related costs through its first 2 years of operation, unless 
the new hospital elects to receive fully prospective payment based on 
100 percent of the Federal rate. (We refer readers to the FY 2002 IPPS 
final rule (66 FR 39910) for a detailed discussion of the statutory 
basis for the system, the development and evolution of the system, the 
methodology used to

[[Page 23677]]

determine capital-related payments to hospitals both during and after 
the transition period, and the policy for providing exception 
payments.)
3. Hospitals Located in Puerto Rico
    Section 412.374 provides for the use of a blended payment amount 
for prospective payments for capital-related costs to hospitals located 
in Puerto Rico. Accordingly, under the capital IPPS, we compute a 
separate payment rate specific to Puerto Rico hospitals using the same 
methodology used to compute the national Federal rate for capital-
related costs. In general, hospitals located in Puerto Rico are paid a 
blend of the applicable capital IPPS Puerto Rico rate and the 
applicable capital IPPS Federal rate.
    Prior to FY 1998, hospitals in Puerto Rico were paid a blended 
capital IPPS rate that consisted of 75 percent of the capital IPPS 
Puerto Rico specific rate and 25 percent of the capital IPPS Federal 
rate. However, effective October 1, 1997 (FY 1998), in conjunction with 
the change to the operating IPPS blend percentage for 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.

B. Revisions to the Capital IPPS Based on Data on Hospital Medicare 
Capital Margins

    As noted above, under the Secretary's broad authority under the 
statute in establishing and implementing the IPPS for hospital 
inpatient capital-related costs, we have established a standard Federal 
payment rate for capital-related costs, as well as the mechanism for 
updating that rate each year. For FY 1992, we computed the standard 
Federal payment rate for capital-related costs under the IPPS by 
updating the FY 1989 Medicare inpatient capital cost per case by an 
actuarial estimate of the increase in Medicare inpatient capital costs 
per case. Each year after FY 1992, we update the capital standard 
Federal rate, as provided at Sec.  412.308(c)(1), to account for 
capital input price increases and other factors. The regulations at 
Sec.  412.308(c)(2) provide that the capital Federal rate is adjusted 
annually by a factor equal to the estimated proportion of outlier 
payments under the capital Federal rate to total capital payments under 
the capital Federal rate. In addition, Sec.  412.308(c)(3) requires 
that the capital Federal rate be reduced by an adjustment factor equal 
to the estimated proportion of payments for (regular and special) 
exceptions under Sec.  412.348. Section 412.308(c)(4)(ii) requires that 
the capital standard Federal rate be adjusted so that the effects of 
the annual DRG reclassification and the recalibration of DRG weights, 
and changes in the geographic adjustment factor are budget neutral.
    In the FY 2008 IPPS final rule with comment period (72 FR 47398 
through 47401), based on our analysis of data on inpatient hospital 
Medicare capital margins that we obtained through our monitoring and 
comprehensive review of the adequacy of the standard Federal payment 
rate for capital-related costs and the updates provided under the 
existing regulations, we made changes in the payment structure under 
the capital IPPS beginning with FY 2008. We summarize these changes 
below. We refer readers to section V.B. of the preamble of the FY 2008 
final rule with comment period (72 FR 47393 through 47401) for a 
detailed discussion of the data used as a basis for these changes. 
These data showed that hospital inpatient Medicare capital margins were 
very high across all hospitals during the period from FY 1996 through 
FY 2004.
    In the FY 2008 IPPS final rule with comment period, as background, 
we noted that, in general, under a PPS, standard payment rates should 
reflect the costs that an average, efficient provider would bear to 
provide the services required for quality patient care. Payment rate 
updates should also account for the changes necessary to continue 
providing such services. Updates should reflect, for example, the 
increased costs that are necessary to provide for the introduction of 
new technology that improves patient care. Updates should also take 
into account the productivity gains that, over time, allow providers to 
realize the same, or even improved, quality outcomes with reduced 
inputs and lower costs. Hospital margins, the difference between the 
costs of actually providing services and the payments received under a 
particular system, thus provide some evidence concerning whether 
payment rates have been established and updated at an appropriate level 
over time for efficient providers to provide necessary services. All 
other factors being equal, sustained substantial positive margins 
demonstrate that payment rates and updates have exceeded what is 
required to provide those services. It is to be expected, under a PPS, 
that highly efficient providers might regularly realize positive 
margins, while less efficient providers might regularly realize 
negative margins. However, a PPS that is correctly calibrated should 
not necessarily experience sustained periods in which providers 
generally realize substantial positive Medicare margins. Under the 
capital IPPS in particular, it seems especially appropriate that there 
should not be sustained significant positive margins across the system 
as a whole. Prior to the implementation of the capital IPPS, Congress 
mandated that the Medicare program pay only 85 percent of hospitals' 
inpatient Medicare capital costs. During the first 5 years of the 
capital IPPS, Congress also mandated a budget neutrality adjustment, 
under which the standard Federal capital rate was set each year so that 
payments under the system as a whole equaled 90 percent of estimated 
hospitals' inpatient Medicare capital costs for the year. Finally, 
Congress has twice adjusted the standard Federal capital rate (a 7.4 
percent reduction beginning in FY 1994, followed by a 17.78 percent 
reduction beginning in FY 1998). On the second occasion in particular, 
the specific congressional mandate was ``to apply the budget neutrality 
factor used to determine the Federal capital payment rate in effect on 
September 30, 1995 * * * to the unadjusted standard Federal capital 
payment rate'' for FY 1998 and beyond. (The designated budget 
neutrality factor constituted a 17.78 percent reduction.) This 
statutory language indicates that Congress considered the payment 
levels in effect during FYs1992 through 1995, established under the 
budget neutrality provision to pay 90 percent of hospitals' inpatient 
Medicare capital costs in the aggregate, appropriate for the capital 
IPPS. The statutory history of the capital IPPS thus suggests that the 
system in the aggregate should not provide for continuous, large 
positive margins.
    As we also discussed in the FY 2008 IPPS final rule with comment 
period, we believed that there could be a number of reasons for the 
relatively high margins that most IPPS hospitals have realized under 
the capital IPPS. One possibility is that the updates to the capital 
IPPS rates have been higher than the actual increases in Medicare 
inpatient capital costs that hospitals

[[Page 23678]]

have experienced in recent years. Another possible reason for the 
relatively high margins of most capital IPPS hospitals may be that the 
payment adjustments provided under the system are too high, or perhaps 
even unnecessary. Specifically, the adjustments for teaching hospitals, 
disproportionate share hospitals, and large urban hospitals appear to 
be contributing to excessive payment levels for these classes of 
hospitals. Since the inception of the capital IPPS in FY 1992, the 
system has provided adjustments for teaching hospitals (the IME 
adjustment factor, under Sec.  412.322 of the regulations), 
disproportionate share hospitals (the DSH adjustment factor, under 
Sec.  412.320), and large urban hospitals (the large urban location 
adjustment factor, under Sec.  412.316(b)). The classes of hospitals 
eligible for these adjustments have been realizing much higher margins 
than other hospitals under the system. Specifically, teaching hospitals 
(11.6 percent for FYs 1998 through 2004), disproportionate share 
hospitals (8.4 percent), and urban hospitals (8.3 percent) have had 
significant positive margins. Other classes of hospitals have 
experienced much lower margins, especially rural hospitals (0.3 percent 
for FYs 1998 through 2004) and nonteaching hospitals (1.3 percent). The 
three groups of hospitals that have been realizing especially high 
margins under the capital IPPS are, therefore, classes of hospitals 
that are eligible to receive one or more specific payment adjustment 
under the system. We believed that the evidence indicates that these 
adjustments have been contributing to the significantly large positive 
margins experienced by the classes of hospitals eligible for these 
adjustments.
    Therefore, in the FY 2008 IPPS final rule with comment period, we 
made two changes to the structure of payments under the capital IPPS, 
as discussed under items 1. and 2. below.
1. Elimination of the Large Add-On Payment Adjustment
    In the FY 2008 IPPS final rule with comment period, we determined 
that the data we had gathered on inpatient hospital Medicare capital 
margins provided sufficient evidence to warrant elimination of the 
large urban add-on payment adjustment starting in FY 2008 under the 
capital IPPS. Therefore, for FYs 2008 and beyond, we discontinued the 
3.0 percent additional payment that had been provided to hospitals 
located in large urban areas (72 FR 24822). This decision was supported 
by comments from MedPAC.
2. Changes to the Capital IME Adjustment
a. Background and Changes Made for FY 2008
    In the FY 2008 IPPS proposed rule, we noted that margin analysis 
indicated that several classes of hospitals had experienced continuous, 
significant positive margins. The analysis indicated that the existing 
payment adjustments for teaching hospitals and disproportionate share 
hospitals were contributing to excessive payment levels for these 
classes of hospitals. Therefore, we stated that it may be appropriate 
to reduce these adjustments significantly, or even to eliminate them 
altogether, within the capital IPPS. These payment adjustments, unlike 
parallel adjustments under the operating IPPS, were not mandated by the 
Act. Rather, they were included within the original design of the 
capital IPPS under the Secretary's broad authority in section 
1886(g)(1) of the Act to include appropriate adjustments and exceptions 
within a capital IPPS. In the FY 2008 final rule with comment period, 
we also noted a MedPAC recommendation that we seriously reexamine the 
appropriateness of the existing capital IME adjustment, that the margin 
analysis indicated such adjustment may be too high, and that MedPAC's 
previous analysis also suggested the adjustment may be too high. In 
light of MedPAC's recommendation, we extended the margin analysis 
discussed in the FY 2008 IPPS proposed rule in order to distinguish the 
experience of teaching hospitals from the experience of urban and rural 
hospitals generally. Specifically, we isolated the margins of urban, 
large urban, and rural teaching hospitals, as opposed to urban, large 
urban, and rural nonteaching hospitals. In conducting this analysis, we 
employed updated cost report information, which allowed us to 
incorporate the margins for an additional year, FY 2005, into the 
analysis. The data on the experience of urban, large urban, and rural 
teaching hospitals as opposed to nonteaching hospitals provided 
significant new information. As the analysis demonstrated, teaching 
hospitals in each class (urban, large urban, and rural) performed 
significantly better than comparable nonteaching hospitals. For the 
period covering FYs 1998 through 2005, urban teaching hospitals 
realized aggregate positive margins of 11.9 percent, compared to a 
positive margin of 0.9 percent for urban nonteaching hospitals. 
Similarly, large urban teaching hospitals realized an aggregate 
positive margin of 12.8 percent during that period, while large urban 
nonteaching hospitals had an aggregate positive margin of only 2.9 
percent. Finally, rural teaching hospitals experienced an aggregate 
positive margin of 4.5 percent, as compared to a negative 1.3 percent 
margin for nonteaching rural hospitals. We noted that the positive 
margins for teaching hospitals did not exhibit a decline to the same 
degree as the margins for all hospitals. For example, the positive 
margins for all IPPS hospitals declined from 8.7 percent in FY 2002 to 
5.3 percent in FY 2004 and 3.7 percent in FY 2005. For urban hospitals, 
aggregate margins decreased from 10.3 percent in FY 2002 to 6.4 percent 
in FY 2004 and 4.8 percent in FY 2005. Rural hospitals experienced a 
decrease from 1.5 percent in FY 2001 to a negative margin of -4.2 
percent in FY 2005. In comparison, the aggregate margin for teaching 
hospitals was 12.1 percent in FY 2001 and 10.6 percent in FY 2005. For 
urban teaching hospitals, margins were 12.5 percent in FY 2001, 14.0 
percent in FY 2002, 13.6 percent in FY 2003, 11.9 percent in FY 2004, 
and 10.9 percent in FY 2005. Rural teaching hospital margins were more 
variable, but did not exhibit a pattern of significant decline. In FY 
2001, rural teaching hospitals had a positive margin of 3.2 percent; in 
FY 2002, 8.2 percent; in FY 2003, 4.7 percent; in FY 2004, 5.7 percent; 
and in FY 2005, 4.0 percent. We are reprinting below the table found in 
the FY 2008 IPPS final rule with comment period showing our analysis 
(72 FR 47400).

                                                       Hospital Inpatient Medicare Capital Margins
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                 Aggregate    Aggregate
                                        1996     1997     1998     1999     2000     2001     2002     2003     2004     2005    1996-2005    1998-2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
U.S.................................     17.6     13.4      7.0      6.8      7.3      8.1      8.7      7.6      5.3      3.7          8.5          6.8
URBAN...............................     17.7     13.8      7.8      7.5      8.4      9.2     10.3      9.0      6.4      4.8          9.4          7.9
RURAL...............................     16.8     11.0      2.1      2.4      1.0      1.5     -1.7     -1.4     -2.3     -4.2          2.6         -0.4
No DSH Payments.....................     16.2     11.7      4.2      4.3      5.6      5.5      4.7      4.4     -1.3     -4.7          5.9          3.2
Has DSH Payments....................     18.5     14.4      8.6      8.1      8.2      9.0     10.0      8.5      7.0      5.9          9.5          8.1

[[Page 23679]]

 
$1-$249,999.........................     14.5     12.9     -0.4      3.1      1.6      4.1      3.2      1.4     -1.7     -4.8          3.2          1.9
$250,000-$999,999...................     15.5      9.0      2.3      1.6      2.8      2.7     -2.4     -1.5     -4.3     -7.3          1.5         -0.9
$1,000,000-$2,999,999...............     16.8     13.0      8.7      9.0      8.7      7.0     10.1      5.2      3.2      2.0          8.2          6.6
$3,000,000 or more..................     20.3     16.6     10.4      9.3      9.7     12.1     13.2     12.5     10.6      9.5         12.2         11.0
TEACHING............................     19.5     15.7      9.8      9.7     11.2     12.1     13.8     13.2     11.7     10.6         12.7         11.6
Urban...............................     19.7     15.9     10.2     10.0     11.4     12.5     14.0     13.6     11.9     10.9         13.0         11.9
Large Urban.........................     20.5     16.8     11.0     10.1     12.5     13.9     15.2     14.7     12.0     11.9         13.9         12.8
Rural...............................     13.9      8.5      1.0      2.9      5.8      3.2      8.2      4.7      5.7      4.0          5.7          4.5
NONTEACHING.........................     15.3     10.5      3.4      2.8      2.2      2.6      1.7      0.0     -3.2     -5.1          2.8          0.3
Urban...............................     14.4     10.1      3.8      3.0      3.0      3.1      3.6      0.9     -2.9     -4.9          3.1          0.9
Large Urban.........................     15.5     11.3      6.2      6.1      5.7      5.2      5.3      1.7     -0.9     -3.2          5.1          2.9
Rural...............................     17.3     11.4      2.3      2.4      0.2      1.2     -3.7     -2.6     -3.9     -6.0          2.0         -1.3
Census Division:
    New England (1).................     27.9     25.9     17.1     15.1     18.2     20.7     21.3     21.1     20.5     20.3         21.0         19.5
    Middle Atlantic (2).............     19.1     15.5     11.1     11.6     14.1     16.5     18.7     18.0     14.7     16.0         15.6         15.2
    South Atlantic (3)..............     18.1     13.9      5.9      4.0      6.0      5.0      6.6      6.9      5.8      2.8          7.4          5.4
    East North Central (4)..........     18.2     12.7      6.4      7.1      8.8      8.5      6.1      7.1      6.6      3.2          8.4          6.7
    East South Central (5)..........     14.9     11.1      3.3      4.1      3.8      3.8      3.8     -0.9     -3.4     -5.8          3.2          0.9
    West North Central (6)..........     14.3      7.0      0.1    --0.3     -1.5      2.0      1.9      3.4      1.6     -0.4          2.8          0.9
    West South Central (7)..........     13.2      8.3      3.3      2.6     -0.7      0.0      1.2     -2.0     -4.0     -6.5          1.2         -1.0
    Mountain (8)....................     17.2     14.7      8.5      7.7      7.2      6.4      2.9      3.3      0.8     -4.7          5.8          3.6
    Pacific (9).....................     20.4     16.1     12.3     11.3     11.9     13.3     14.7     12.1      9.8      8.8         13.0         11.7
    Code 99.........................     23.7     24.1     14.5     16.8     19.8     20.7     20.5     25.1     21.6     24.8         21.4         20.8
Bed Size:
    < 100 beds......................     17.7     13.0      4.6      3.5      2.7      2.5     -1.8     -1.2     -6.1     -9.6          2.0         -0.9
    100-249 beds....................     15.1     10.5      3.7      4.5      4.3      6.1      6.0      4.2      1.5      0.8          5.6          3.8
    250-499 beds....................     18.9     14.1      8.9      8.3     10.6     10.7     12.1     11.6     10.3      7.7         11.4         10.1
    500-999 beds....................     19.9     17.1     10.7     10.4     11.3     10.8     12.6     10.1      7.3      7.8         11.6         10.1
    >= 1000 beds....................      8.2     14.0      2.2     -1.3     -6.6     -3.6      6.5      8.1      6.5      2.1          3.5         2.3
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Notes:
Based on Medicare Cost Report hospital data updated as of the 1st quarter of 2007.
Medicare payments are from Worksheet E, Part A, Lines 9 and 10.
Expenses are from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8.
We apply the outlier trimming methodology developed with MedPAC.
Code 99 applies when census division information was not specified in the Medicare Cost Report hospital data.

    As we indicated in the FY 2008 IPPS final rule with comment period 
(72 FR 47401), the statutory history of the capital IPPS suggests that 
the system in the aggregate should not provide for continuous, large 
positive margins. As we also indicated, a possible reason for the 
relatively high margins of many capital IPPS hospitals may be that the 
payment adjustments provided under the system are too high, or perhaps 
even unnecessary. We agreed with MedPAC's recommendation and reexamined 
the appropriateness of the teaching adjustment. We concluded that the 
record of relatively high and persistent positive margins for teaching 
hospitals under the capital IPPS indicated that the teaching adjustment 
is unnecessary, and that it was therefore appropriate to exercise our 
discretion under the capital IPPS to eliminate this adjustment. At the 
same time, we believed that we should mitigate abrupt changes in 
payment policy and that we should provide time for hospitals to adjust 
to changes in the payments that they can expect under the program.
    Therefore, in the FY 2008 IPPS final rule with comment period, we 
adopted a policy to phase out the capital teaching adjustment over a 3-
year period beginning in FY 2008. Specifically, we maintained the 
adjustment for FY 2008, in order to give teaching hospitals an 
opportunity to plan and make adjustments to the change. During the 
second year of the transition, FY 2009, the formula for determining the 
amount of the teaching adjustment was revised so that adjustment 
amounts will be half of the amounts provided under the current formula. 
For FY 2010 and after, hospitals will no longer receive an adjustment 
for teaching activity under the capital IPPS.
b. Public Comments Received on Phase Out of Capital IPPS Teaching 
Adjustment Provisions Included in the FY 2008 Final Rule With Comment 
Period and Further Solicitation of Public Comments
    As indicated above, in the FY 2008 IPPS final rule with comment 
period, we formally adopted as final policy a phase out of the capital 
IPPS teaching adjustment over a 3-year period, maintaining the current 
adjustment for FY 2008, making a 50-percent reduction in FY 2009, and 
eliminating the adjustment for FY 2010 and subsequent years. However, 
because we concluded that this change to the structure of payments 
under the capital IPPS was significant, we provided the public with an 
opportunity for further comment on these provisions through a 90-day 
comment period after publication of the FY 2008 IPPS final rule with 
comment period (72 FR 47401). In addition, as we indicated in that 
final rule with comment period, to provide a more than adequate 
opportunity for hospitals, associations, and other interested parties 
to raise issues and concerns related to our policy, we are providing 
additional opportunity for public comment during this FY 2009 proposed 
rulemaking cycle for the IPPS.
    We received numerous timely pieces of correspondence that commented 
on the policy of phasing out the capital IPPS teaching adjustment as 
described in the FY 2008 IPPS final rule with comment period. These 
comments are available on our e-rulemaking Web site, at http://www.cms.hhs.gov/eRulemaking/ECCMSR/list.asp. We will also accept public 
comments on this policy during the comment period for this proposed 
rule. We will respond to

[[Page 23680]]

both sets of public comments when we issue the FY 2009 IPPS final rule, 
which is scheduled for publication in August 2008.

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

A. Proposed Payments to Excluded Hospitals and Hospital Units

    Historically, hospitals and hospital units excluded from the 
prospective payment system received payment for inpatient hospital 
services they furnished on the basis of reasonable costs, subject to a 
rate-of-increase ceiling. An annual per discharge limit (the target 
amount as defined in Sec.  413.40(a)) was set for each hospital or 
hospital unit based on the hospital's own cost experience in its base 
year. The target amount was multiplied by the Medicare discharges and 
applied as an aggregate upper limit (the ceiling as defined in Sec.  
413.40(a)) on total inpatient operating costs for a hospital's cost 
reporting period. Prior to October 1, 1997, these payment provisions 
applied consistently to all categories of excluded providers, which 
include rehabilitation hospitals and units (now referred to as IRFs), 
psychiatric hospitals and units (now referred to as IPFs), LTCHs, 
children's hospitals, and cancer hospitals.
    Payment for children's hospitals and cancer hospitals that are 
excluded from the IPPS continues to be subject to the rate-of-increase 
ceiling based on the hospital's own historical cost experience. (We 
note that, in accordance with Sec.  403.752(a) of the regulations, 
RNHCIs are also subject to the rate-of-increase limits established 
under Sec.  413.40 of the regulations.)
    In this FY 2009 IPPS proposed rule, we are proposing that the 
percentage increase in the rate-of-increase limits for cancer and 
children's hospitals and RNHCIs would be the proposed percentage 
increase in the FY 2009 IPPS operating market basket, which is 
estimated to be 3.0 percent. Consistent with our historical approach, 
we calculated the proposed IPPS operating market basket for FY 2009 
using the most recent data available. However, if more recent data are 
available for the final rule, we will use them to calculate the IPPS 
operating market basket. For cancer and children's hospitals and 
RNHCIs, the proposed FY 2009 rate-of-increase percentage that is 
applied to FY 2008 target amounts in order to calculate FY 2009 target 
amounts is 3.0 percent, based on Global Insight, Inc.'s 2008 first 
quarter forecast of the IPPS operating market basket increase, in 
accordance with the applicable regulations in 42 CFR 413.40.
    IRFs, IPFs, and LTCHs were paid previously under the reasonable 
cost methodology. However, the statute was amended to provide for the 
implementation of prospective payment systems for IRFs, IPFs, and 
LTCHs. In general, the prospective payment systems for IRFs, IPFs, and 
LTCHs 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 (certain providers do not receive a 
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.
    For cost reporting periods beginning on or after October 1, 2002, 
all IRFs are paid 100 percent of the adjusted Federal rate under the 
IRF PPS. Therefore, for cost reporting periods beginning on or after 
October 1, 2002, no portion of an IRF PPS payment is subject to 42 CFR 
Part 413. Similarly, for cost reporting periods beginning on or after 
October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal 
prospective payment rate under the LTCH PPS. Therefore, for cost 
reporting periods beginning on or after October 1, 2006, no portion of 
the LTCH PPS payment is subject to 42 CFR Part 413. (We note that, to 
the extent a portion of a LTCH's PPS payment was subject to reasonable 
cost principles, the Secretary utilized his broad authority under 
section 123 of the BBRA, as amended by section 307 of the BIPA, to make 
such portion subject to 42 CFR Part 413 and various provisions in 
section 1886(b) of the Act.) Likewise, for cost reporting periods 
beginning on or after January 1, 2008, all IPFs are paid 100 percent of 
the Federal per diem amount under the IPF PPS. Therefore, for cost 
reporting periods beginning on or after January 1, 2008, no portion of 
an IPF PPS payment is subject to 42 CFR Part 413.

B. IRF PPS

    Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 
105-33, provided for a phase-in of a case-mix adjusted PPS for 
inpatient hospital services furnished by IRFs for cost reporting 
periods beginning on or after October 1, 2000, and before October 1, 
2002, with payments based entirely on the adjusted Federal prospective 
payment for cost reporting periods beginning on or after October 1, 
2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 
106-113 to require the Secretary to use a discharge as the payment unit 
for services furnished under the PPS for inpatient rehabilitation 
hospitals and inpatient rehabilitation units of hospitals (referred to 
as IRFs), and to establish classes of patient discharges by functional-
related groups. Section 305 of Pub. L. 106-554 further amended section 
1886(j) of the Act to allow IRFs, subject to the blended methodology, 
to elect to be paid the full Federal prospective payment rather than 
the transitional period payments specified in the Act.
    On August 7, 2001, we issued a final rule in the Federal Register 
(66 FR 41316) establishing the PPS for IRFs, effective for cost 
reporting periods beginning on or after January 1, 2002. There was a 
transition period for cost reporting periods beginning on or after 
January 1, 2002, and ending before October 1, 2002. For cost reporting 
periods beginning on or after October 1, 2002, payments are based 
entirely on the adjusted Federal prospective payment rate determined 
under the IRF PPS.

C. LTCH PPS

    On August 30, 2002, we issued a final rule in the Federal Register 
(67 FR 55954) establishing the PPS for LTCHs, effective for cost 
reporting periods beginning on or after October 1, 2002. Except for a 
LTCH that made an election under Sec.  412.533(c) or a LTCH that is 
defined as new under Sec.  412.23(e)(4), there was a transition period 
under Sec.  412.533(a) for LTCHs. For cost reporting periods beginning 
on or after October 1, 2006, all LTCHs are paid 100 percent of the 
adjusted Federal prospective payment rate.

D. IPF PPS

    In accordance with section 124 of Pub. L. 106-113 and section 
405(g)(2) of Pub. L. 108-173, we established a PPS for inpatient 
hospital services furnished in IPFs. On November 15, 2004, we issued in 
the Federal Register a final rule (69 FR 66922) that established the 
IPF PPS, effective for IPF cost reporting periods beginning on or after 
January 1, 2005. Under the requirements of that final rule, we computed 
a Federal per diem base rate to be paid to all IPFs for inpatient 
psychiatric services based on the sum of the average routine operating, 
ancillary, and capital costs for each patient day of psychiatric care 
in an IPF, adjusted for budget neutrality. The Federal per diem base 
rate is adjusted to reflect certain patient characteristics, including 
age, specified DRGs, selected high-cost comorbidities, days of the 
stay, and certain facility characteristics, including a wage index

[[Page 23681]]

adjustment, rural location, indirect teaching costs, the presence of a 
full-service emergency department, and COLAs for IPFs located in Alaska 
and Hawaii.
    We established a 3-year transition period during which IPFs whose 
cost reporting periods began on or after January 1, 2005, and before 
January 1, 2008, would be paid a PPS payment, a portion of which was 
based on reasonable cost principles and a portion of which was the 
Federal per diem payment amount. For cost reporting periods beginning 
on or after January 1, 2008, all IPFs are paid 100 percent of the 
Federal per diem payment amount.

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the 
LTCH PPS

    In general, we use a LTCH's overall CCR, which is computed based on 
either the most recently settled cost report or the most recent 
tentatively settled cost report, whichever is from the latest cost 
reporting period, in accordance with Sec.  412.525(a)(4)(iv)(B) and 
Sec.  412.529(c)(4)(iv)(B) for high cost outliers and short-stay 
outliers, respectively. (We note that, in some instances, we use an 
alternative CCR, such as the statewide average CCR in accordance with 
the regulations at Sec.  412.525(a)(4)(iv)(C) and Sec.  
412.529(c)(4)(iv)(C), or a CCR that is specified by CMS or that is 
requested by the hospital under the provisions of the regulations at 
Sec.  412.525(a)(4)(iv)(A) and Sec.  412.529(c)(4)(iv)(A).) 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 Chapter 3, section 
150.24, of the Medicare Claims Processing Manual (CMS Pub. 100-4)) as 
compared to total charges. Specifically, a LTCH's CCR is calculated by 
dividing a LTCH's total Medicare costs (that is, the sum of its 
operating and capital inpatient routine and ancillary costs) by its 
total Medicare charges (that is, the sum of its operating and capital 
inpatient routine and ancillary charges).
    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, these CCRs should not be used to 
identify and make payments for outlier cases. Such data are clearly 
errors and should not be relied upon. Thus, under our established 
policy, 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.
    In the FY 2008 IPPS final rule with comment period, in accordance 
with Sec.  412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec.  
412.529(c)(4)(iv)(C)(2) for short-stay outliers, using our established 
methodology for determining the LTCH total CCR ceiling, based on IPPS 
total CCR data from the March 2007 update to the Provider-Specific File 
(PSF), we established a total CCR ceiling of 1.284 under the LTCH PPS 
effective October 1, 2007, through September 30, 2008. (For further 
detail on our methodology for annually determining the LTCH total CCR 
ceiling, we refer readers to the FY 2007 IPPS final rule (71 FR 48117 
through 48121) and the FY 2008 IPPS final rule with comment period (72 
FR 47403 through 47404).)
    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 high-cost outlier policy at Sec.  412.525(a)(4)(iv)(C) and the 
short-stay outlier policy at Sec.  412.529(c)(4)(iv)(C), the fiscal 
intermediary (or MAC) 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) A new LTCH 
that has not yet submitted its first Medicare cost report (for this 
purpose, a new LTCH is defined as an entity that has not accepted 
assignment of an existing hospital's provider agreement in accordance 
with Sec.  489.18); (2) a LTCH whose CCR is in excess of the LTCH CCR 
ceiling (as discussed above); and (3) any other LTCH for whom data with 
which to calculate a CCR are not available (for example, missing or 
faulty data). (Other sources of data that the fiscal intermediary (or 
MAC) may consider in determining a LTCH's CCR include data from a 
different cost reporting period for the LTCH, data from the cost 
reporting period preceding the period in which the hospital began to be 
paid as a LTCH (that is, the period of at least 6 months that it was 
paid as a short-term acute care hospital), or data from other 
comparable LTCHs, such as LTCHs in the same chain or in the same 
region.)
    In this proposed rule, in accordance with Sec.  
412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec.  
412.529(c)(4)(iv)(C)(2) for short-stay outliers, using our established 
methodology for determining the LTCH total CCR ceiling (described 
above), based on IPPS total CCR data from the December 2007 update to 
the PSF), we are proposing a total CCR ceiling of 1.262 under the LTCH 
PPS, effective for discharges occurring on or after October 1, 2008, 
and before October 1, 2009. If more recent data become available before 
publication of the final rule, we will use such data to determine the 
final total CCR ceiling under the LTCH PPS for FY 2009.
    In this FY 2009 IPPS proposed rule, in accordance with Sec.  
412.525(a)(4)(iv)(C) for high-cost outliers and Sec.  
412.529(c)(4)(iv)(C) for short-stay outliers, using our established 
methodology for determining the LTCH statewide average CCRs (described 
above), based on the most recent complete IPPS total CCR data from the 
December 2007 update of the PSF, we are proposing LTCH PPS statewide 
average total CCRs for urban and rural hospitals that would be 
effective for discharges occurring on or after October 1, 2008, and 
before October 1, 2009, presented in Table 8C of the Addendum to this 
proposed rule. If more recent data become available before publication 
of the final rule, we will use such data to determine the final 
statewide average total CCRs for urban and rural hospitals under the 
LTCH PPS for FY 2009 using our established methodology described above.
    We note that, for this proposed rule, as we established when we 
revised our methodology for determining the applicable LTCH statewide 
average CCRs in the FY 2007 IPPS final rule (71 FR 48119 through 
48121), and as is the case under the IPPS, all areas in the District of 
Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as 
urban, and, therefore, there are no proposed rural statewide average 
total CCRs listed for those jurisdictions in Table 8C of the Addendum 
to this proposed rule. In addition, as we established when we revised 
our methodology for determining the applicable LTCH statewide average 
CCRs in that same final rule, and as is the case under the IPPS, 
although Massachusetts has areas that are designated as rural, there 
were no short-term acute care IPPS hospitals or LTCHs located in those 
areas as of December 2007. Therefore, for this proposed rule, there is 
no proposed rural statewide average total CCR listed for rural 
Massachusetts in Table 8C of the

[[Page 23682]]

Addendum of this proposed rule. As we also established when we revised 
our methodology for determining the applicable LTCH statewide average 
CCRs in the FY 2007 IPPS final rule (71 FR 48120 through 48121), in 
determining the urban and rural statewide average total CCRs for 
Maryland LTCHs paid under the LTCH PPS, we 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 accurate (as discussed in greater detail in that 
same final rule (71 FR 48120)).

F. Proposed Change to the Regulations Governing Hospitals-Within-
Hospitals

    On September 1, 1994, we published hospital-within-hospital (HwH) 
regulations for LTCHs to address inappropriate Medicare payments to 
entities that were effectively units of other hospitals (59 FR 45330). 
There was concern that the HwH model was being used by some acute care 
hospitals paid under the IPPS as a way of inappropriately receiving 
higher payments for a subset of their cases. Moreover, IPPS-exclusion 
of long-term care ``units'' was and remains inconsistent with the 
statutory scheme.
    Therefore, we established the HwH regulations at 42 CFR 412.23 
(currently at Sec.  412.22) for a LTCH HwH that is co-located with 
another hospital. A co-located hospital is a hospital that occupies 
space in the same building or on the same campus as another hospital. 
The regulations at Sec.  412.23(e) required that, to be excluded from 
the IPPS, long-term care HwHs must have a separate governing body, 
chief medical officer, medical staff, and chief executive officer from 
that of the co-located hospital. In addition, the HwH must meet either 
of the following two criteria: The HwH must perform certain specified 
basic hospital functions on its own and not receive them from the host 
hospital or a third entity that controls both hospitals; or the HwH 
must receive at least 75 percent of its inpatients from sources other 
than the co-located hospital. A third option was added to the 
regulations on September 1, 1995 (60 FR 45778) that allowed HwHs to 
demonstrate their separateness by showing that the cost of the services 
that the hospital obtains under contracts or other agreements with the 
co-located hospital or a third entity that controls both hospitals is 
no more than 15 percent. In 1997, we extended application of the HwH 
rules at Sec.  412.22 to all classes of IPPS excluded hospitals. 
Therefore, effective for cost reporting periods beginning on or after 
October 1, 1997, psychiatric, rehabilitation, cancer, and children's 
hospitals that are co-located with another hospital are also required 
to meet the ``separateness'' criteria at Sec.  412.22(e).
    In addition, a ``grandfathering'' provision was added to the 
regulations at Sec.  412.22(f), as provided for under section 4417 of 
the Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33). This provision 
of the regulations allowed a LTCH that was excluded from the IPPS on or 
before September 30, 1995, and at that time occupied space in a 
building also used by another hospital, or in one or more buildings 
located on the same campus as buildings used by another hospital, to 
retain its IPPS-excluded status even if the HwH criteria at Sec.  
412.22(e) could not be met, as long as the hospital continued to 
operate under the same terms and conditions as were in effect on 
September 30, 1995. Consistent with the grandfathering provision under 
the BBA, which only applied to LTCHs, we extended the application of 
the grandfathering rule to the other classes of IPPS-excluded hospitals 
that are HwHs but did not meet the criteria at Sec.  412.22(e). (We 
subsequently expanded this provision to allow for a grandfathered 
hospital to make specified changes during particular timeframes.)
    Despite our efforts to allow those HwHs for whom the IPPS-exclusion 
status is appropriate to meet the HwH criteria, it appears that there 
may be a gap in our regulations. There remain certain HwHs under 
current rules that may be unnecessarily restricted from expanding their 
bed size. These HwHs are State hospitals that are co-located with 
another State hospital and that are grandfathered under Sec.  
412.22(f). Where a State law defines the structure and authority of the 
State's agencies and institutions, and the State hospital is co-located 
with another hospital that is under State governance, each hospital may 
have control over the day-to-day operations of its respective facility 
and have separate management, patient intake, and billing systems and 
medical staff, as well as a governing board. However, State law may 
require that the legal accountability for the budgets and activities of 
entities operating within a State-run institution rests with the State. 
Therefore, the co-located State hospitals may also be governed by a 
common governing body. Because of State law requirements, these HwHs 
are, therefore, precluded from meeting the HwH criteria at Sec.  
412.22(e)(1)(i) that requires the governing body of a co-located 
hospital to be separate from the governing body of the hospital with 
which it shares space. The excluded hospital's governing body cannot be 
under the control of the hospital occupying space in the same building 
or on the same campus, or of any third entity that controls both 
hospitals. Currently, there are State HwHs in these types of 
arrangements that have been able to retain their IPPS-excluded status 
solely because of the grandfathering provision in Sec.  412.22(f). 
These HwHs were IPPS-excluded even before the HwH criteria were 
implemented and only remain excluded HwHs under Sec.  412.22(f) as long 
as they continue to meet the requirements specified under Sec.  
412.22(f)(1), (f)(2), and (f)(3). Because they are grandfathered, these 
HwHs cannot increase their bed size without losing their IPPS-excluded 
status under the grandfathering provisions (Sec.  412.22(f)). 
Furthermore, if a grandfathered State-run HwH increased its bed size, 
it would be unable to qualify as an IPPS-excluded HwH under Sec.  
412.22(e) because it cannot meet the HwH criteria at Sec.  
412.22(e)(1)(i) as a result of State law requirements regarding its 
organizational structure and governance. These HwHs are precluded from 
the flexibility to expand their bed size, which is available to other 
HwHs whose organizational structure is not bound by State law.
    As discussed in the previous paragraph, the organizational 
arrangements were in place for these State-operated HwHs before the HwH 
regulations were adopted. To the extent the arrangements are required 
by State law, we believe they do not reflect attempts by entities to 
establish a nominal hospital and, in turn, seek inappropriate 
exclusions. We also believe it may be unnecessary to prevent hospitals 
that were created before the HwH requirements, and that because of 
State statutory requirements cannot meet the subsequently issued 
separate governing body requirements, from being excluded from the 
IPPS. Accordingly, we are proposing to add a provision to the 
regulations that would apply only to State hospitals that were in 
existence when the HwH regulations were established. This proposed 
provision would not apply to other State hospitals that chose to open 
as a HwH subsequent to the establishment of the HwH regulations in FY 
1994, under an organizational structure the same as or similar to the 
one described in this section. These hospitals knew, in advance of 
becoming a HwH, the requirements that had to be met in order to be an 
IPPS-excluded HwH, unlike

[[Page 23683]]

those hospitals that existed before the HwH regulations were 
established.
    Accordingly, we are proposing to add a new paragraph (e)(1)(vi) to 
Sec.  412.22 to provide that if a hospital cannot meet the criteria in 
Sec.  412.22(e)(1)(i) solely because it is a State hospital occupying 
space with another State hospital, the HwH can nevertheless qualify for 
an exclusion from the IPPS if that hospital meets the other applicable 
criteria in Sec.  412.22(e) and--
    <bullet> Both State hospitals share the same building or same 
campus and have been continuously owned and operated by the State since 
October 1, 1995;
    <bullet> Is required by State law to be subject to the governing 
authority of the State hospital with which it shares space or the 
governing authority of a third entity that controls both hospitals; and
    <bullet> Was excluded from the inpatient prospective payment system 
before October 1, 1995, and continues to be excluded from the IPPS 
through September 30, 2008.
    We believe the proposed criteria capture the segment of 
grandfathered, State-operated HwHs that are unable to increase their 
bed size because of State law regarding governance. We emphasize that 
we intend to allow an exception to the criteria in Sec.  412.22 
(e)(1)(i) only if the hospital that meets the proposed criteria above 
cannot meet the separate governing body requirement because of State 
law. We do not intend to provide similar treatment for hospitals that 
are not subject to State statutory requirements regarding governance 
but have chosen not to organize in a manner that would allow them to be 
an IPPS-excluded hospital that meets the HwH criteria at Sec.  
412.22(e)(1)(i).

VII. Disclosure Required of Certain Hospitals and Critical Access 
Hospitals Regarding Physician Ownership (Sec.  489.2(u) and (v))

    Section 1866 of the Act states that any provider of services 
(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 1861(e) of the Act defines the term ``hospital.'' Section 
1861(e)(9) of the Act authorizes the Secretary to establish 
requirements for hospitals as he finds necessary in the interest of 
patient health and safety. Section 1820(e)(3) of the Act authorizes the 
Secretary to establish criteria necessary for an institution to be 
certified as a ``critical access hospital.''
    In the FY 2008 IPPS final rule with comment period, we revised our 
regulations governing Medicare provider agreements, specifically Sec.  
489.20(u), to require a hospital to disclose to all patients whether it 
is physician-owned and, if so, the names of its physician owners (72 FR 
47385 through 47387). In addition, we added a definition of physician-
owned hospital at Sec.  489.3. The disclosure requirement in current 
Sec.  489.20(u) is applicable only to those hospitals with physician 
ownership. (For purposes of this proposal, the term ``hospital'' also 
includes ``critical access hospital'' (CAH).) We neglected to include 
those hospitals in which no physician held an ownership or investment 
interest, but in which an immediate family member of a physician held 
an ownership or investment interest. However, it was always our intent 
to have consistency between the disclosure requirements and the 
physician self-referral statute and regulations. The physician self-
referral statute and regulations, which recognize the potential for 
program and patient abuse where a financial relationship exists, are 
applicable to both a physician and the immediate family member of the 
physician. We believe that it is necessary to revise our definition of 
physician-owned hospital because a physician's potential conflict of 
interest occurs not only in those instances where he or she has a 
financial relationship in the form of an ownership or investment 
interest, but also where his or her immediate family member has a 
similar interest, and patients should be informed of this as part of 
making an informed decision concerning treatment. Therefore, we are 
proposing to revise the language in Sec.  489.3 to define a 
``physician-owned hospital'' as a participating hospital in which a 
physician, or an immediate family member of a physician (as defined at 
Sec.  411.351), has an ownership or investment interest in the 
hospital.
    To effectuate the changes made in the FY 2008 IPPS final rule with 
comment period, we relied on our authority in sections 1861(e)(9), 
1820(e)(3) and 1866 of the Act, and on our general rulemaking authority 
in sections 1871 and 1102 of the Act. Following publication of the FY 
2008 IPPS final rule with comment period, we became aware that some 
physician-owned hospitals have no physician owners who refer patients 
to the hospital (for example, in the case of a hospital whose 
physician-owners have retired from the practice of medicine). We 
believe that requiring a hospital with no referring physician owners to 
disclose to all patients that it is physician-owned and to provide the 
patients with a list of the (nonreferring) physician owners would be an 
unnecessary burden on the hospital and of no value in assisting a 
patient in making an informed decision as to where to seek treatment. 
Similarly, we do not believe that it is useful to require a hospital to 
make such disclosures when no referring physician has an immediate 
family member who has an ownership or investment interest in the 
hospital. Accordingly, we are proposing to include in Sec.  489.20(v) 
new language to provide for an exception to the disclosure requirements 
for a physician-owned hospital (as defined at Sec.  489.3) that does 
not have any physician owners who refer patients to the hospital (and 
that has no referring physicians (as defined at Sec.  411.351) who have 
an immediate family member with an ownership or investment interest in 
the hospital), provided that the hospital attests, in writing, to that 
effect and maintains such attestation in its files for review by State 
and Federal surveyors or other government officials. (We note that, as 
explained below, we are proposing to redesignate the existing 
paragraphs (v) and (w) of Sec.  489.20 as paragraphs (w) and (x), 
respectively.)
    We are proposing to revise Sec.  489.20(u) to specify that a 
hospital must furnish to patients the list of owners and investors who 
are physicians (or immediate family members of physicians) at the time 
the list is requested by or on behalf of the patient. In response to 
the FY 2008 IPPS proposed rule, we received public comments that noted 
that our proposal did not establish a timeframe within which the 
hospital must furnish to patients the required list of the hospital's 
physician owners or investors. These commenters suggested that we 
require that the list be provided to the patient at the time the 
request for the list is made by or on behalf of the patient. We stated 
in the preamble of the FY 2008 IPPS final rule with comment period that 
we would not revise the provision to include any specific timeframe for 
making the list available because we believed that it was important to 
allow hospitals some degree of flexibility regarding the manner and 
form in which it notified patients of the identity of its physician 
owners and investors (72 FR 47386). However, we also stated later in 
the preamble that we were revising proposed Sec.  489.20(u) to specify 
that the

[[Page 23684]]

hospital should furnish a list of physician owners to a patient at the 
beginning of his or her hospital stay or outpatient visit, but the 
regulation text did not reflect this change (72 FR 47387).
    We have reconsidered the issue and are proposing in Sec.  
489.20(u)(1) that the list of the hospital's owners or investors who 
are physicians or immediate family members of physicians (as defined at 
Sec.  411.351) must be furnished at the time the patient or someone on 
the patient's behalf requests it. We are proposing this change for two 
reasons. First, in the FY 2008 IPPS final rule with comment period, in 
response to public comments received on the FY 2008 IPPS proposed rule, 
we stated that we believed that the physician ownership disclosure 
proposal would permit an individual to make more informed decisions 
regarding his or her treatment and to evaluate whether the existence of 
a financial relationship, in the form of an ownership interest, 
suggests a conflict of interest that is not in his or her best 
interest. However, we maintain that the provision of a generic notice 
that the hospital is owned by physicians or immediate family members of 
physicians is insufficient to permit an individual to make a truly 
informed decision. We believe that it is critical that the patient 
receives the list of names of the relevant owners or investors at the 
time the request is made by or on behalf of the patient so that the 
patient may make a determination as to whether his or her admitting or 
referring physician has a potential conflict of interest. Second, 
furnishing the list at the time the request is made by the patient or 
on behalf of the patient is crucial to affording the patient an 
opportunity to make an informed decision before treatment is furnished 
at the hospital. We are not specifying a form to be used for the list; 
rather, we are addressing the timeframe for the hospital to furnish the 
list to the patient.
    In addition, we are proposing to add new Sec.  489.20(u)(2) to 
require a hospital to require all physicians who are members of the 
hospital's medical staff to agree, as a condition of continued medical 
staff membership or admitting privileges, to disclose in writing to all 
patients who they refer to the hospital any ownership or investment 
interest in the hospital held by themselves or by an immediate family 
member. We would require that physicians agree to make such disclosures 
at the time they refer patients to the hospital. We proposed a similar 
requirement in the FY 2008 IPPS proposed rule, but decided not to adopt 
it as final. In response to a public comment, we stated that we would 
not finalize the proposal because we believed that it would not provide 
any additional protections for patients that would not already be 
offered by the requirement for hospitals to disclose their physician 
ownership to patients. We have revisited this issue.
    In the FY 2008 IPPS final rule with comment period, we stated that 
the scheduling of most hospital inpatient or outpatient services is 
performed by a staff member in the physician's office, often weeks, or 
even months, in advance of the furnishing of the service. As discussed 
previously, we believe that early notification of physician ownership 
or investment in the hospital is beneficial to the patient's 
decisionmaking concerning his or her treatment. Currently, under Sec.  
489.20(u), scheduling of inpatient stays and outpatient visits at 
physician-owned hospitals would be permitted without notification to 
the patient of the referring physician's ownership or investment 
interest in the hospital. If a patient were notified of the physician 
ownership or investment at the time of the referral, he or she would 
have an opportunity to discuss the physician's ownership or investment 
in the hospital and make a more informed decision. We believe that it 
would be in the best interests of the patient and the physician owner 
or investor to disclose the physician's (or his or her immediate family 
member's) ownership in the hospital at the time the physician is 
referring the patient to the hospital. We are revising Sec.  489.20(u) 
accordingly.
    We note that notification of physician ownership or investment in a 
hospital may not be viewed negatively by all interested parties. For 
instance, some physician owners or investors in hospitals believe that 
disclosing their ownership or investment interests in the hospital to 
their patients at the time of the referral is extremely beneficial for 
both the physician and the patient. They communicate to patients their 
belief that their ownership in the hospital permits them to have total 
control over scheduling, staffing, and quality mechanisms. Section 5006 
of the Medicare, Prescription Drug, Improvement, and Modernization Act 
of 2003 (MMA) required, among other things, that HHS study the quality 
of care and patient satisfaction with specialty hospitals. HHS 
concluded that specialty hospital patients have very favorable 
perceptions of the clinical quality of care they receive, and that 
overall patient satisfaction is very high.
    We are also proposing to revise Sec.  489.53 to permit CMS to 
terminate the Medicare provider agreement if the hospital fails to 
comply with the provisions of proposed Sec.  489.20(u)(1) or (u)(2). We 
believe that these revisions would be necessary to enforce the proposed 
disclosure requirements set forth in Sec.  489.20.
    We are not inclined to make a corresponding change to the medical 
staff bylaws condition of participation (CoP) in Sec.  482.22(c). We 
believe that the proposed disclosure requirement is appropriate for 
inclusion in the regulations governing Medicare provider agreements for 
the following reasons. As stated in the FY 2008 IPPS final rule with 
comment period, each participating provider must comply with all 
applicable provisions of the provider agreement regulations found in 42 
CFR Part 489, and CMS may terminate a provider agreement if the 
provider is not in substantial compliance with these requirements (72 
FR 47391). A provider's compliance with applicable provider agreement 
regulations is reviewed through a variety of means, including onsite 
investigation of complaints. Thus, compliance with this proposed 
requirement could be easily monitored. We also note that any revisions 
to the medical staff bylaws concerning the requirement that the 
disclosure be given at the time of the referral would be difficult to 
enforce as a CoP because the required notification generally would be 
given outside of the hospital's or CAH's premises. However, we are 
considering whether these proposed changes would be better effectuated 
through changes to our regulations governing the CoPs applicable to 
hospitals and CAHs, which appear at 42 CFR Part 482 and 42 CFR Part 
485, Subpart F, respectively, and, therefore, we are soliciting public 
comments on this issue.
    In the FY 2008 IPPS final rule with comment period, we added a new 
provision at Sec.  489.20(v) to require that hospitals and CAHs: (1) 
Furnish all patients written notice at the beginning of their inpatient 
hospital stay or outpatient service if a doctor of medicine or a doctor 
of osteopathy is not present in the hospital 24 hours per day, 7 days 
per week; and (2) describe how the hospital or CAH will meet the 
medical needs of any patient who develops an emergency medical 
condition at a time when no physician is present in the hospital (72 FR 
47387). (We are proposing to redesignate existing Sec.  489.20(v) and 
(w) as Sec.  489.20(w) and (x), respectively, to accommodate the 
addition of the proposed exception to the requirements in Sec.  
489.20(v) discussed above.) We stated that it is important to ensure 
that consumers are provided accurate information on the availability of

[[Page 23685]]

physician services at the point when they are about to become patients 
of a hospital or CAH. In order to be fully informed, consumers should 
be made aware of whether a hospital or CAH has a physician on-site 24 
hours per day, 7 days per week, and should be made aware of the 
hospital's or CAH's processes for addressing medical emergencies that 
may occur when a physician is not on site. Given the patient safety 
measures addressed by these provisions, we are proposing to set forth 
penalties for failure to comply with these requirements. Specifically, 
we are proposing to revise Sec.  489.53 to permit CMS to terminate the 
provider agreement of any hospital or CAH that fails to comply with the 
requirements set forth in proposed redesignated Sec.  489.20(w).
    We are also soliciting public comments on whether hospitals and 
CAHs should educate patients about the availability of information 
regarding physician ownership under the proposed disclosure 
requirements and, if so, by what means (for example, by a posting in 
the admissions office or in a patient brochure).

VIII. Physician Self-Referral Provisions (Sec. Sec.  411.351, 411.352 
and 411.354)

A. Stand in the Shoes Provisions

1. Physician ``Stand in the Shoes'' Provisions
a. Background
    Section 1877 of the Act, also known as the physician self-referral 
law: (1) Prohibits a physician from making referrals for certain 
designated health services (``DHS'') payable by Medicare to an entity 
with which he or she (or an immediate family member) has a financial 
relationship (ownership, investment or compensation), unless an 
exception applies; and (2) prohibits the entity from filing claims with 
Medicare (or billing another individual, entity, or third party payor) 
for those referred services. The statute establishes a number of 
specific exceptions and grants the Secretary the authority to create 
regulatory exceptions for financial relationships that pose no risk of 
program or patient abuse. Determining whether DHS entities and 
referring physicians (or their immediate family members) have direct or 
indirect financial relationships is a key step in applying the statute.
    In the final rule entitled ``Medicare Program; Physicians' 
Referrals to Health Care Entities With Which They Have Financial 
Relationships (Phase III),'' published in the Federal Register on 
September 5, 2007 (72 FR 51012) (``Phase III''), we interpreted certain 
provisions of section 1877 of the Act, including provisions relating to 
direct and indirect compensation arrangements. Specifically, the Phase 
III final rule included provisions under which referring physicians are 
treated as standing in the shoes of their physician organizations for 
purposes of applying the rules that describe direct and indirect 
compensation arrangements in Sec.  411.354 (72 FR 51026 through 51030). 
A ``physician organization'' is defined at Sec.  411.351 as ``a 
physician (including a professional corporation of which the physician 
is the sole owner), a physician practice, or a group practice that 
complies with the requirements of Sec.  411.352.'' Therefore, when 
determining whether a direct or indirect compensation arrangement 
exists between a physician and an entity to which the physician refers 
Medicare patients for DHS, the referring physician stands in the shoes 
of: (1) Another physician who employs the referring physician; (2) his 
or her wholly-owned professional corporation (``PC''); (3) a physician 
practice (that is, a medical practice) that employs or contracts with 
the referring physician or in which the physician has an ownership 
interest; or (4) a group practice of which the referring physician is a 
member or independent contractor. The referring physician is considered 
to have the same compensation arrangements (with the same parties and 
on the same terms) as the physician organization in whose shoes the 
referring physician stands.
    Subsequent to the publication of Phase III, industry stakeholders, 
including academic medical centers (``AMCs''), integrated tax-exempt 
health care delivery systems, and their representatives, expressed 
concern about the application of the Phase III ``stand in the shoes'' 
provisions to compensation arrangements involving ``mission support 
payments'' and ``similar payments'' (referred to in this proposed rule 
generally as ``support payments''). The stakeholders believed that 
certain payments did not previously trigger application of the 
physician self-referral law but, after Phase III, need to satisfy the 
requirements of an exception. One example offered was a DHS entity 
component (such as a hospital) of an AMC that transfers funds to the 
faculty practice plan component of the AMC. If a referring physician 
stands in the shoes of his or her faculty practice plan, the 
compensation arrangement between the hospital providing the support 
payment and the faculty practice plan will be considered to be a direct 
compensation arrangement between the hospital and the physician and 
would need to satisfy the requirements of a direct compensation 
arrangement exception, if the physician is to continue referring 
Medicare patients to the component for DHS. According to the industry 
stakeholders, before Phase III, such arrangements would have been 
analyzed under the rules regarding indirect compensation arrangements 
and would, in their view, have been permitted. After Phase III, in 
their view, it is unlikely that the requirements of an available 
exception could be satisfied given the nature of support payments; that 
is, support payments usually are not tied to specific items or services 
provided by the faculty practice plan (or group practice within an 
integrated health care delivery system), but rather are intended to 
support the overall mission of the AMC or maintain operations in an 
integrated health care delivery system. For this reason, support 
payments likely do not satisfy the requirement, present in many 
exceptions, that the compensation be fair market value for items or 
services provided. Similarly, some stakeholders raised concerns about 
support payments made from faculty practice plans to AMC components. 
Although AMCs are free to use the exception for services provided by an 
AMC in Sec.  411.355(e) (which would protect support payments made 
among AMC components if all of the conditions of the exception are 
met), industry stakeholders explained that many AMCs do not do so, 
preferring instead to rely on other available exceptions and the rules 
regarding indirect compensation arrangements (especially prior to Phase 
III).
    To provide CMS sufficient time to study the ``stand in the shoes'' 
provisions as they relate to compensation arrangements involving 
support payments, seek additional public comment, and develop an 
approach for addressing this issue, on November 15, 2007, we issued a 
final rule entitled ``Medicare Program; Delay of the Date of 
Applicability for Certain Provisions of Physicians' Referrals to Health 
Care Entities With Which They Have Financial Relationships (Phase 
III)'' (72 FR 64164) that delayed the effective date of the provisions 
in Sec.  411.354(c)(1)(ii), Sec.  411.354(c)(2)(iv), and Sec.  
411.354(c)(3) for 12 months after the effective date of Phase III (that 
is, until December 4, 2008). That final rule was applicable to the 
following compensation arrangements between the following physician 
organizations and entities ONLY:
    <bullet> With respect to an AMC as described in Sec.  
411.355(e)(2),

[[Page 23686]]

compensation arrangements between a faculty practice plan and another 
component of the same AMC; and
    <bullet> With respect to an integrated section 501(c)(3) health 
care system, compensation arrangements between an affiliated DHS entity 
and an affiliated physician practice in the same integrated section 
501(c)(3) health care system.
    Following the publication of the November 15, 2007 final rule, 
other industry stakeholders asserted that, in addition to section 
501(c)(3) health care systems, most integrated health care delivery 
systems, including ones involving for-profit entities, make support 
payments. The stakeholders further asserted that, although under the 
``stand in the shoes'' provisions such payments must now satisfy a 
direct compensation arrangement exception, there is, in fact, no 
applicable exception. These stakeholders urged that any approach to 
addressing the impact of the Phase III ``stand in the shoes'' 
provisions on support payments and other monetary transfers within 
integrated health care delivery systems should have universal 
applicability that is not dependent on whether the system meets the 
definition of an AMC or has a particular status under the rules of the 
Internal Revenue Service.
b. Proposals
    Given the potential widespread impact of the ``stand in the shoes'' 
provisions, as well as the considerable industry interest in their 
application, we are revisiting the ``stand in the shoes'' policy and 
regulations issued in Phase III. We believe that a more refined 
approach to the ``stand in the shoes'' provisions would accomplish our 
goals of simplifying the analysis of many financial arrangements and 
reducing program abuse by bringing more financial relationships within 
the scope of the physician self-referral law (such as certain 
potentially abusive arrangements between DHS entities and physician 
organizations that may not have met the definition of an ``indirect 
compensation arrangement''). We note that we are not suggesting that 
support payments and other similar compensation arrangements are 
without risk of program or patient abuse, nor are we endorsing such 
payments and arrangements.
    We are proposing here two alternative ways to address the ``stand 
in the shoes'' issues described above, and are seeking industry input 
on each proposal, as well as on other possible approaches. The first is 
a multi-faceted approach to revising the Phase III ``stand in the 
shoes'' provisions. The second proposal would leave the Phase III 
``stand in the shoes'' provisions as promulgated and would, instead, 
create a new exception using our authority under section 1877(b)(4) of 
the Act for nonabusive arrangements that warrant protection not 
available under existing exceptions. We are also interested in public 
comments on other approaches and on whether changes to the existing 
``stand in the shoes'' provisions are needed at all.
    For the first proposal, we propose revising Sec.  411.354(c)(2)(iv) 
to provide that a physician would be deemed not to stand in the shoes 
of his or physician organization if the compensation arrangement 
between the physician organization and the physician satisfies the 
requirements of the exception in Sec.  411.357(c) (for bona fide 
employment relationships), the exception in Sec.  411.357(d) (for 
personal service arrangements), or the exception in Sec.  411.357(l) 
(for fair market value compensation). Currently, all physicians stand 
in the shoes of their physician organizations, regardless of the nature 
of the compensation they receive from the physician organization. Under 
our proposal, the first step in the analysis would be to look at the 
compensation a referring physician receives from his or her physician 
organization. A compensation arrangement between a physician 
organization and a physician that satisfies the requirements of Sec.  
411.357(c), (d), or (l) would be consistent with fair market value by 
design and not determined in a manner that takes into account (directly 
or indirectly) the volume or value of any referrals by the physician to 
the physician organization. Although such compensation could, in some 
circumstances, be determined in a manner that takes into account 
(directly or indirectly) the volume or value of the physician's 
referrals to the DHS entity (see 66 FR 869), we believe that the risk 
of program or patient abuse will be addressed sufficiently by analyzing 
such arrangements between DHS entities and referring physicians who do 
not stand in the shoes of their physician organizations using the rules 
regarding indirect compensation arrangements. Therefore, under this 
proposal, if the compensation arrangement between a physician 
organization and one of its referring physicians satisfies the 
requirements of one of the exceptions noted above, the referring 
physician would be deemed not to stand in the shoes of the physician 
organization for purposes of applying the definitions of, and 
provisions related to, direct and indirect compensation arrangements in 
Sec.  411.354(c). Arrangements between DHS entities and physician 
organizations whose physicians do not stand in their shoes may still 
create indirect compensation arrangements that would need to satisfy 
the requirements of the exception for indirect compensation 
arrangements in Sec.  411.357(p).
    Under this first proposed approach, physician owners and investors 
would continue to stand in the shoes of their physician organizations. 
However, we are concerned that considering all physician owners of, or 
physician investors in, a physician organization to stand in the shoes 
of the physician organization, as they currently do under the Phase III 
``stand in the shoes'' provisions, might be over-inclusive. For 
example, in a State that prohibits the corporate practice of medicine, 
a physician owner of a captive or ``friendly'' PC who has no right to 
the distribution of profits would stand in the shoes of his or her 
physician organization, even though his or her employment arrangement 
with the group satisfies the requirements of the exception for bona 
fide employment relationships in Sec.  411.357(c). We are considering 
whether these and similarly situated physician owners should have to 
stand in the shoes of their physician organizations when their 
ownership interest is nominal in nature and their compensation 
arrangement with the physician organization satisfies the requirements 
of one of the exceptions in Sec.  411.357(c), (d), or (l). We are 
soliciting public comments on this issue.
    As described above, a physician-employee or contractor whose 
compensation arrangement with a physician organization does not satisfy 
the requirements of Sec.  411.357(c), (d), or (l) would stand in the 
shoes of the physician organization. This is necessary to address our 
concern that an arrangement between a DHS entity and a physician 
organization that compensates its physicians in a manner that does not 
satisfy the requirements of an exception may be particularly prone to 
abuse. For example, where a physician-employee's compensation 
arrangement with his or her group practice exceeds fair market value 
for services provided to the group practice employer (and, thus, does 
not satisfy the requirements of the exception in Sec.  411.357(c)), and 
the physician-employee's DHS referrals to the group practice instead 
are protected under the exception for in-office ancillary services in 
Sec.  411.355(b), there is risk that the physician-employee's above-
fair-market-value compensation may reflect the volume or value of 
referrals to the DHS

[[Page 23687]]

entity. This could be the result of a support or other payment between 
the DHS entity and the group practice that is designed to channel 
compensation to the physician-employee for referrals to the DHS entity.
    We are also considering, and solicit comments on, an approach under 
which only owners of a physician organization would stand in the shoes 
of that physician organization (in which case, a physician would not 
stand in the shoes of a physician organization unless he or she holds 
an ownership or investment interest, even if the physician's 
compensation arrangement with that physician organization does not 
satisfy the requirements of Sec.  411.357(c), (d), or (l)). In 
conjunction with this approach, we are interested in receiving comments 
on whether and under what circumstances the ``stand in the shoes'' 
provisions should apply to a physician organization that has no 
physician owners.
    In this first approach, we also propose to revise Sec.  
411.354(c)(3)(ii) to provide that the provisions of Sec. Sec.  
411.354(c)(1)(ii) and (c)(2)(iv) do not apply when the requirements of 
Sec.  411.355(e) are satisfied. In other words, a physician would not 
stand in the shoes of his or her physician organization (for example, a 
faculty practice plan) when his or her referral for DHS is protected 
under the exception in Sec.  411.355(e) for services provided by an 
AMC. We note that, if all of the requirements of the exception in Sec.  
411.355(e) are not satisfied, a physician would stand in the shoes of 
his or her physician organization unless, as discussed above with 
respect to proposed revised Sec.  411.354(c)(2)(iv), the compensation 
from the physician organization to the physician satisfies the 
requirements of the exception for bona fide employment relationships, 
the exception for personal service arrangements, or the exception for 
fair market value compensation in Sec.  411.357(c), (d), and (l), 
respectively. We are proposing to include a specific revision to the 
regulation in Sec.  411.354(c)(2)(iv); however, we are seeking public 
comment as to whether this policy is better achieved by revising Sec.  
411.354(c)(3) to delete the reference to applying the exceptions in 
Sec.  411.355, and thereby providing that the ``stand in the shoes'' 
provisions do not apply where the prohibition on referrals is not 
applicable because all of the requirements of any of the exceptions in 
Sec.  411.355 are satisfied.
    In this first approach, we also propose to revise Sec.  
411.354(c)(3)(ii) to provide that the provisions of Sec.  
411.354(c)(1)(ii) and (c)(2)(iv) do not apply when compensation is 
provided by a component of an AMC to a physician organization 
affiliated with that AMC through a written contract to provide services 
required to satisfy the AMC's obligations under the Medicare graduate 
medical education (GME) rules where the contract is limited to only 
services necessary to fulfill the GME obligations as set forth in 42 
CFR, Part 413, Subpart F. We have in mind certain arrangements between 
a hospital component of an AMC and a community physician group to serve 
as a teaching site for the AMC's residents, as required by the GME 
rules. If adopted, this proposal would not mean that such arrangements 
necessarily are lawful, but rather that they would be analyzed by 
applying the rules regarding indirect compensation arrangements.
    Under this first proposal, if adopted, some referring physicians 
would no longer stand in the shoes of their physician organizations as 
they currently do under the Phase III ``stand in the shoes'' 
provisions. In such circumstances, the rules regarding direct and 
indirect compensation arrangements would still apply, and financial 
relationships would still need to be analyzed for compliance with the 
statute and regulations. We are concerned that, where physicians do not 
stand in the shoes of their physician organizations, some potentially 
abusive arrangements between DHS entities and physician organizations 
might be viewed incorrectly as falling outside the definition of an 
``indirect compensation arrangement'' at Sec.  411.354(c)(2) and, 
therefore, as not within the scope of the physician self-referral law. 
The definition of ``indirect compensation arrangement'' generally 
requires that three elements be present: (1) An unbroken chain of 
financial relationships between the DHS entity and the referring 
physician; (2) aggregate compensation to the referring physician (from 
the entity in the chain closest to the physician) that varies with or 
takes into account in any manner the volume or value of referrals to, 
or other business generated for, the DHS entity; and (3) knowledge by 
the DHS entity that the referring physician receives such compensation. 
(We refer readers to 66 FR 864 through 870, 69 FR 16057 through 16063, 
and 72 FR 51026 through 51031 for further explanation.) We believe that 
some parties may be construing these elements (particularly the second 
and the third) too narrowly. For example, we believe that aggregate 
compensation can vary with or take into account the volume or value of 
referrals to, or business generated for, DHS entities in a wide range 
of circumstances, including, without limitation, arrangements 
involving: variable, per-click, or percentage-based compensation; 
exclusive contracts; inflated fixed payments; or explicit or implicit 
tying of compensation to other referrals. To address this issue, we may 
provide additional guidance on the application of the three elements of 
the definition of ``indirect compensation arrangement'' in the FY 2009 
IPPS final rule. We are interested in public comments regarding ways in 
which we can ensure that the full range of potentially abusive 
arrangements between DHS entities and physician organizations are 
appropriately addressed in situations where physicians do not stand in 
the shoes of their physician organizations.
    As discussed above, we are proposing an alternative approach to 
addressing the Phase III ``stand in the shoes'' provisions. (However, 
we are proposing regulation text for the first proposal only.) Our 
alternative proposal is to make no revisions to the Phase III ``stand 
in the shoes'' provisions in Sec. Sec.  411.354(c)(1)(ii), (c)(2)(iv), 
and, (c)(3) and, to the extent necessary to protect nonabusive 
arrangements, promulgate a separate exception using our authority under 
section 1877(b)(4) of the Act to create exceptions for arrangements 
that do not pose a risk of program or patient abuse. The new exception 
would apply to specific types of nonabusive payments or arrangements 
that are not otherwise covered by existing exceptions (for example, 
certain support payments, as described above), subject to conditions 
necessary to protect against program and patient abuse, similar to 
those conditions incorporated into the existing exception for services 
provided by an AMC in Sec.  411.355(e). Specifically, we are 
considering establishing a new exception, using our authority under 
section 1877(b)(4) of the Act, for compensation arrangements between 
DHS entities and physician organizations and physicians for ``mission 
support'' payments (or similar compensation arrangements) and, if so, 
how we should define those payments (or similar compensation 
arrangements), and what criteria such an exception should include to 
protect against program or patient abuse. We are soliciting comments 
about this proposal, including whether an exception should be limited 
to ``mission support'' payments, whether other specific types of 
payments or compensation arrangements should be eligible for such an 
exception, the types of parties that should be permitted to use the

[[Page 23688]]

exception (for example, AMC components, physician practices), and the 
conditions that should apply to such an exception to ensure that a 
protected compensation arrangement poses no risk of program or patient 
abuse. We are concerned that some ``mission support'' payments or 
similar payments are subject to fraud and abuse. We are interested in 
public comments that identify with specificity the types of 
compensation agreements that should be permitted under an applicable 
exception.
    Under this approach, the proposed exception might address 
compensation arrangements between components of certain well-defined 
integrated delivery systems, perhaps with tightly-crafted conditions 
similar to those in the existing exception for services provided by an 
AMC in Sec.  411.355(e). For example, some industry stakeholders have 
recommended that we establish an exception for compensation 
arrangements between a DHS entity component of an integrated health 
care delivery system and a physician organization component of the same 
integrated health care delivery system. We are concerned that the term 
``integrated health care delivery system'' is loosely used in the 
industry to describe a wide variety of systems, with varying degrees of 
actual integration, and that it may prove infeasible to craft a 
sufficiently circumscribed definition. In many circumstances, payment 
arrangements between components of ``integrated health care delivery 
systems,'' as well as payments from ``integrated health care delivery 
systems'' to physicians affiliated with those systems are susceptible 
to fraud and abuse. However, we are soliciting public comments defining 
a fully integrated health care delivery system, what types of 
compensation arrangements should be protected (for example, support 
payments), and what conditions should be included in an exception that 
would ensure no risk of program or patient abuse. We note that any 
exception established using our authority under section 1877(b)(4) of 
the Act would include documentation requirements and a requirement that 
the arrangement not violate the anti-kickback statute or any Federal or 
State law or regulation governing billing or claims submission, 
consistent with the existing exceptions created under this authority.
    According to some industry stakeholders, an ``integrated health 
care delivery system'' could be defined, for example, as a health care 
delivery system comprised of two or more entities that are related and 
substantially integrated by common ownership or control, and which 
includes at least one hospital and one physician organization that has 
no physician owners or investors who make referrals for DHS to any 
component of the health care delivery system. Entities that file 
consolidated financial statements could be deemed to be substantially 
integrated for purposes of this definition. For purposes of this 
approach, ownership could exist if an individual or individuals possess 
50 percent ownership or equity in the component of the integrated 
health care delivery system, and control would exist if an individual 
or an organization has the power, directly or indirectly, significantly 
to influence or direct the actions or policies of the component of the 
integrated health care delivery system. As noted above, it would be 
necessary to define ``integrated health care delivery system,'' as well 
as ``ownership'' and ``control,'' and to determine whether to permit 
integrated health care delivery systems to include entities related 
through written contractual affiliation agreements and, if so, what 
limitations (if any) should be placed on the types of contractually 
affiliated entities we would permit to be included as components of an 
integrated health care delivery system. We would need also to determine 
what characteristics indicate substantial integration and identify the 
types of compensation arrangements that exist between components of 
integrated health care delivery systems. We are seeking public comments 
regarding this possible approach (including the specific issues noted), 
as well as public comments on other alternative approaches to 
addressing the concerns regarding support payments and similar monetary 
transfers noted by industry stakeholders and described above.
2. DHS Entity ``Stand in the Shoes'' Provisions
    On July 12, 2007, we published in the Federal Register a proposed 
rule entitled ``Medicare Program; Proposed Revisions to Payment 
Policies Under the Physician Fee Schedule, and Other Part B Payment 
Policies for CY 2008; Proposed Revisions to the Payment Policies of 
Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and 
the Proposed Elimination of the E-Prescribing Exemption for Computer-
Generated Facsimile Transmissions; Proposed Rule'' (the ``CY 2008 PFS 
proposed rule'') (72 FR 38122). In that rule, we proposed a corollary 
provision to the Phase III ``stand in the shoes'' provisions that 
addressed the DHS entity side of physician--DHS entity financial 
relationships. Specifically, we proposed to amend Sec.  411.354(c) to 
provide that, where a DHS entity owns or controls an entity to which a 
physician refers Medicare patients for DHS, the DHS entity would stand 
in the shoes of the entity that it owns or controls and would be deemed 
to have the same compensation arrangements with the same parties and on 
the same terms as does the entity that it owns or controls. For 
example, a hospital would stand in the shoes of a medical foundation 
that it owns or controls (such as where the hospital is the sole member 
of a nonprofit corporation). Thus, under the CY 2008 PFS proposed rule 
proposal, if a hospital owns or controls a medical foundation that 
contracts with a physician to provide physician services at a clinic 
owned by the medical foundation, the hospital would stand in the shoes 
of the medical foundation and would be deemed to have a direct 
compensation relationship with the contractor physician. We solicited 
public comments as to whether and how we would employ a ``stand in the 
shoes'' approach for these types of relationships, as well as for other 
types of financial relationships.
    In response to the CY 2008 PFS proposed rule, we received comments 
from a variety of industry stakeholders, including physicians, medical 
associations, and their representatives. Although several commenters 
supported the proposed entity ``stand in the shoes'' provisions because 
they share our concerns regarding parties ability to avoid application 
of the physician self-referral law by simply inserting an entity in the 
chain of financial relationships linking a DHS entity and a referring 
physician, many commenters expressed concern that the proposal was 
unclear and potentially overly broad. Commenters requested guidance 
regarding the level of ownership or control that would trigger the 
application of the entity ``stand in the shoes'' provisions. One 
commenter recommended that, instead of finalizing the entity ``stand in 
the shoes'' provisions, we issue, through a notice of proposed 
rulemaking, a more detailed proposal that would give industry 
stakeholders the opportunity to provide more meaningful comments.
    We did not finalize the DHS entity ``stand in the shoes'' 
provisions in the CY 2008 PFS final rule published in the Federal 
Register on November 27, 2007 (72 FR 66222, 66306). Because the DHS 
entity ``stand in the shoes'' provisions are integrally related to the 
physician ``stand in the shoes'' provisions that we finalized in Phase 
III and for which we

[[Page 23689]]

are proposing the regulatory revisions described above, we are re-
proposing here the DHS entity ``stand in the shoes'' provisions, with 
some modification. We believe that a comprehensive approach to the 
``stand in the shoes'' provisions that addresses both physicians and 
physician organizations, as well as DHS entities and other entities 
that they own or control, is the best vehicle to address the goals 
outlined in the Phase III final rule, namely: (1) Simplifying the 
analysis of many financial arrangements; and (2) reducing program abuse 
by bringing more financial relationships within the ambit of the 
physician self-referral law.
    We are proposing to revise Sec.  411.354(a) to provide that an 
entity that furnishes DHS would be deemed to stand in the shoes of an 
organization in which it has a 100 percent ownership interest and would 
be deemed to have the same compensation arrangements with the same 
parties and on the same terms as does the organization that it owns. We 
believe this approach is straightforward and can be readily applied. We 
note that, under this approach (as compared to our CY 2008 PFS 
proposal), a DHS entity would stand in the shoes of any wholly-owned 
organization, not merely a wholly-owned DHS entity. An organization may 
be in any legal form (for example, a limited liability company, 
partnership, or corporation, regardless of status as nonprofit or 
exempt from taxation). We are seeking public comments specifically as 
to whether we should consider a DHS entity to stand in the shoes of 
another organization in which the DHS entity holds less than a 100 
percent ownership interest and, if so, what amount of ownership should 
trigger application of the entity ``stand in the shoes'' provisions. In 
addition, we are seeking public comments as to whether we should deem a 
DHS entity to stand in the shoes of an organization that it controls 
(for example, an entity would stand in the shoes of a nonprofit 
organization of which it is the sole member); we would consider a DHS 
entity to control an organization if the DHS entity has the power, 
directly or indirectly, significantly to influence or direct the 
actions or policies of the organization. We are seeking public comments 
as to what level of control should trigger the application of the 
entity ``stand in the shoes'' provisions.
3. Application of the Physician ``Stand in the Shoes'' and the Entity 
``Stand in the Shoes'' Provisions
    In order to protect against program and patient abuse when multiple 
links involving various corporate and other entities exist in a chain 
of financial relationships between a DHS entity and a referring 
physician, we are proposing that, when applying the physician ``stand 
in the shoes'' provisions and the entity ``stand in the shoes'' 
provisions to a chain of financial relationships between a physician 
and a DHS entity, the following conventions would apply:
    <bullet> First, parties would apply the physician ``stand in the 
shoes'' provisions and deem the physician to stand in the shoes of his 
or her physician organization (in those instances where the physician 
``stand in the shoes'' provisions apply to the particular physician and 
physician organization).
    <bullet> However, if applying the physician ``stand in the shoes'' 
provisions would result in only one financial relationship remaining 
between the DHS entity and the ``collapsed'' physician/physician 
organization and that relationship is an ownership interest, the 
physician ``stand in the shoes'' provisions would not be applied, and 
the entity ``stand in the shoes'' provisions instead would be applied 
first.
    <bullet> If more than two organizations remain after first 
``collapsing'' the physician and the physician organization (that is, 
if at least two links remain in the chain of financial relationships 
between the physician who is standing in the shoes of his or her 
physician organization and the DHS entity), the next step would be to 
apply the entity ``stand in the shoes'' provisions.
    These conventions ensure that at least one compensation arrangement 
remains between the DHS entity and the referring physician for purposes 
of analyzing the chain of relationships under the physician-self 
referral rules. For example, if a chain of financial relationships 
runs: hospital--wholly-owned home health agency--group practice--
physician owner of the group practice, the first step would be to apply 
the physician ``stand in the shoes provisions'' such that the physician 
owner would stand in the shoes of the group practice. The next step 
would be to apply the entity ``stand in the shoes'' provisions and deem 
the hospital to stand in the shoes of its wholly-owned home health 
agency. Assuming that the financial relationship between the home 
health agency and the group practice is a compensation arrangement, the 
remaining financial relationship would be deemed to be a direct 
compensation arrangement between the hospital (standing in the shoes of 
the home health agency) and the physician (standing in the shoes of the 
group practice). By contrast, the example of a chain of financial 
relationships that runs: hospital--group practice wholly-owned by the 
hospital--employed physician of the group practice (whose compensation 
does not satisfy the requirements of the exception in Sec.  
411.357(c)), is illustrative. If the relationship between the hospital 
and the group practice is solely an ownership interest (that is, there 
is no separate compensation arrangement between them), applying the 
physician ``stand in the shoes'' provisions first, so that the 
physician-employee stands in the shoes of the group practice, would 
result in one remaining financial link between the group practice and 
the hospital, and that relationship would be an ownership interest. In 
those circumstances, the entity ``stand in the shoes'' provisions would 
be applied first and the hospital would stand in the shoes of its 
wholly-owned group practice. The physician would not stand in the shoes 
of the group practice. The remaining financial relationship would be 
deemed to be a direct compensation arrangement between the hospital 
(standing in the shoes of the group practice) and the physician. (We 
note that, in this example, the physician's compensation from the group 
practice does not satisfy the requirements of the exception for bona 
fide employment relationships in Sec.  411.357(c) and, thus, no direct 
exception would apply to that compensation arrangement.) Using the same 
chain of financial relationships, but assuming instead that the 
hospital has a compensation arrangement with (in addition to being the 
sole owner of) the group practice (for example, an office space rental 
agreement), under the proposals described above, the physician would 
stand in the shoes of the group practice, but the hospital would not 
stand in the shoes of the group practice because, after first applying 
the physician ``stand in the shoes'' provisions, only two organizations 
would remain (that is, only one link in the chain of financial 
relationships remains). The remaining financial relationship created by 
the rental agreement would be deemed to be a direct compensation 
arrangement between the hospital and the physician, which would need to 
satisfy the requirements of an exception.
    We are not proposing regulation text at this time with respect to 
the application of the physician and entity ``stand in the shoes'' 
provisions. At such time as these provisions are finalized, we would 
amend the regulation text, as appropriate, to codify requirements

[[Page 23690]]

related to the application of the provisions.
4. Definitions: ``Physician'' and ``Physician Organization''
    In an interim final rule with comment period entitled ``Medicare 
Program; Physicians' Referrals to Health Care Entities With Which They 
Have Financial Relationships (Phase II); Interim Final Rule,'' 
published in the Federal Register on March 26, 2004 (72 FR 16054) 
(``Phase II''), we revised the definition of ``referring physician'' at 
Sec.  411.351 to provide that a referring physician is deemed to stand 
in the shoes of his or her wholly-owned PC (69 FR 16060). In that rule, 
we stated that it is not necessary to treat a referring physician as 
separate from his or her wholly-owned PC. In the Phase III final rule, 
for purposes of implementing the physician ``stand in the shoes'' 
provisions, the term ``physician organization'' was newly defined at 
Sec.  411.351 as ``a physician (including a professional corporation of 
which the physician is the sole owner), a physician practice, or a 
group practice that complies with the requirements of Sec.  411.352.'' 
Our intent was that, when applying the physician ``stand in the shoes'' 
provisions in Sec.  411.354, a physician would stand in the shoes of: 
(1) Another physician who employs the physician; (2) his or her wholly-
owned PC; (3) a physician practice that employs or contracts with the 
physician or in which the physician has an ownership interest; or (4) a 
group practice of which the physician is a member or independent 
contractor.
    Essentially, we intended this definition to incorporate the Phase 
II policy that a physician stands in the shoes of, or is considered the 
same as, the PC of which he or she is the sole owner. In determining 
whether a direct or indirect compensation arrangement exists between a 
DHS entity and a referring physician, we intended that parties should 
first ``collapse'' the physician into his or her wholly-owned PC, and 
then deem that ``collapsed'' physician/PC unit to stand in the shoes of 
the physician organization (if one exists). However, we are concerned 
that parties may interpret the rules, using the definition of 
``physician organization'' exclusive of the definition of ``referring 
physician,'' as requiring only that they deem a physician to stand in 
the shoes of his or her wholly-owned PC without further deeming the 
``collapsed'' physician/PC unit to stand in the shoes of the physician 
organization. That is, with respect to a chain of financial 
relationships that runs: hospital--group practice--PC--physician, 
parties might interpret our rules as requiring only that the physician 
stand in the shoes of the PC and not in the shoes of the group 
practice, so that the resulting chain of financial relationships (after 
the application of the ``stand in the shoes'' provisions) would run: 
hospital--group practice--PC/physician. However, our intention was 
that, after application of the ``stand in the shoes'' provisions, the 
chain of financial relationships would run: hospital--group practice/
PC/physician.
    Therefore, we are proposing revisions to the definitions of 
``physician'' and ``physician organization'' to clarify that: (1) A 
physician and the PC of which he or she is the sole owner are always 
treated the same for purposes of applying the physician self-referral 
rules; and (2) a physician who stands in the shoes of his or her 
wholly-owned PC also stands in the shoes of his or her physician 
organization in accordance with Sec.  411.354(c)(1)(ii) and (c)(2)(iv).

B. Period of Disallowance

    In response to the Phase II interim final rule with comment period, 
several commenters questioned what the time period would be for which 
the physician could not refer patients for DHS to an entity and for 
which the entity could not bill Medicare (the ``period of 
disallowance'') where a financial relationship between a referring 
physician and an entity failed to satisfy the requirements of an 
exception to the general prohibition on self-referral. (See 72 FR 51024 
through 51025; and 72 FR 38183.) In the Phase III final rule, in 
response to these inquiries, we stated that the statute provides no 
explicit limitation on the billing and claims submission prohibition 
(72 FR 51025). In the CY 2008 PFS proposed rule, we stated that the 
statute contemplates that the period of disallowance begins with the 
date that a financial relationship failed to comply with the statute 
and the regulations, and ends with the date that the arrangement came 
into compliance or ended (72 FR 38183). We noted that, in some cases, 
it may not be clear when a financial relationship has ended. We 
provided the example of an entity leasing space to a physician at a 
rental price that is substantially below fair market value. We stated 
that such an arrangement may raise the inference that the below-market 
rent was in exchange for future referrals, including referrals made 
beyond the expiration of the lease. We solicited comments with respect 
to: (1) The types of noncompliance for which it is not clear when a 
financial relationship ended; and (2) whether we should always employ a 
case-by-case approach or deem certain types of financial relationships 
to continue for a prescribed period of time. We also solicited public 
comments as to whether we should allow a prescribed period of 
disallowance to terminate where the parties have returned (or paid back 
the value of) any excess compensation. For example, if we were to 
impose a period of disallowance for a prescribed period of time because 
it would not be clear when a noncompliant compensation arrangement 
ended, we stated that we might allow the parties to terminate the 
period of disallowance sooner than the prescribed period if the 
prohibited compensation were returned. In the CY 2008 PFS proposed 
rule, we cautioned that we did not envision allowing such an option 
where the parties knew or, in our judgment, reasonably should have 
known, that the arrangement did not satisfy the requirements of an 
exception. Finally, we sought public comments as to whether we should 
impose a period of disqualification, prohibiting the parties from using 
an exception where an arrangement has failed to satisfy the 
requirements of that exception. We gave the example of nonmonetary 
compensation provided by an entity to a physician that greatly exceeded 
the permissible limit prescribed in Sec.  411.357(k), and questioned 
whether, in addition to whatever period of disallowance would apply, 
the parties should be disqualified, for some period of time, from using 
this exception.
    We received few public comments in response to the CY 2008 PFS 
proposed rule solicitation of comments; however, with respect to the 
length of the period of disallowance, one commenter asserted that the 
appropriate period of disallowance should match the period that the 
financial relationship did not satisfy the requirements of an 
exception, but that the period should be limited to a maximum term. In 
addition, commenters asserted that, if the parties unwind the 
relationship and return the prohibited compensation, the period of 
disallowance should end. Another commenter suggested that the period of 
disallowance should end once the hospital corrects or terminates the 
arrangement and the physician repays to the hospital any compensation 
in excess of what is permitted. Alternatively, according to the 
commenter, if the physician does not repay the excess compensation, the 
period of disallowance should end once the hospital repays to Medicare 
the excess compensation, and the hospital should be prohibited from 
paying any further compensation to the physician until the

[[Page 23691]]

physician reimburses the hospital for the excess compensation. One 
commenter asserted that certain circumstances warrant no period of 
disallowance. For instance, according to the commenter, if parties to 
an arrangement were unaware that the arrangement violates the physician 
self-referral law but later were notified by CMS or its contractor of 
the possible violation, they should be able to amend the arrangement so 
that it satisfies the requirements of an exception without any period 
of disallowance. The commenter also asserted that there should be no 
period of disqualification preventing the parties from using an 
exception in light of the onerous penalties under the physician self-
referral law.
    At this time, we are proposing to amend Sec.  411.353(c) to provide 
that, where the reason(s) a financial relationship does not meet any 
applicable exception is not related to compensation (for example, a 
signature is missing or an agreement is not in writing as required by 
the applicable exception), the period of disallowance would begin on 
the date the arrangement first was out of compliance and end no later 
than the date the arrangement was brought into compliance (for example, 
by obtaining a missing signature on an agreement or executing a written 
agreement as required by the applicable exception). For example, where 
a hospital and a physician enter into a personal service arrangement 
for medical director services and begin performing under the 
arrangement on January 1, but do not execute a written agreement until 
January 31, provided that all of the requirements of Sec.  411.357(d) 
(the exception for personal service arrangements) are satisfied as of 
January 31, the period of disallowance would begin on January 1 and end 
no later than January 31. As discussed below, we believe that it is 
possible that a financial arrangement may end prior to the arrangement 
being brought into compliance. In such circumstances, a determination 
as to the duration of the period of disallowance necessarily would be 
made on a case-by-case basis considering the facts and circumstances, 
and we are not proposing a prescribed period of disallowance for such a 
situation.
    We are also proposing that, where the reason a financial 
relationship does not meet any applicable exception is related to the 
payment or receipt of excess compensation (for example, the 
compensation paid to a physician is greater than fair market value or 
exceeds the limits in Sec.  411.357(k) or (m)), the period of 
disallowance would begin on the date the arrangement first was out of 
compliance and end no later than the date the excess compensation 
(including interest, as appropriate) was returned by the party 
receiving it to the party that provided it and all other requirements 
of the applicable exception are met. For example, if a hospital 
provided nonmonetary compensation totaling $100 in excess of the limits 
in Sec.  411.357(k) on February 1 and the parties did not discover the 
noncompliance until October 1 (and, therefore, could not avail 
themselves of the provisions in Sec.  411.357(k)(3) permitting parties 
to remain in compliance with the exception if excess nonmonetary 
compensation (within certain limits) provided inadvertently is 
discovered and returned with 180 days of its receipt), the period of 
disallowance would begin on February 1 and end no later than the date 
that the physician returned the excess nonmonetary compensation or its 
value ($100 plus interest, as appropriate) to the hospital. Assuming 
that the physician paid the hospital $100 (plus interest, as 
appropriate) on October 15, the period of disallowance would run from 
February 1 through no later than October 15.
    Our proposal would also prescribe a period of disallowance where 
the reason a financial relationship does not meet any applicable 
exception is related to the payment or receipt of compensation that is 
insufficient to satisfy the requirements of an exception (for example, 
office space or equipment rental payments that are below fair market 
value). We are proposing that the period of disallowance would begin on 
the date the arrangement first was out of compliance and end no later 
than the date the shortfall was paid to the party to which it is owed 
and all other requirements of the applicable exception are met. The 
``shortfall'' would be that amount (including interest, as appropriate) 
necessary to bring the arrangement into compliance from the date of its 
inception. For example, assume a hospital and physician entered into a 
2-year office space rental agreement on January 1 (of Year 1) which 
specified rental charges (consistent with fair market value) of $20 per 
square foot during Year 1 and automatically adjusted upward each 
January 1 by any increase in the CPI-U. If, on January 1 of Year 2 of 
the agreement, the rental charges increased to $21 per square foot 
based on the amount of increase in the CPI-U, but the physician 
continued to pay $20 per square foot until the compliance failure was 
identified on June 30 of Year 2, the period of disallowance would run 
from January 1 of Year 2 until no later than June 30 of Year 2, 
provided that the physician paid the hospital on June 30 of Year 2 the 
shortfall of $1 per square foot for the 6-month shortfall period (plus 
interest, as appropriate) and, as of July 1 through the term of the 
agreement, the physician paid $21 per square foot for the office space, 
and the arrangement otherwise satisfied the requirements of the 
exception in Sec.  411.357(d). As discussed below, we believe that it 
is possible that an arrangement may end prior to excess compensation 
being returned or a shortfall being paid; however, such a determination 
as to the duration of the period of disallowance necessarily would be 
made on a case-by-case basis considering the facts and circumstances, 
and we are not proposing a prescribed period of disallowance for such a 
situation.
    We also note that an arrangement may be noncompliant for reasons 
that are related to compensation, but which do not involve the payment 
or receipt of excess compensation or a shortfall in compensation paid 
or received. For example, many of our exceptions require that the 
compensation not take into account the volume or value of referrals or 
other business generated between the parties and that the compensation 
be commercially reasonable, even if no referrals were made between the 
parties. It is possible that the amount of compensation provided under 
an arrangement is fair market value or is consistent with a prescribed 
limit in one of the exceptions (such as in Sec.  411.357(k)), but, for 
example, takes into account the volume or value of referrals and this 
results in a noncompliant arrangement. We are not proposing a 
prescribed period of disallowance for arrangements that are 
noncompliant for reasons that are related to compensation but which do 
not involve only the payment or receipt of excess compensation or a 
shortfall in compensation paid or received. Rather, the appropriate 
period of disallowance for such arrangements would need to be 
determined on a case-by-case basis.
    Essentially, our proposals place an outside limit on the period of 
disallowance in certain circumstances. That is, where the reason(s) for 
noncompliance does not relate to compensation, the latest the period of 
disallowance would end would be the date the arrangement was brought 
into compliance. Where the reason for noncompliance is the fact that 
excess compensation was provided or too little compensation was paid, 
the latest the

[[Page 23692]]

period of disallowance would end would be the date that the party 
receiving the excess compensation returned it to the party that 
provided it or the party owing the shortfall in compensation paid it to 
the party to which it was owed (assuming the arrangement otherwise 
satisfies the requirements of an applicable exception).
    We recognize, of course, that parties to a financial relationship 
that is noncompliant may never bring the relationship into compliance 
with an applicable exception. The financial relationship may expire 
according to the terms of the underlying agreement (such as the date of 
expiration of a personal service contract), or it may end earlier or 
later than the expiration date provided in the underlying agreement. 
However, we do not propose to prescribe with specificity when such a 
noncompliant financial relationship (and, thus, the period of 
disallowance) might end. Likewise, if a party that receives excess 
compensation never repays the excess compensation, or a party who owes 
additional compensation (the shortfall) never pays it, the question 
arises as to when the financial relationship ends. To return to the 
example that we gave in the CY 2008 PFS proposed rule and that we 
reference above, if an entity leases space to a physician at a rental 
price that is substantially below fair market value, the inference may 
be raised that the below-market rent was in exchange for future 
referrals, including referrals made beyond the expiration of the lease 
agreement. Therefore, in such a situation, if the physician does not 
pay the rental charges shortfall, the financial relationship may not 
end at the expiration of the written lease agreement, but rather could 
extend for some period beyond the expiration of the written lease 
agreement. We are not proposing to establish any specific time period 
or even guidelines for when the financial relationship in the above 
example would be deemed to end (so that future referrals would not be 
tainted); rather the determination of when the financial relationship 
ends must depend on the facts and circumstances. We note that our 
proposals pertain only to placing an outside limit on the period of 
disallowance for making referrals and billing the Medicare program in 
the case of certain noncompliant financial relationships; they do not 
address whether the anti-kickback statute is implicated and/or whether 
civil monetary penalties under the physician self-referral statute are 
potentially applicable due to noncompliant financial relationships.
    We are not proposing, as one commenter suggested, that, in a 
situation involving noncompliance due to excess compensation paid by an 
entity to a physician (or the physician's immediate relative), the 
period of disallowance would end no later than the date the entity 
repays the excess compensation to the Medicare program, should the 
physician not repay the excess compensation to the entity. This 
approach is not consistent with the statute. We are also not proposing, 
as another commenter suggested, to impose no period of disallowance for 
the situation in which parties allegedly were unaware of the 
noncompliant nature of a financial relationship. We do not have the 
authority under section 1877 of the Act to waive violations of the 
physician self-referral law. We note also that there would be practical 
problems in determining whether parties were unaware of the 
noncompliant nature of the arrangement and that we would be 
discouraging parties from carefully structuring arrangements and 
monitoring them. In the CY 2008 PFS proposed rule, we proposed an 
alternative method of compliance that may address some of the 
commenter's concerns, and that proposal is still under consideration 
for final rulemaking. Finally, we are not proposing to impose a period 
of disqualification during which the parties to a noncompliant 
financial relationship would be prohibited from using a particular 
exception due to that relationship. We may propose rulemaking on this 
subject in the future.

C. Gainsharing Arrangements

1. Background
    The term ``gainsharing'' typically refers to an arrangement under 
which a hospital gives physicians a share of the reduction in the 
hospital's costs (that is, the hospital's cost savings) attributable in 
part to the physicians' efforts. Gainsharing may take several forms. 
Some arrangements are narrowly targeted, giving the physician a 
financial incentive to select specific medical devices and products 
that are less expensive or to adopt specific clinical practices or 
protocols that reduce costs. Other, more problematic arrangements are 
not targeted at utilization of specific supplies or specific clinical 
practices, but instead offer the physician payments to reduce total 
average costs per case below target amounts.
    Gainsharing arrangements seek to align physician incentives with 
those of hospitals by offering physicians a share of the hospital's 
variable cost savings attributable to the physicians' efforts in 
controlling the cost of providing patient care. Following the 
institution of the Medicare Part A DRG system of hospital reimbursement 
and with the growth of managed care, hospitals have experienced 
significant financial pressure to reduce costs. However, because 
physicians are paid separately under Medicare Part B and Medicaid, 
physicians do not share necessarily a hospital's incentive to control 
the hospital's patient care costs. Gainsharing arrangements are 
designed to align hospital and physician incentives by offering 
physicians a portion of the hospital's cost savings in exchange for 
identifying and implementing cost-saving strategies.
2. Statutory Impediments to Gainsharing Arrangements
    Whereas gainsharing promotes hospital cost reductions by aligning 
physician incentives with those of the hospital, these arrangements 
also implicate the physician self-referral statute (section 1877 of the 
Act). Section 1877(a)(1) of the Act states that, except as provided in 
section 1877(b) of the Act, if a physician (or an immediate family 
member of such physician) has a financial relationship with an entity, 
the physician may not make a referral to the entity for the furnishing 
of DHS for which payment otherwise may be made under title XVIII of the 
Act. The provision of monetary or nonmonetary remuneration by a 
hospital to a physician through a gainsharing arrangement would 
constitute a financial relationship with an entity for purposes of the 
physician self-referral statute.
    Gainsharing arrangements also implicate two specific fraud and 
abuse statutes. First, sections 1128A(b)(1) and (b)(2) of the Act, 
commonly referred to as the Civil Monetary Penalty, or CMP, statute, 
prohibit a hospital from knowingly making a payment directly or 
indirectly to a physician as an inducement to reduce or limit items or 
services furnished to Medicare or Medicaid beneficiaries, and a 
physician from knowingly accepting such payment. Second, gainsharing 
arrangements implicate section 1128B(b) of the Act (the ``anti-kickback 
statute'') if one purpose of the cost savings payment is to influence 
referrals of Federal health care program business.
3. Office of Inspector General (OIG) Approach Towards Gainsharing 
Arrangements
    The HHS Office of Inspector General (``OIG'') historically has been 
wary of

[[Page 23693]]

gainsharing arrangements. In July 1999, OIG issued a Special Advisory 
Bulletin that addressed the application of sections 1128A(b)(1) and (2) 
of the Act to gainsharing arrangements. Although OIG recognized that 
appropriately structured gainsharing arrangements may offer significant 
benefits where there is no adverse impact on the quality of care 
received by patients, section 1128A(b) of the Act clearly prohibits 
arrangements that are intended as an inducement to limit or reduce 
services to Medicare or Medicaid patients. In addition, OIG stated that 
regulatory relief from the CMP prohibition would require statutory 
authorization.
    OIG has issued several favorable advisory opinions regarding 
individual gainsharing arrangements, although the opinions (like all 
OIG advisory opinions) do not have general applicability. When 
evaluating the risks posed by a gainsharing arrangement, OIG has 
generally looked for three types of safeguards, namely: (1) Measures 
that promote accountability and transparency; (2) adequate quality 
controls; and (3) controls on payments related to referrals. Properly 
structured, gainsharing arrangements may offer opportunities for 
hospitals to reduce costs without causing inappropriate reductions in 
medical services or rewarding referrals of Federal health care program 
patients. In a number of specific cases involving limited proposed 
arrangements, OIG has issued advisory opinions in which it concluded 
that the proposed arrangement presents a low risk of abuse and, 
therefore, it would exercise its prosecutorial discretion not to impose 
sanctions. In these cases, OIG has concluded, based on the totality of 
facts and circumstances and the presence of adequate safeguards, that: 
(1) The proposed arrangement would constitute an improper payment to 
induce the reduction or limitation of services as prohibited by 
sections 1128A(b)(1) and (2) of the Act, but that OIG would not impose 
sanctions on the requestors of the advisory opinion; and (2) the 
proposed arrangement would potentially generate prohibited remuneration 
under the anti-kickback statute if the requisite intent to induce or 
reward referrals of Federal health care program business were present, 
but that OIG would not impose administrative sanctions on the 
requestors under section 1128A(a), or under section 1128(b)(7) or 
section 1128A(a)(7), as those sections relate to the commission of acts 
described in the anti-kickback statute.
4. MedPAC Recommendation
    MedPAC, in its March 2005 Report to Congress, ``Physician-owned 
Specialty Hospitals,'' recommended that gainsharing arrangements 
between physicians and hospitals be permitted. Specifically, MedPAC 
stated that, ``[t]he Congress should grant the Secretary the authority 
to allow gainsharing arrangements between physicians and hospitals and 
to regulate those arrangements to protect the quality of care and 
minimize financial incentives that could affect physician referrals.'' 
(See http://www.medpac.gov/publications/congressional repots/
Mar05EntireReport.pdf, at page 47). In addition, MedPAC stated that, 
drawing on OIG's work, the Secretary could require that gainsharing 
arrangements:
    <bullet> Identify specific actions that would produce savings, such 
as limiting the inappropriate use of supplies;
    <bullet> Are transparent and disclosed to patients;
    <bullet> Include periodic reviews of quality of care by an 
independent organization;
    <bullet> Limit the amount of time during which physicians can share 
cost savings in order to prevent hospitals from using these agreements 
as a mechanism to induce physician referrals;
    <bullet> Avoid rewarding physicians for increasing referrals to the 
hospitals, such as capping potential savings based on the number of 
prior year admissions; and
    <bullet> Monitor changes in the severity, age, and insurance 
coverage of patients affected by the gainsharing arrangement.
5. Demonstration Programs
    CMS has long been interested in evaluating the association between 
payments and the quality of care. In 1991, CMS initiated a 
demonstration program entitled the ``Medicare Participating Heart 
Bypass Center Demonstration.'' This demonstration was conducted to 
assess the feasibility and cost effectiveness of a negotiated all-
inclusive bundled payment arrangement for coronary artery bypass graft 
(CABG) surgery while maintaining high quality care. CMS originally 
negotiated contracts with four applicants. In 1993, the demonstration 
was expanded to include three more participants. The results of the 
demonstration showed that an all-inclusive bundled payment arrangement 
can provide an incentive to physicians and hospitals to work together 
to provide services more efficiently, improve quality, and reduce 
costs. The bundling of the physician and hospital payments did not have 
a negative impact on the post-discharge health improvements of the 
demonstration patients. Three of the four original hospitals were able 
to make major changes in physician practice patterns and operations 
that generated significant cost savings. A hospital's participation in 
the demonstration appeared to have little or no effect on physician 
referral patterns.
    A second demonstration project that involves gainsharing 
arrangements is authorized by section 646 of the MMA, which added a new 
section 1866C of the Act and established the Medicare Health Care 
Quality MHCQ Demonstration Program. MHCQ demonstration projects are 
intended to ``* * * examine health delivery factors that encourage the 
delivery of improved quality in patient care.'' Using the authority 
provided by section 1866C of the Act, CMS decided to implement a 3-year 
demonstration that would test gainsharing models involving physicians 
and collaborations between hospitals working with physicians in a 
single geographic area to improve the quality of inpatient hospital 
care. In contrast to traditional models of gainsharing, the proposed 
demonstration approaches must be across single or multiple 
organizations and involve long-term followup to ensure both documented 
improvements in quality and reductions in the overall costs of care. 
CMS is particularly interested in demonstration designs that: (1) Track 
patients well beyond a hospital episode to determine the impact of 
hospital-physician collaborations on preventing short and longer-term 
complications, duplication of services, and coordination of care across 
settings; and (2) offer other quality improvements for eliminating 
preventable complications and unnecessary costs.
    A third series of demonstration projects was authorized by section 
5007 of the Deficit Reduction Act of 2005 (the ``DRA'') (Pub. L. 109-
171). This provision requires the Secretary to establish a qualified 
gainsharing demonstration under which the Secretary shall approve up to 
six demonstration projects. Section 5007 demonstration projects would 
involve arrangements between a hospital and physicians and 
practitioners under which the hospital provides for remuneration (that 
is, gainsharing payments) to certain physicians and to certain 
practitioners (as defined in 1842(b)(18)(C) of the Act) that represents 
solely a share of the savings incurred directly as a result of 
collaborative efforts between the hospital and a particular physician 
(or practitioner) to improve overall quality and efficiency. Each 
demonstration

[[Page 23694]]

project must also provide measures to monitor quality and efficiency in 
the participating project hospital(s).
6. Solicitation of Comments
    In the CY 2008 PFS proposed rule, we noted that we are concerned 
about compensation arrangements between entities and physicians under 
which compensation is determined on a percentage basis (for example, 
rental charges for office space that are determined based on a 
percentage of a group practice's revenues) (72 FR 38184). We proposed 
to clarify that percentage-based compensation arrangements may be used 
only for paying for personally performed physician services and that 
such arrangements must be based on the revenues directly resulting from 
the physician services rather than based on some other factor such as a 
percentage of the savings by the hospital department. The proposed 
changes, if finalized, might prevent typical gainsharing arrangements 
between physicians and hospitals to which they refer for DHS. We have 
not yet finalized our proposal in the CY 2008 PFS final rule; however, 
it remains under active consideration.
    Notwithstanding our general concern with arrangements that involve 
the use of a percentage-based compensation formula (other than payment 
to a physician for work personally performed by the physician), we 
recognize the value to the Medicare program and its beneficiaries where 
the alignment of hospital and physician incentives results in 
improvements in quality of care. Therefore, we are considering whether 
to issue an exception specific to gainsharing arrangements. Under 
section 1877(b)(4) of the Act, we may issue additional exceptions (that 
is, exceptions not specified in the statute) only where doing so would 
create no risk of program or patient abuse. At this time, we decline to 
issue a specific proposal concerning an exception for gainsharing 
arrangements, but rather are soliciting comments as to whether we 
should establish an exception for gainsharing arrangements, and, if so, 
what safeguards should be included in the exception. Specifically, we 
are interested in receiving comments on: (1) What types of requirements 
and safeguards should be included in any exception for gainsharing 
arrangements; and (2) whether certain services, clinical protocols, or 
other arrangements should not qualify for the exception.

D. Physician-Owned Implant and Other Medical Device Companies

1. Background
    We have recently become aware of an increase in physician 
investment in implant and other medical device manufacturing, 
distribution, and purchasing companies. We recognize that physician 
involvement often adds value to device manufacturing companies and that 
many physicians may have legitimate investment interests in these 
companies. Physicians participate in the research, development, and 
testing involved in creating and producing many lifesaving and quality-
of-life enhancing medical devices. The added value of physician 
involvement in distribution and purchasing companies, essentially 
middlemen companies, is less clear. When physicians profit from the 
referrals they make to hospitals through physician-owned implant and 
medical device companies (``POCs''), we are concerned about possible 
program or patient abuse. POCs exist in three primary forms: 
manufacturers, distributors, and group purchasing organizations 
(``GPOs''). Our understanding, however, is that many POCs are not 
manufacturers, but rather are companies that profit from the purchase 
and resale of products made by another organization (that is, they act 
as distributors) or from GPO fees paid by device vendors. In many 
cases, the physician investors bear little, if any, economic risk with 
respect to the medical devices. It is also our understanding that some 
physicians are offered investment interests in ``private label'' or 
similar manufacturing entities when the physicians have provided 
little, if any, necessary research, design, or testing services. We are 
concerned that some physician-owned organizations may serve little 
purpose other than providing physicians the opportunity to earn 
economic benefits in exchange for nothing more than ordering medical 
devices or other products that the physician-investors use on their own 
patients. The financial incentives paid to the physicians may foster an 
anti-competitive climate, raise quality of care concerns, and lead to 
overutilization of the device or other product to which the physician 
is linked. Physicians are responsible for selecting or recommending the 
devices ordered for the hospital's patients. It is reasonable to 
believe that medical device or implant companies without physician 
investment will have difficulty finding referral sources in areas where 
many physicians are invested in a POC that offers competing products.
    In response to our proposed change to the definition of ``entity'' 
at Sec.  411.351 in the CY 2008 PFS proposed rule, we received public 
comments regarding whether a physician-owned implant or other medical 
device company should or should not be considered to be an ``entity.'' 
One commenter noted that orthopedic surgeons may have an ownership 
interest in a manufacturer of spinal implants that sells its implants 
to the hospital where the surgeon performs his or her surgeries. 
According to the commenter, because the proposed definition of 
``entity'' would extend to an entity that ``performs the DHS,'' the 
manufacturer arguably could be considered to be an ``entity'' under 
Sec.  411.351. This commenter urged us to exclude such manufacturers 
from the definition of ``entity.'' The commenter stated that indirect 
arrangements involving spinal implants would trigger the self-referral 
prohibition if they are not at fair market value. Comments submitted on 
behalf of a manufacturer of spinal implants asserted that, despite 
superficial similarities, joint ventures involving medical devices 
differ in many material ways from the types of arrangements about which 
we expressed concern. This commenter also asserted that the meaning of 
``has performed the DHS'' is unclear and that we should clarify that 
the proposal applied only to ``true'' ``under arrangement'' 
relationships with hospitals, but that, in any event, implantable 
devices are not DHS. According to the commenter, even if implantable 
devices were deemed to be DHS, the rigorous physician self-referral 
exceptions (for example, the exception for indirect compensation 
arrangements in Sec.  411.357(p)) are still available to protect the 
arrangement and against program or patient abuse.
    In an October 6, 2006 letter response to a request for guidance 
regarding certain physician investments in the medical device industry, 
OIG stated that it was aware of an apparent proliferation of physician 
investments in medical device and distribution companies, including 
GPOs, and that, given the strong potential for improper inducements 
between and among the physician investors, the companies, device 
vendors, and medical device purchasers, it believed that all of these 
ventures should be closely scrutinized under the fraud and abuse laws. 
OIG also clarified that its 1989 Special Fraud Alert on Joint Ventures 
applies to all physician joint ventures and would, therefore, apply to 
physician investments in medical device manufacturing and distribution

[[Page 23695]]

companies, as well as GPOs. OIG confirmed that the fact that a 
substantial portion of a venture's gross revenues is derived from 
participant-driven referrals is a potential indicator of a problematic 
joint venture. The October 6, 2006 letter response is available at 
http://oig.hhs.gov/fraud/docs/alertsandbulletins/GuidanceMedicalDevice%20(2).pdf. See also http://oig.hhs.gov/testimony/docs/2008/demske_testimony022708.pdf.
    A medical device company requested that we take a closer look at 
the current prevalence of POCs and the impact that these companies may 
have on program or patient abuse, as well as the negative impact on 
competition among POCs and nonphysician owned medical device companies. 
This company noted that, in the CY2008 PFS proposed rule, we proposed 
revising the definition of ``entity'' to include, among other things, 
an entity that causes a claim to be submitted to Medicare. It suggested 
that we finalize our proposal and that we deem POCs to be DHS entities 
under certain circumstances. It also suggested that, in certain 
circumstances, physician investors in POCs should be deemed to have a 
direct compensation relationship with the hospitals that order and use 
implantable devices furnished by the POCs. The company suggested that a 
POC should not be considered to have caused a claim to be presented 
where the referring physician is named as an inventor on an issued 
patent for the implantable item, provided that the physician does not 
receive any remuneration from the POC based on the volume or value of 
his or her referrals, or where the physician's investment interest 
satisfies the requirements of the exception in Sec.  411.356(a) for 
large, publicly traded entities. We note that it is not clear to us 
under what circumstances a patent holder physician, who presumably 
receives royalty payments from the POC, would receive remuneration that 
does not relate to the volume or value of referrals or other business 
generated by the physician. In the Phase II final rule with comment 
period, we noted that we received a comment that questioned whether the 
payment of a royalty by an equipment manufacturer to a physician 
inventor for a device implanted during surgeries performed by the 
physician inventor is permitted or whether that arrangement would 
create an indirect compensation relationship with the hospital that 
purchased the device. We stated, in response, that the physician 
inventor would have an indirect compensation arrangement with the 
hospital in which the surgeries are performed but, provided the royalty 
payment was fair market value, the relationship should satisfy the 
exception for indirect compensation arrangements in Sec.  411.357(p) 
(69FR 16060).
2. Solicitation of Comments
    At this time, we are not issuing a specific proposal regarding 
POCs. The statute and our existing regulations, specifically those 
related to indirect compensation arrangements, address many POCs. In 
some problematic circumstances, an unbroken chain of financial 
relationships will connect the physician owner of a POC to a DHS entity 
to which the physician makes referrals, and the other elements of an 
indirect compensation arrangement contained in Sec.  411.354(c)(2) will 
also be present, including the requisite knowledge by the DHS entity of 
the physician's interest in the POC. In many instances, the arrangement 
would not satisfy the requirements of the exception for indirect 
compensation arrangements in Sec.  411.357(p), and would, therefore, 
run afoul of the physician self-referral statute. However, we are 
soliciting public comments as to whether our physician self-referral 
rules should address POCs and similar physician owned companies more 
specifically, or whether the concerns surrounding POCs and similar 
organizations, to the extent that they are not addressed by the statute 
and our current rules, are better addressed through enforcement of the 
False Claims Act, the anti-kickback statute and similar fraud and abuse 
laws, other public laws, and through other applicable Federal, State, 
and local regulations. In this regard, we are seeking comments as to 
whether, and to what degree, physician investment in POCs and similar 
organizations presents risks of overutilization, substandard care, and 
increased costs to the Medicare program and its beneficiaries, or 
whether the risk is confined to possible anti-competitive behavior. To 
the extent that commenters believe that certain physician investment in 
POCs and similar organizations should be addressed more specifically 
under our physician self-referral rules, commenters are encouraged to 
provide us with suggestions as to specific actions we should take (for 
example, considering POCs to be DHS entities under certain 
circumstances, considering physician investors in POCs who influence 
hospitals as to the ordering of medical devices to have direct 
compensation relationships with the hospitals, excepting certain 
investment interests from coverage under our rules, etc.).

IX. Financial Relationships Between Hospitals and Physicians

A. Background

    As stated earlier, under section 1877 of the Act, a physician is 
prohibited from referring a Medicare patient for DHS to an entity 
(including an individual) with which the physician (or an immediate 
family member of the physician) has a financial relationship, unless an 
exception applies. In addition, section 1877 of the Act provides that 
an entity may not present or cause to be presented a claim or bill to 
Medicare or any individual, third party payor, or other entity for DHS 
furnished as a result of a prohibited referral. Also, section 1877 of 
the Act prohibits us from making payment for DHS furnished pursuant to 
a prohibited referral. The statute contains several exceptions for 
certain types of compensation arrangements and ownership or investment 
interests, including the exception in section 1877(d)(3) of the Act for 
ownership or investment by a physician in the hospital itself and not 
merely in a subdivision of the hospital (that is, the ``whole'' 
hospital). Section 1877(b)(4) of the Act authorizes us to create 
additional exceptions, provided that they do not create a risk of 
program or patient abuse. As a result of the statutory exceptions in 
section 1877 of the Act, and the exceptions we have created using our 
authority under section 1877(b)(4) of the Act, our regulations contain 
approximately 40 exceptions to the prohibition on physician self-
referrals. (We refer readers to 42 CFR 411.351 through 411.357 of our 
regulations and the September 5, 2007 ``Phase III'' final rule (72 FR 
51012).)
    Section 1877(f) of the Act provides that: ``Each entity providing 
covered items or services for which payment may be made under this 
title [42 USCS 1395 et seq.] shall provide the Secretary with the 
information concerning the entity's ownership, investment, and 
compensation arrangements, including: (1) The covered items and 
services provided by the entity, and (2) the names and unique physician 
identification numbers of all physicians with an ownership or 
investment interest (as described in subsection (a)(2)(A)), or with a 
compensation arrangement (as described in subsection (a)(2)(B)), in the 
entity, or whose immediate relatives have such an ownership or 
investment interest or who have a compensation relationship with the 
entity. Such information shall be provided in such form, manner, and

[[Page 23696]]

at such times as the Secretary shall specify.'' (Emphasis added)
    Some industry representatives have argued that the reference to 
financial relationships as described in section 1877(a)(2)(A) and 
(a)(2)(B) of the Act limits our ability to obtain information on 
financial relationships that do not satisfy one of the statutory or 
regulatory exceptions. We disagree. The statute clearly contains a 
broad authorization for the Secretary to obtain information concerning 
an entity's financial relationships, ``including,'' but not limited to, 
financial relationships that satisfy an exception. We believe that 
there would have been little point to the Congress providing us with 
the authority to compel information on excepted arrangements only, 
because, as we have noted previously, ``an entity could decide that one 
or more of its financial relationships falls within an exception, fail 
to retain data concerning those financial relationships, and thereby 
prevent the government from reviewing the arrangements to determine if 
they qualify for an exception.'' (72 FR 51069.) Accordingly, our 
regulation in Sec.  411.361 requires entities to report ``any ownership 
or investment interest, as defined at Sec.  411.354(b), or any 
compensation arrangement, as defined at Sec.  411.354(c), except for 
ownership or investment interests that satisfy the exceptions set forth 
in Sec.  411.356(a) and Sec.  411.356(b) regarding publicly-traded 
securities and mutual funds'' (emphasis added). The statute provides 
that an ownership or investment interest in the entity may be through 
equity, debt, or other means, and includes an interest in an entity 
that holds an ownership or investment interest in any entity that 
furnishes DHS.
    Our regulations have been drafted to reflect clearly our 
commonsense interpretation of the statutory reporting requirements. In 
the proposed rule entitled ``Medicare and Medicaid Programs; 
Physicians'' Referrals to Health Care Entities With Which They Have 
Financial Relationships,'' published in the Federal Register on January 
9, 1998 (63 FR 1703), we proposed to modify Sec.  411.361 to require 
that entities report information concerning their reportable financial 
relationships to us on a prescribed form and thereafter report annually 
all changes to the submitted information that occurred in the previous 
12 months. In addition, we revisited the statute and interpreted the 
opening paragraph of section 1877(f) of the Act to permit us to gather 
any data on financial relationships, including, but not necessarily 
limited to, financial relationships for which there are no exceptions 
under section 1877(a)(2)(A) or (a)(2)(B) of the Act. Therefore, we 
proposed to amend Sec.  411.361 to reflect explicitly our authority to 
ask for a broader scope of information than the regulation permitted at 
that time.
    In the Phase II final rule with comment period (69 FR 16121), we 
modified the reporting requirement in Sec.  411.361 to remove all 
references to the use of a prescribed form, to require entities to make 
information available only upon request, and to maintain the 
information only for the length of time specified by the applicable 
regulatory requirements for the information (that is, the rules of the 
Internal Revenue Service, Securities and Exchange Commission, Medicare, 
Medicaid, or other programs). In addition, we modified Sec.  411.361 to 
provide that entities need not report ownership or investment interests 
that satisfy the exceptions in Sec.  411.356(a) and (b) for publicly-
traded securities and mutual funds.
    Most, if not all, hospitals have financial relationships with 
referring physicians. These financial relationships may involve 
ownership or investment interests, compensation arrangements, or both. 
The financial relationships can be direct or they may be indirect (such 
as through a physician group practice or limited liability company). 
The physician self-referral statute was first enacted in 1989, and the 
reporting requirements in the regulations in Sec.  411.361 were first 
implemented in our December 3, 1991 interim final rule with comment 
period, published in the Federal Register at 56 FR 61374. Since that 
time, CMS has not engaged in a comprehensive reporting initiative to 
examine financial relationships between hospitals and physicians. 
Consistent with congressional intent in enacting the physician self-
referral statute, we believe it is important to query hospitals 
concerning their financial relationships with physicians.

B. Section 5006 of the Deficit Reduction Act (DRA) of 2005

    Section 5006 of the DRA required the Secretary to develop a 
strategic and implementing plan to address certain issues relating to 
physician-owned specialty hospitals. The specific issues the Secretary 
was required to address were: (1) Proportionality of investment return; 
(2) bona fide investment; (3) annual disclosure of investment 
information; (4) the provision by specialty hospitals of (i) care to 
patients who are eligible for Medicaid (or who are not eligible for 
Medicaid but who are regarded as such because they receive benefits 
under a section 1115 waiver) and (ii) charity care; and (5) appropriate 
enforcement. In order to assist us in preparing the report and 
implementing plan required by section 5006 of the DRA, we sent a 
voluntary survey to 130 specialty hospitals and 220 competitor 
hospitals, which sought information regarding, among other things, the 
hospitals' ownership and investment relationships, and their 
compensation arrangements with physicians. In the enforcement section 
of the strategic and implementing plan that was included in our ``Final 
Report to the Congress and Strategic and Implementing Plan Required 
under Section 5006 of the Deficit Reduction Act of 2005'' issued on 
August 8, 2006, available on our Web site at http://www.cms.hhs.gov/PhysicianSelfReferral/06a_DRA_Reports.asp (hereinafter referred to as 
the ``DRA Report to Congress''), we stated that we would require all 
hospitals (that is, not just specialty hospitals) to provide us 
information on a periodic basis concerning the investment interests in 
the hospital of physicians and the hospital's compensation arrangements 
with physicians (DRA Report to Congress 69). We stated that we would 
not limit our requirement to information concerning physician 
investments in specialty hospitals for two reasons. First, physician 
investments in any type of hospital raise potential issues concerning 
compensation arrangements that can be associated with the investment. 
For example, a disproportionate return on investment or non-bona fide 
investment (through, for example, a sham loan), creates a prohibited 
compensation arrangement under the physician self-referral law and 
raises the possibility of an illegal kickback scheme. Second, other 
types of compensation arrangements (that is, those that are not 
associated with an investment interest), implicate the physician self-
referral law, such as leasing, employment, and personal service 
arangements. It is also important to note that, although a physician 
may be highly motivated to refer patients to a hospital in which he or 
she has an ownership interest, the physician may be just as likely to 
refer patients to a hospital with which he or she has a compensation 
relationship, given that the physician may see a more direct and 
immediate financial benefit from the compensation arrangement. In the 
DRA Report to Congress, we stated that we would implement a regular 
disclosure process, but that we had not designed

[[Page 23697]]

the process at that point, and that we would consider such issues as 
whether we should: (1) Survey all hospitals annually; (2) stagger our 
survey so that all hospitals are queried but not all in the same year; 
and/or (3) focus our inquiry on certain types of relationships or 
certain hospitals. We stated that we would also consider whether, 
having once provided information, hospitals need only submit updated 
information on a yearly or other periodic basis.

C. Disclosure of Financial Relationships Report (DFRR)

    Following up on our commitment to capture information concerning 
financial relationships between all types of hospitals and physicians, 
and to assist in enforcement of the physician self-referral statute and 
implementing regulations, we created an information collection 
instrument, referred to as the Disclosure of Financial Relationships 
Report (``DFRR''). The DFRR is designed to collect information 
concerning the ownership and investment interests and compensation 
arrangements between hospitals and physicians. (Appendix C of this 
proposed rule contains the DFRR instrument and instructions for public 
comment.) We believe information submitted by hospitals would permit us 
to analyze the types of financial relationships involving hospitals and 
physicians, the structure of various compensation arrangements and 
trends therein, and potentially whether the hospitals are in compliance 
with the physician self-referral law and implementing regulations. 
Using our authority under section 1877(f) of the Act and 42 CFR 
411.361, we are proposing to send the DFRR to 500 hospitals, a number 
that we believe is necessary to provide us with sufficient information: 
(1) To determine compliance; and (2) to assist us in any future 
rulemaking concerning the reporting requirements and other physician 
self-referral provisions.
    We intend for our sample size to be a significant percentage of the 
total number of Medicare-participating hospitals. The 2007 CMS 
Statistics Handbook determined that, as of December 2006, there were 
approximately 6,200 Medicare-participating hospitals. Our goal is to 
begin by sending the DFRR to 8 to 10 percent of the Medicare-
participating hospitals (496 to 620 hospitals). We reviewed our 
available funding and determined that our resources would permit us to 
review data from 500 hospitals (both general acute care hospitals and 
specialty hospitals).
    As discussed further below, the DFRR also may assist us in making 
an informed decision as to whether to propose rulemaking for an annual 
(or other periodic) disclosure requirement for all hospitals. By posing 
a comprehensive set of questions to a significant number of hospitals, 
we believe that we will be informed not only as to whether we should 
engage in such rulemaking, but also as to what the design of the 
proposed information collection should look like.
    Originally, we had planned to pilot this information collection 
request in advance of rulemaking. Thus, we prepared a proposed 
information collection request in accordance with the Paperwork 
Reduction Act. We announced and sought public comment on the 
information collection request in a 60-day Federal Register notice 
(CMS-10236) that was published on May 18, 2007 (72 FR 28056). On 
September 14, 2007, we published in the Federal Register a revised 
information collection request in which we increased the time estimate 
for completing the DFRR and increased the time for submission of the 
DFRR from 45 days to 60 days (72 FR 52568). (For additional 
information, we refer the reader to 72 FR 28056 and 72 FR 52568.)
    In this proposed rule, we are providing a discussion of the 
potential burden associated with completing the DFRR, including an 
analysis that provides estimates of the burden for small, medium, and 
large hospitals. To better understand the potential burden for 
completing the DFRR collection, we reviewed the bed size of Medicare-
participating hospitals and developed three categories of hospitals 
(small, medium, and large hospitals). We randomly selected 20 hospitals 
from each category and requested that these 60 hospitals estimate the 
aggregate number of hours it would take them to complete and submit the 
entire DFRR collection. The 33 hospitals that responded included 11 
small, 11 medium, and 11 large hospitals. We reviewed the responses 
from the 33 hospitals and determined that the average number of hours 
to complete the DFRR was 31 hours. This figure represents a significant 
increase from our most recent time and burden estimate. Therefore, we 
believe it would be beneficial to seek further comments on the accuracy 
of the time and burden estimates associated with this information 
collection instrument. Because the information that we seek is that 
which hospitals should already be keeping in the normal course of their 
business activities (even apart from the need to document compliance 
with the physician self-referral law), we anticipate that the majority 
of the time spent completing the DFRR will be spent by administrative 
staff. We believe that the tasks involved would include retrieving the 
information and printing it from electronic files or copy it from hard 
files, which largely should involve administrative personnel. In 
addition, the review and organization of the materials would also 
impose burden on the respondent. Nevertheless, in order to err on the 
side of more potential burden rather than less, we have calculated 
costs using an hourly rate for accountants.

D. Civil Monetary Penalties

    We are proposing that the DFRR be completed, certified by the 
appropriate officer of the hospital, and received by CMS within 60 days 
of the date that appears on the cover letter or e-mail transmission of 
the DFRR. We are soliciting comment on the proposed 60-day timeframe 
for completing the DFRR.
    Section 411.361(f) provides that failure to timely submit the 
requested information concerning an entity's ownership, investment, and 
compensation arrangements may result in civil monetary penalties of up 
to $10,000 for each day beyond the deadline established for disclosure. 
Although we have the authority to impose civil monetary penalties, we 
seek not to invoke this authority and will work with entities to comply 
with the reporting requirements. Prior to imposing a civil monetary 
penalty in any amount, we would issue a letter to any hospital that 
does not return the completed DFRR, inquiring as to why the hospital 
did not return timely the completed DFRR. In addition, a hospital may, 
upon a demonstration of good cause, receive an extension of time to 
submit the requested information.

E. Uses of Information Captured by the DFRR

    As noted above, we anticipate that the DFRR will be useful in 
determining whether the financial relationships between 500 hospitals 
and the physicians associated with those hospitals are in compliance 
with the physician self-referral statute and regulations. In addition, 
the results of the DFRR may assist us in other rulemaking efforts.
    In the CY 2008 PFS proposed rule, we proposed certain changes to 
our physician self-referral rules (72 FR 38179 through 38187). With the 
exception of the anti-markup provisions, however, we have not yet 
finalized any of the proposals. We are actively working on the 
proposals, and although we expect to finalize the proposals before 
receiving and

[[Page 23698]]

analyzing the completed DFRRs, information gleaned from the completed 
DFRRs may shape our final rulemaking if that rulemaking is delayed. Our 
analysis of the DFRRs may affect subsequent proposals on these and 
other related issues.

F. Solicitation of Comments

    We are soliciting comments on the DFRR information collection 
instrument through this proposed rule as follows:
    <bullet> Whether the collection effort should be recurring, and, if 
so, whether it should be implemented on an annual or some other 
periodic basis.
    <bullet> Whether we are collecting too much or not enough 
information, and whether we are collecting the correct (or incorrect) 
type of information.
    <bullet> The amount of time it will take hospitals to complete the 
DFRR and the costs associated with completing the DFRR; the amount of 
time we should give hospitals to complete and return their responses to 
us.
    <bullet> Whether we should direct the collection instrument to all 
hospitals, and, if so, whether we should stagger the collection so that 
only a certain number of hospitals are subject to it in any given year.
    <bullet> Whether hospitals, once having completed the DFRR, should 
have to send in yearly updates and report only changed information.

X. MedPAC Recommendations

    We are required by section 1886(e)(4)(B) of the Act to respond to 
MedPAC's recommendations regarding hospital inpatient payments in our 
annual proposed and final IPPS rules. We have reviewed MedPAC's March 
2008 ``Report to the Congress: Medicare Payment Policy'' and have given 
it careful consideration in conjunction with the proposed policies set 
forth in this document. MedPAC's Recommendation 2A-1 states that ``The 
Congress should increase payment rates for the acute inpatient and 
outpatient prospective payment systems in 2009 by the projected rate of 
increase in the hospital market basket index, concurrent with 
implementation of a quality incentive payment program.'' This 
recommendation is discussed in Appendix B to this proposed rule.
    Recommendation 2A-2: MedPAC recommended that ``The Congress should 
reduce the indirect medical education adjustment in 2009 by 1 
percentage point to 4.5 percent per 10 percent increment in the 
resident-to-bed ratio. The funds obtained by reducing the indirect 
medical education adjustment should be used to fund a quality incentive 
payment program.''
    Response: Redirecting funds obtained by reducing the IME adjustment 
to fund a quality incentive payment program is consistent with the VBP 
initiatives to improve the quality of care and, therefore, merits 
consideration. However, section 502(a) of Pub. L. 108-173 modified the 
formula multiplier (c) to be used in the calculation of the IME 
adjustment beginning midway through FY 2004 and provided for a new 
schedule of formula multipliers for FYs 2005 and thereafter. 
Consequently, CMS could not implement MedPAC's recommendation to reduce 
the IME adjustment in 2009 without a statutory change. We note that 
included in the President's FY 2009 budget proposal was a proposal to 
reduce the IME adjustment from 5.5 percent to 2.2 percent over 3 years, 
starting in FY 2009, in order to better align IME payments with the 
estimated costs per case that teaching hospitals may face.
    In its June 2007 ``Report to Congress: Promoting Greater Efficiency 
in Medicare,'' MedPAC made recommendations concerning the Medicare 
hospital wage index. 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 hospital wage index classification 
system applied under the Medicare IPPS, including any alternatives that 
MedPAC recommended 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 taking into account MedPAC's 
recommendations on the Medicare hospital wage index classification 
system, to include in this 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 MedPAC 
recommendations and our proposals concerning the Medicare hospital wage 
index are discussed in section III.B. of the preamble of this proposed 
rule.
    For further information relating specifically to the MedPAC reports 
or to obtain a copy of the reports, contact MedPAC at (202) 653-7220, 
or visit MedPAC's Web site at: http://www.medpac.gov.

XI. Other Required Information

A. Requests for Data From the Public

    In order to respond promptly to public requests for data related to 
the prospective payment system, we have established a process under 
which commenters can gain access to raw data on an expedited basis. 
Generally, the data are available in computer tape or cartridge format. 
However, some files are available on diskette as well as on the 
Internet at: http://www.cms.hhs.gov/providers/hipps. Data files and the 
cost for each file, if applicable, are listed below. Anyone wishing to 
purchase data tapes, cartridges, or diskettes should submit a written 
request along with a company check or money order (payable to CMS-PUF) 
to cover the cost to the following address: Centers for Medicare & 
Medicaid Services, Public Use Files, Accounting Division, P.O. Box 
7520, Baltimore, MD 21207-0520, (410)-786-3691. Files on the Internet 
may be downloaded without charge.
1. CMS Wage Data
    This file contains the hospital hours and salaries for FY 2005 used 
to create the proposed FY 2009 prospective payment system wage index. 
The file is currently available for the NPRM and will be available by 
the beginning of May for the final rule.

------------------------------------------------------------------------
                                                 Wage data    PPS fiscal
                Processing year                     year         year
------------------------------------------------------------------------
2008..........................................         2005         2009
2007..........................................         2004         2008
2006..........................................         2003         2007
2005..........................................         2002         2006
2004..........................................         2001         2005
2003..........................................         2000         2004
2002..........................................         1999         2003
2001..........................................         1998         2002
2000..........................................         1997         2001
1999..........................................         1996         2000
1998..........................................         1995         1999
1997..........................................         1994         1998
1996..........................................         1993         1997
1995..........................................         1992         1996
1994..........................................         1991         1995
1993..........................................         1990         1994
1992..........................................         1989         1993
1991..........................................         1988         1992
------------------------------------------------------------------------

    These files support the following:
    <bullet> Notice of proposed rulemaking published in the Federal 
Register.
    <bullet> Final rule published in the Federal Register.
    Media: Diskette/most recent year on the Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2009 PPS Update.
2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index 
Values Only)
    This file contains a history of all wage indices since October 1, 
1983.
    Media: Diskette/most recent year on the Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2009 PPS Update.

[[Page 23699]]

3. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW 
by Provider
    This file includes each hospital's adjusted and unadjusted average 
hourly wage.
    Media: Internet.
    Periods Available: FY 2009 PPS Update.
4. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW 
and Pre-Reclassified Wage Index by CBSA
    This file includes each CBSA's adjusted and unadjusted average 
hourly wage.
    Media: Internet.
    Periods Available: FY 2009 PPS Update.
5. Provider Occupational Mix Adjustment Factors for Each Occupational 
Category
    This file contains each hospital's occupational mix adjustment 
factors by occupational category.
    Media: Internet.
    Periods Available: FY 2009 PPS Update.
6. PPS SSA/FIPS MSA State and County Crosswalk
    This file contains a crosswalk of State and county codes used by 
the Social Security Administration (SSA) and the Federal Information 
Processing Standards (FIPS), county name, and a historical list of 
Metropolitan Statistical Areas (MSAs).
    Media: Diskette/Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2009 PPS Update.
7. Reclassified Hospitals New Wage Index (Formerly: Reclassified 
Hospitals by Provider Only)
    This file contains a list of hospitals that were reclassified for 
the purpose of assigning a new wage index. Two versions of these files 
are created each year. They support the following:
    <bullet> Notice of proposed rulemaking published in the Federal 
Register.
    <bullet> Final rule published in the Federal Register.
    Media: Diskette/Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2009 PPS Update.
8. PPS-IV to PPS-XII Minimum Data Set
    The Minimum Data Set contains cost, statistical, financial, and 
other information from Medicare hospital cost reports. The data set 
includes only the most current cost report (as submitted, final 
settled, or reopened) submitted for a Medicare participating hospital 
by the Medicare fiscal intermediary to CMS. This data set is updated at 
the end of each calendar quarter and is available on the last day of 
the following month.
    Media: Tape/Cartridge.
    File Cost: $770.00 per year.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-IV........................................     10/01/86     10/01/87
PPS-V.........................................     10/01/87     10/01/88
PPS-VI........................................     10/01/88     10/01/89
PPS-VII.......................................     10/01/89     10/01/90
PPS-VIII......................................     10/01/90     10/01/91
PPS-IX........................................     10/01/91     10/01/92
PPS-X.........................................     10/01/92     10/01/93
PPS-XI........................................     10/01/93     10/01/94
PPS-XII.......................................     10/01/94     10/01/95
------------------------------------------------------------------------
(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-
  XIX PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Minimum Data Sets are
  part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII,
  PPS-XIX, PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Hospital Data Set
  Files (refer to item 10 below).)

9. PPS-IX to PPS-XII Capital Data Set
    The Capital Data Set contains selected data for capital-related 
costs, interest expense and related information and complete balance 
sheet data from the Medicare hospital cost report. The data set 
includes only the most current cost report (as submitted, final settled 
or reopened) submitted for a Medicare certified hospital by the 
Medicare fiscal intermediary to CMS. This data set is updated at the 
end of each calendar quarter and is available on the last day of the 
following month.
    Media: Tape/Cartridge.
    File Cost: $770.00 per year.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-IX........................................     10/01/91     10/01/92
PPS-X.........................................     10/01/92     10/01/93
PPS-XI........................................     10/01/93     10/01/94
PPS-XII.......................................     10/01/94     10/01/95
------------------------------------------------------------------------

    (Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, 
PPS-XIX PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Capital Data Sets are 
part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, 
PPS-XIX, PPS-XX, PPS-XXI, PPS-XXII, and PPS-XXIII Hospital Data Set 
Files (refer to item 10 below).)
10. PPS-XIII to PPS-XXIII Hospital Data Set
    The file contains cost, statistical, financial, and other data from 
the Medicare Hospital Cost Report. The data set includes only the most 
current cost report (as submitted, final settled, or reopened) 
submitted for a Medicare-certified hospital by the Medicare fiscal 
intermediary to CMS. The data set is updated at the end of each 
calendar quarter and is available on the last day of the following 
month.
    Media: Diskette/Internet.
    File Cost: $2,500.00.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-XIII......................................     10/01/95     10/01/96
PPS-XIV.......................................     10/01/96     10/01/97
PPS-XV........................................     10/01/97     10/01/98
PPS-XVI.......................................     10/01/98     10/01/99
PPS-XVII......................................     10/01/99     10/01/00
PPS-XVIII.....................................     10/01/00     10/01/01
PPS-XIX.......................................     10/01/01     10/01/02
PPS-XX........................................     10/01/02     10/01/03
PPS-XXI.......................................     10/01/03     10/01/04
PPS-XXII......................................     10/01/04     10/01/05
PPS-XXIII.....................................     10/01/05     10/01/06
------------------------------------------------------------------------

11. 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 payments for 
individual bills. The file contains records for all prospective payment 
system eligible hospitals, including hospitals in waiver States, and 
data elements used in the prospective payment system recalibration 
processes and related activities. Beginning with December 1988, the 
individual records were enlarged to include pass-through per diems and 
other elements.
    Media: Diskette/Internet.
    File Cost: $265.00.
    Periods Available: FY 2009 PPS Update.
12. CMS Medicare Case-Mix Index File
    This file contains the Medicare case-mix index by provider number 
as published in each year's update of the Medicare hospital inpatient 
prospective payment system. The case-mix index is a measure of the 
costliness of cases treated by a hospital relative to the cost of the 
national average of all Medicare hospital cases, using DRG weights as a 
measure of relative costliness of cases. Two versions of this file are 
created each year. They support the following:
    <bullet> Notice of proposed rulemaking published in the Federal 
Register.
    <bullet> Final rule published in the Federal Register.
    Media: Diskette/most recent year on Internet.
    Price: $165.00 per year/per file.
    Periods Available: FY 1985 through FY 2009.

[[Page 23700]]

13. MS-DRG Relative Weights (Formerly Table 5 DRG)
    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. The hard copy 
image has been copied to diskette. There are two versions of this file 
as published in the Federal Register:
    <bullet> Notice of proposed rulemaking.
    <bullet> Final rule.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2009 PPS Update.
14. PPS Payment Impact File
    This file contains data used to estimate payments under Medicare's 
hospital inpatient prospective payment systems for operating and 
capital-related costs. The data are taken from various sources, 
including the Provider-Specific File, Minimum Data Sets, and prior 
impact files. The data set is abstracted from an internal file used for 
the impact analysis of the changes to the prospective payment systems 
published in the Federal Register. This file is available for release 1 
month after the proposed and final rules are published in the Federal 
Register.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2009 PPS Update.
15. 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:
    <bullet> Notice of proposed rulemaking published in the Federal 
Register.
    <bullet> Final rule published in the Federal Register.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2009 PPS Update.
16. Prospective Payment System (PPS) Standardizing File
    This file contains information that standardizes the charges used 
to calculate relative weights to determine payments under the 
prospective payment system. Variables include wage index, cost-of-
living adjustment (COLA), case-mix index, disproportionate share, and 
the Metropolitan Statistical Area (MSA). The file supports the 
following:
    <bullet> Notice of proposed rulemaking published in the Federal 
Register.
    <bullet> Final rule published in the Federal Register.
    Media: Internet.
    File Cost: No charge.
    Periods Available: FY 2009 PPS 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:
    <bullet> The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
    <bullet> The accuracy of our estimate of the information collection 
burden.
    <bullet> The quality, utility, and clarity of the information to be 
collected.
    <bullet> Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
2. Solicitation of Comments on Proposed Requirements in Regulatory Text
    We are soliciting public comment on each of the issues listed under 
section XI.B.1. of this preamble for the following sections of this 
document that contain information collection requirements (ICRs):
a. ICRs Regarding Physician Reporting Requirements (Sec.  411.361)
    Section 411.361(a) of the regulations states that except for 
entities that furnish 20 or fewer Part A and Part B services during a 
calendar year or for Medicare covered services furnished outside the 
United States, all entities furnishing services for which payment may 
be made under Medicare must submit information to CMS or to the Office 
of the Inspector General (OIG) concerning their reportable financial 
relationships (any ownership or investment interest, or compensation 
arrangement) in the form, manner, and at times that CMS or OIG 
specifies. As described in section IX. of the preamble of this proposed 
rule, and in accordance with its authority under 42 CFR 411.361(e), CMS 
is requiring that hospitals provide information concerning their 
ownership, investment and compensation arrangements with physicians by 
completing the DFRR instrument.
    An information collection request concerning the DFRR was 
previously submitted to OMB for approval. We announced and sought 
public comment on the information collection request in both 60-day and 
30-day Federal Register notices that published on May 18, 2007 (72 FR 
28056), and September 14, 2007 (72 FR 52568), respectively. As further 
discussed in section IX. of this preamble, we have decided to obtain 
additional input from the public concerning the time and cost burden 
associated with completing and submitting the DFRR instrument. (The 
instrument is included as Appendix C to this proposed rule.) We believe 
that hospital accounting personnel would be responsible for: (1) 
Ensuring that the appropriate data or supporting documentation is 
retrieved; (2) completing the DFRR; and (3) submitting the DFRR to the 
Chief Executive Officer, Chief Financial Officer, or comparable officer 
of the hospital for his or her signature on the certification 
statement.
    Initially, CMS would require 500 hospitals to complete and submit 
the DFRR instrument. We estimate that these tasks would require 31 
hours for each of the 500 hospitals to complete the DFRR. Thus, the 
total number of burden hours required for 500 hospitals to complete the 
DFRR instrument is 15,500 hours.
b. ICRs Regarding Risk Adjustment Data (Sec.  422.310)
    As discussed in section IV.H. of the preamble of this proposed 
rule, Sec.  422.310(b) states that each MA organization must submit to 
CMS (in accordance with CMS instructions) the data necessary to 
characterize the context and purposes of each item and service provided 
to a Medicare enrollee by a provider, supplier, physician, or other 
practitioner. In addition, Sec.  422.310(b) states that CMS may collect 
data necessary to characterize the functional limitations of enrollees 
of

[[Page 23701]]

each MA organization. Section 422.310(c) lists the nature of the data 
elements to be submitted to CMS.
    The burden associated with these requirements is the time and 
effort necessary for the MA organization to submit the necessary data 
to CMS. These requirements are subject to the PRA and the associated 
burden is currently approved under OMB control number 0938-0878. 
However, under notice and comment periods separate from this proposed 
rule, we intend to revise the currently approved information collection 
to include burden estimates as they pertain to Sec.  422.310. The 
preliminary burden estimate for this proposed rule is as follows: 
Currently, there are 676 MA organizations. Assuming that 99 percent of 
encounter data claims are submitted electronically and 1 percent are 
submitted manually, we estimate that it will take 1,089 hours annually 
for submission of electronic claims and 73,335 hours annually for 
submission of manual claims. The estimated annual burden associated 
with these requirements is an annual average of 110 hours per MA 
organization.
c. ICRs Regarding Basic Commitments of Providers (Sec.  489.20)
    As discussed in section IV.I. of the preamble of this proposed 
rule, proposed Sec.  489.20(r)(2) states that a hospital, as defined in 
Sec.  489.24(b), must maintain an on-call list of physicians on its 
medical staff to provide treatment necessary to stabilize patients who 
are receiving services required under Sec.  489.24 in accordance with 
the resources available to the hospital. The burden associated with 
this requirement is the time and effort necessary to draft, maintain, 
and periodically update the list of on-call physicians. We estimate 
that it will take 3 hours for each of the 100 Medicare-participating 
hospitals to comply with this recordkeeping requirement. The estimated 
annual burden associated with this requirement is 300 hours.
    As discussed in section VII. of the preamble of this proposed rule, 
proposed Sec.  489.20(u)(1) states that, in the case of a physician-
owned hospital as defined in Sec.  489.3, the hospital must furnish 
written notice to all patients at the beginning of their hospital stay 
or outpatient visit that the hospital is a physician-owned facility. In 
addition, patients must be advised that a list of the hospital's owners 
or investors who are physicians (or immediate family members of 
physicians) is available upon request. Upon receiving the request of 
the patient or an individual on behalf of the patient, a hospital must 
immediately disseminate the list to the requesting patient.
    The burden associated with the requirements in this section is the 
time and effort necessary for a hospital to furnish written notice to 
all patients that the hospital is a physician-owned hospital. Whereas 
this requirement is subject to the PRA, the associated burden is 
currently approved under OMB control number 0938-1034, with an 
expiration date of February 28, 2011.
    In addition, there is burden associated with furnishing a patient 
with the list of the hospital's owners or investors who are physicians 
(or immediate family members of physicians) at the time of the patient 
request. However, CMS has no way to accurately quantify the burden 
because we cannot estimate the number of this type of request that a 
hospital may receive. We are soliciting public comments on the annual 
number of requests a hospital may receive for lists of physician-owners 
and investors, and will reevaluate this issue in the final rule stage 
of rulemaking.
    Proposed Sec.  489.20(u)(2) would require disclosure of physician 
ownership as a condition of continued medical staff membership or 
admitting privileges. The burden associated with this requirement is 
the time and effort required for a hospital to develop, draft, and 
implement changes to its medical staff bylaws and other policies 
governing admitting privileges. Approximately 175 physician-owned 
hospitals would be required to comply with this requirement. We 
estimate that it will require a hospital's general counsel 4 hours to 
revise a hospital's medical staff bylaws and policies governing 
admitting privileges. Therefore, the total annual hospital burden would 
be 700 hours.
    In addition, the proposed Sec.  489.20(u)(2) imposes a burden on 
physicians. As stated earlier, all physicians who are also members of 
the hospital's medical staff must agree, as a condition of continued 
medical staff membership or admitting privileges, to disclose, in 
writing, to all patients they refer to the hospital any ownership or 
investment interest in the hospital held by themselves or by an 
immediate family member. The disclosure must be made at the time the 
referral is made. The burden associated with this requirement is the 
time and effort necessary for a physician to draft a disclosure and to 
provide it to the patient at the time the referral is made to the 
physician-owned hospital. We estimate that it will take each physician, 
or designated office staff member, 1 hour to develop a disclosure 
notice and make copies that will be distributed to patients. In 
addition, we estimate 30 seconds to provide the disclosure to each 
patient and an additional 30 seconds to record the proof of disclosure 
into each patient's medical record.
    Although we can estimate the number of physician-owned hospitals, 
we are unable to quantify the number of physicians that possess an 
ownership or investment interest in hospitals. There is limited data 
available concerning physician ownership in hospitals. The studies to 
date, including those by CMS and the Government Accountability Office, 
pertain to physician ownership in specialty hospitals (cardiac, 
orthopedic, and surgical hospitals). These specialty hospital studies 
published data concerning the average percentage of shares of direct 
ownership by physicians (less than 2 percent), indirect ownership 
through group practices, and the aggregate percentage of physician 
ownership, but did not publish the number of physician owners in these 
types of hospitals. More importantly, proposed Sec.  489.20(u)(2) would 
apply to physician ownership in any type of hospital. Our other 
research involved a review of enrollment data. However, the CMS 
enrollment application (CMS-855) requires the reporting of ownership 
interests that exceed 5 percent or greater, and, thus, most physician 
ownership is not captured. In summary, because we are unable to 
estimate the total physician burden associated with this reporting 
requirement, we are seeking public comment pertaining to this burden 
and will reevaluate this issue in the final rule stage of rulemaking.
    Proposed Sec.  489.20(v) states that the aforementioned 
requirements in Sec.  489.20(u)(1) and (u)(2) do not apply to a 
physician-owned hospital that does not have at least one referring 
physician who has an ownership or investment interest in the hospital 
or who has an immediate family member who has an ownership or 
investment interest in the hospital. To comply with this exception, an 
eligible hospital must sign an attestation to that effect and maintain 
the document in its records. Therefore, the number of hospitals that 
are now subject to the disclosure requirement would be slightly 
reduced. However, there may be a minimal burden attributable to the 
proposed requirement that the hospital maintain an attestation 
statement in its records.
    The burden associated with this requirement will be limited to 
those physician-owned hospitals that do not have at least one referring 
physician who has an ownership or investment interest in the hospital 
or who has an immediate family member who has an

[[Page 23702]]

ownership or investment interest in the hospital. The burden would 
include the time and effort for these hospitals to develop, sign, and 
maintain the attestations in their records. We estimate that 10 
percent, or approximately 18, of the estimated 175 physician-owned 
hospitals would be subject to this requirement. We estimate that it 
would take each of these physician-owned hospitals an average of 1 hour 
to develop, sign, and maintain the attestation in its records. The 
estimated annual burden associated with this requirement is 18 hours. 
However, because we have no way of knowing for certain the number of 
physician-owned hospitals that do not have at least one referring 
physician who has an ownership or investment interest in the hospital 
or who has an immediate family member who has an ownership or 
investment interest in the hospital, we are requesting public comment 
regarding the accuracy of our estimate and the associated burden with 
the attestation requirement.
    Section 489.20(w) requires all hospitals, as defined in Sec.  
489.24(b), to furnish all patients notice, in accordance with Sec.  
482.13(b)(2), at the beginning of their hospital stay or outpatient 
visit if a doctor of medicine or a doctor of osteopathy is not present 
in the hospital 24 hours per day, 7 days per week. The notice must 
indicate how the hospital will meet the medical needs of any inpatient 
who develops an emergency medical condition, as defined in Sec.  
489.24(b), at a time when there is no physician present in the 
hospital. The burden associated with this requirement is the time and 
effort necessary for each hospital to develop a standard notice to 
furnish to its patients. Whereas this requirement is subject to the 
PRA, the associated burden is approved under OMB control number 0938-
1034 with a current expiration date of February 28, 2011.

                               Estimated Annual Reporting and Recordkeeping Burden
----------------------------------------------------------------------------------------------------------------
                                                                                    Burden per
     Regulation section(s)       OMB control No.    Respondents      Responses       response      Total annual
                                                                                      (hours)     burden (hours)
----------------------------------------------------------------------------------------------------------------
Sec.  411.361.................  0938-New........             500             500              31          15,500
Sec.  422.310(b)..............  0938-0878.......             676             676             110        * 74,424
Sec.  489.20(r)...............  0938-New........             100             100               3             300
Sec.  489.20(u)(1) and (w)....  0938-1034.......           2,679      49,735,635              **         839,599
Sec.  489.20(u)(2)............  0938-New........             175             175               4             700
Sec.  489.20(v)...............  0938-New........              18              18               1              18
                                                                                 -------------------------------
    Total.....................  ................  ..............  ..............  ..............         930,541
----------------------------------------------------------------------------------------------------------------
* Burden estimate is based on proposed revisions to the currently approved OMB control number.
** There are multiple requirements associated with the regulation section approved under this OMB control
  number. There is no uniform estimate of the burden per response.

3. Associated Information Collections Not Specified in Regulatory Text
    This proposed rule imposes collection of information requirements 
as outlined in the regulation text and specified above. However, this 
proposed rule also makes reference to several associated information 
collections that are not discussed in the regulation text. The 
following is a discussion of these collections, which have already 
received OMB approval.
a. Present on Admission (POA) Indicator Reporting
    Section II.F.8 of the preamble of this proposed rule discusses the 
present on admission indicator (POA) reporting requirements. As stated 
earlier, POA indicator information is necessary to identify which 
conditions were acquired during hospitalization for the hospital-
acquired condition (HAC) payment provision and for broader public 
health uses of Medicare data. Through Change Request No. 5499 (released 
May 11, 2007), CMS issued instructions requiring IPPS hospitals to 
submit the 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 codes on Medicare claims. While 
the requirement is subject to the PRA; the associated burden is 
approved under 0938-0997 with an expiration date of August 31, 2009.
b. Proposed Add-On Payments for New Services and Technologies
    Section II.J. of the preamble of this proposed rule discusses 
proposed add-on payments for new services and technologies. 
Specifically, this section states that applicants for add-on payments 
for new medical services or technologies for FY 2010 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 a final 
rule published in the Federal Register on September 7, 2001 (66 FR 
46902). As stated in that final rule, we believe the associated burden 
is exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). 
Collection of the information for this requirement will be conducted on 
an individual case-by-case basis.
c. Reporting of Hospital Quality Data for Annual Hospital Payment 
Update
    As noted in section IV.B. of the preamble of this proposed rule, 
the RHQDAPU program was originally established to implement section 
501(b) of Pub. L. 108-173, thereby expanding our voluntary Hospital 
Quality Initiative. 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, 2010.
    We added additional quality measures to the RHQDAPU program and 
submitted the information collection request to OMB for approval. This 
expansion of the RHQDAPU measures was part of our implementation of 
section 5001(a) of the DRA. Section 1886(b)(3)(B)(viii)(III) of the 
Act, added

[[Page 23703]]

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 furnished by hospitals in inpatient settings.'' The 
burden associated with these reporting requirements is currently 
approved under OMB control number 0938-1022 with a current expiration 
date of December 31, 2008.
    However, for FY 2009, we submitted to OMB for approval a revised 
information collection request using the same OMB control number (0938-
1022). In the revised request, we proposed to add three new RHQDAPU 
quality measures that we adopted for the FY 2009 RHADAPU program to the 
PRA process. These three measures are as follows:
    <bullet> Pneumonia 30-day Mortality (Medicare patients);
    <bullet> SCIP Infection 4: Cardiac Surgery Patients with Controlled 
6AM Postoperative Serum Glucose; and
    <bullet> SCIP Infection 6: Surgery Patients with Appropriate Hair 
Removal.
    The revised information collection request was announced in the 
Federal Register via an emergency notice on January 28, 2008 (73 FR 
4868). The information collection request is currently under review by 
OMB. Once approved, we will submit another revision of the information 
collection request to obtain approval for the new measures contained in 
this proposed rule.
    Section IV.B.5. of the preamble of this proposed rule also 
discusses the requirements for the continuous collection of HCAHPS 
quality data. The HCAHPS survey is designed to produce comparable data 
on the patient's perspective on care that allows objective and 
meaningful comparisons between hospitals on domains that are important 
to consumers. We also added the HCAHPS survey to the PRA process in the 
information collection request currently approved under OMB control 
number 0938-1022 with a current expiration date of December 31, 2008.
    Section IV.B.9. of the preamble of this proposed rule addresses the 
reconsideration and appeal procedures for a hospital that we believe 
did not meet the RHQDAPU program requirements. If a hospital disagrees 
with our determination, it may submit a written request to us 
requesting that we reconsider our decision. The hospital's letter must 
explain the reasons it believes it did meet the RHQDAPU program 
requirements. While this is a reporting requirement, the burden 
associated with it is not subject to the PRA under 5 CFR 1320.4(a)(2). 
The burden associated with information collection requirements imposed 
subsequent to an administrative action is not subject to the PRA.
d. Occupational Mix Adjustment to the FY 2009 Index (Hospital Wage 
Index Occupational Mix Survey)
    Section III. of the preamble of this proposed rule details the 
proposed changes to the hospital wage index. Specifically, section 
III.D. addresses the proposed occupational mix adjustment to the 
proposed FY 2009 index. While the preamble does not contain any new 
information collection requirements, it is important to note that there 
is an OMB approved collection associated with the hospital wage index.
    Section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of 
the Act to require CMS to collect data at least once every 3 years on 
the occupational mix of employees for each short-term, acute care 
hospital participating in the Medicare program, in order to construct 
an occupational mix adjustment to the wage index. We collect the data 
via the occupational mix survey.
    The burden associated with this information collection request is 
the time and effort required to collect and submit the data in the 
Hospital Wage Index Occupational Mix Survey to CMS. While this burden 
is subject to the PRA, it is already approved under OMB control number 
0938-0907, with an expiration date of February 28, 2011.
4. Addresses for Submittal of Comments on Information Collection 
Requirements
    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
    2. Mail copies to the address specified in the ADDRESSES section of 
this proposed rule and to-- Office of Information and Regulatory 
Affairs, Office of Management and Budget, Room 10235, New Executive 
Office Building, Washington, DC 20503, Attn: Carolyn L. Raffaelli, CMS 
Desk Officer, CMS-1390-P; E-mail: <a href="/cdn-cgi/l/email-protection#c083a1b2afacb9ae9f8cee9f92a1a6a6a1a5acaca980afada2eea5afb0eea7afb6"><span class="__cf_email__" data-cfemail="135072617c7f6a7d4c5f3d4c4172757572767f7f7a537c7e713d767c633d747c65">[email protected]</span></a>. 
Fax (202) 395-6974.

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.

List of Subjects

42 CFR Part 411

    Kidney diseases, Medicare, Physician referral, Reporting and 
recordkeeping requirements.

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

42 CFR Part 422

    Administrative practice and procedure, Grant programs--health, 
Health care, Health insurance, Health maintenance organizations (HMO), 
Loan programs--health, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.

    For the reasons stated in the preamble of this proposed rule, the 
Centers for Medicare & Medicaid Services is proposing to amend 42 CFR 
Chapter IV as follows:

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE 
PAYMENT

    1. The authority citation for part 411 continues to read as 
follows:

    Authority: Secs. 1102, 1860D-1 through 1860D-42, 1871, and 1877 
of the Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-
152, 1395hh, and 1395nn).

    2. Section 411.351 is amended by--
    a. Revising the definition of ``physician''.
    b. Revising the definition of ``physician organization''.
    The revisions read as follows:


Sec.  411.351  Definitions.

* * * * *
    Physician means a doctor of medicine or osteopathy, a doctor of 
dental surgery or dental medicine, a doctor of podiatric medicine, a 
doctor of optometry, or a chiropractor, as defined in section 1861(r) 
of the Act. A physician and the

[[Page 23704]]

professional corporation of which he or she is a sole owner are the 
same for purposes of this subpart.
* * * * *
    Physician organization means a physician, a physician practice, or 
a group practice that complies with the requirements of Sec.  411.352.
* * * * *
    3. Section 411.353 is amended by revising paragraph (c) to read as 
follows:


Sec.  411.353  Prohibition on certain referrals by physicians and 
limitations on billing.

* * * * *
    (c) Denial of payment. Except as provided in paragraph (e) of this 
section, no Medicare payment may be made for a designated health 
service that is furnished pursuant to a prohibited referral. The period 
during which referrals are prohibited is the period of disallowance. 
For purposes of this section, with respect to the following types of 
noncompliance, the period of disallowance begins at the time the 
financial relationship fails to satisfy the requirements of an 
applicable exception and ends no later than--
    (1) Where the noncompliance is unrelated to compensation, the date 
that the financial relationship satisfies all of the requirements of an 
applicable exception;
    (2) Where the noncompliance is due to the payment of excess 
compensation, the date on which the excess compensation is returned to 
the party that paid it and the financial relationship satisfies all of 
the requirements of an applicable exception; or
    (3) Where the noncompliance is due to the payment of compensation 
that is of an amount insufficient to satisfy the requirements of an 
applicable exception, the date on which the additional required 
compensation is paid to the party to which it is owed such that the 
financial relationship would satisfy all of the requirements of the 
exception as of its date of inception.
* * * * *
    4. Section 411.354 is amended by--
    a. Adding a new paragraph (a)(1)(iii).
    b. Revising paragraph (c)(2)(iv).
    c. Revising paragraph (c)(3)(ii).
    The addition and revisions read as follows:


Sec.  411.354  Financial relationship, compensation, and ownership or 
investment interest.

    (a) * * *
    (1) * * *
    (iii) For purposes of paragraph (c) of this section, an entity that 
furnishes DHS is deemed to stand in the shoes of an organization in 
which it has a 100 percent ownership interest.
* * * * *
    (c) * * *
    (2) * * *
    (iv) For purposes of paragraph (c)(2)(i) of this section, a 
physician is deemed to ``stand in the shoes'' of his or her physician 
organization unless the total compensation from the physician 
organization to the physician satisfies the requirements of Sec.  
411.357(c), (d), or (l).
    (3) * * *
    (ii) The provisions of paragraphs (c)(1)(ii) and (c)(2)(iv) of this 
section--
    (A) Need not apply during the original term or current renewal term 
of an arrangement that satisfied the requirements of Sec.  411.357(p) 
as of September 5, 2007 (42 CFR parts 400-413, revised as of October 1, 
2007);
    (B) Do not apply to an arrangement that satisfies the requirements 
of Sec.  411.355(e); and
    (C) Do not apply with respect to an arrangement between a physician 
organization and a component of an academic medical center listed in 
Sec.  411.355(e)(2) for the provision to that academic medical center 
of only services required to satisfy the academic medical center's 
obligations under the Medicare graduate medical education (GME) rules 
in part 413, subpart F of this chapter.
* * * * *

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    5. 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).

    6. Section 412.4 is amended by revising paragraph (c)(3) to read as 
follows:


Sec.  412.4  Discharges and transfers.

* * * * *
    (c) * * *
    (3) To home under a written plan of care for the provision of home 
health services from a home health agency and those services begin--
    (i) Effective for fiscal years prior to FY 2009, within 3 days 
after the date of discharge; and
    (ii) Effective FY 2009, within 7 days after the date of discharge.
* * * * *
    7. Section 412.22 is amended by--
    a. In the introductory text of paragraph (e), removing the phrase 
``paragraph (f) of this section'' and adding in its place ``paragraphs 
(e)(1) (vi) and (f) of this section''.
    b. Adding a new paragraph (e)(1)(vi).
    The addition reads as follows:


Sec.  412.22  Excluded hospitals and hospital units: General rules.

* * * * *
    (e) * * *
    (1) * * *
    (vi) Effective October 1, 2008, if a State hospital that is 
occupying space in the same building or on the same campus as another 
State hospital cannot meet the criterion under paragraph (e)(1)(i) of 
this section solely because its governing body is under the control of 
the State hospital with which it shares a building or a campus, or is 
under the control of a third entity that also controls the State 
hospital with which it shares a building or a campus, the State 
hospital can nevertheless qualify for an exclusion if it meets the 
other applicable criteria in this section and--
    (A) Both State hospitals occupy space in the same building or on 
the same campus and have been continuously owned and operated by the 
State since October 1, 1995;
    (B) Is required by State law to be subject to the governing 
authority of the State hospital with which it shares space or the 
governing authority of a third entity that controls both hospitals; and
    (C) Was excluded from the inpatient prospective payment system 
before October 1, 1995, and continues to be excluded from the inpatient 
prospective payment system through September 30, 2008.
* * * * *
    8. Section 412.64 is amended by--
    a. Republishing the introductory text of paragraph (b)(1)(ii) and 
revising paragraph (b)(1)(ii)(A).
    b. In the introductory text of paragraph (h)(4), removing the date 
``September 30, 2008'' and adding in its place ``September 30, 2011''.
    The revision reads as follows:


Sec.  412.64  Federal rates for inpatient operating costs for Federal 
fiscal year 2005 and subsequent fiscal years.

* * * * *
    (b) * * *
    (1) * * *
    (ii) The term urban area means--
    (A) A Metropolitan Statistical Area or a Metropolitan division (in 
the case where a Metropolitan Statistical Area is divided into 
Metropolitan Divisions), as defined by the Executive Office of 
Management and Budget; or
* * * * *
    9. Section 412.87 is amended by--

[[Page 23705]]

    a. Revising paragraph (b)(1).
    b. Adding a new paragraph (c).
    The revision and addition read as follows:


Sec.  412.87  Additional payment for new medical services and 
technologies: General provisions.

* * * * *
    (b) * * *
    (1) A new medical service or technology represents an advance that 
substantially improves, relating to technologies previously available, 
the diagnosis or treatment of Medicare beneficiaries.
* * * * *
    (c) Announcement of determinations and deadline for consideration 
of new medical service or technology applications. CMS will consider 
whether a new medical service or technology meets the eligibility 
criteria specified in paragraph (b) of this section and announce the 
results in the Federal Register as part of its annual updates and 
changes to the IPPS. CMS will only consider, for add-on payments for a 
particular fiscal year, an application for which the new medical 
service or technology has received FDA approval or clearance by July 1 
prior to the particular fiscal year.
    10. Section 412.230 is amended by--
    a. Revising paragraph (d)(1)(iv)(C).
    b. Adding a new paragraph (d)(1)(iv)(D).
    The addition and revision read as follows:


Sec.  412.230  Criteria for an individual hospital seeking 
redesignation to another rural area or an urban area.

* * * * *
    (d) * * *
    (1) * * *
    (iv) * * *
    (C) With respect to redesignations for fiscal years 2002 through 
2009, the hospital's average hourly wage is equal to, in the case of a 
hospital located in a rural area, at least 82 percent, and in the case 
of a hospital located in an urban area, at least 84 percent of the 
average hourly wage of hospitals in the area to which it seeks 
redesignation.
    (D) With respect to redesignations for fiscal year 2010 and later 
fiscal years, the hospital's average hourly wage is equal to, in the 
case of a hospital located in a rural area, at least 86 percent, and in 
the case of a hospital located in an urban area, at least 88 percent of 
the average hourly wage of hospitals in the area to which it seeks 
redesignation.
* * * * *
    11. Section 412.232 is amended by revising paragraphs (c)(1) and 
(c)(2) to read as follows:


Sec.  412.232  Criteria for all hospitals in a rural county seeking 
urban redesignation.

* * * * *
    (c) * * *
    (1) Aggregate hourly wage for fiscal years before fiscal year 
2010--(i) Aggregate hourly wage. With respect to redesignations 
effective beginning fiscal year 1999 and before fiscal year 2010, the 
aggregate average hourly wage for all hospitals in the rural county 
must be equal to at least 85 percent of the average hourly wage in the 
adjacent urban area.
    (ii) Aggregate hourly wage weighted for occupational mix. For 
redesignations effective before fiscal year 1999, the aggregate hourly 
wage for all hospitals in the rural county, weighed for occupational 
categories, is at least 90 percent of the average hourly wage in the 
adjacent urban area.
    (2) Aggregate hourly wage for fiscal year 2010 and later fiscal 
years. With respect to redesignations effective for fiscal year 2010 
and later fiscal years, the aggregate average hourly wage for all 
hospitals in the rural county must be equal to at least 88 percent of 
the average hourly wage in the adjacent urban area.
* * * * *
    12. Section 412.234 is amended by revising paragraphs (b)(1) and 
(b)(2) to read as follows:


Sec.  412.234  Criteria for all hospitals in an urban county seeking 
redesignation to another urban area.

* * * * *
    (b) * * *
    (1) Aggregate hourly wage for fiscal years before fiscal year 
2010--(i) Aggregate hourly wage. With respect to redesignations 
effective beginning fiscal year 1999 and before fiscal year 2010, the 
aggregate average hourly wage for all hospitals in the urban county 
must be at least 85 percent of the average hourly wage in the urban 
area to which the hospitals in the county seek reclassification.
    (ii) Aggregate hourly wage weighted for occupational mix. For 
redesignations effective before fiscal year 1999, the aggregate hourly 
wage for all hospitals in the county, weighed for occupational 
categories, is at least 90 percent of the average hourly wage in the 
adjacent urban area.
    (2) Aggregate hourly wage for fiscal year 2010 and later fiscal 
years. With respect to redesignations effective for fiscal year 2010 
and later fiscal years, the aggregate average hourly wage for all 
hospitals in the urban county must be at least 88 percent of the 
average hourly wage in the urban area to which the hospitals in the 
county seek reclassification.
* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT 
RATES FOR SKILLED NURSING FACILITIES

    13. 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).


Sec.  413.79  [Amended]

    14. In Sec.  413.79(f)(6)(iv), remove the cross-reference ``Sec.  
413.75(d)'' and add the cross-reference ``paragraph (d) of this 
section'' in its place.

PART 422--MEDICARE ADVANTAGE PROGRAM

    15. The authority citation for Part 422 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    16. Section 422.310 is revised to read as follows:


Sec.  422.310  Risk adjustment data.

    (a) Definition of risk adjustment data. Risk adjustment data are 
all data that are used in the development and application of a risk 
adjustment payment model.
    (b) Data collection: Basic rule. Each MA organization must submit 
to CMS (in accordance with CMS instructions) the data necessary to 
characterize the context and purposes of each item and service provided 
to a Medicare enrollee by a provider, supplier, physician, or other 
practitioner. CMS may also collect data necessary to characterize the 
functional limitations of enrollees of each MA organization.
    (c) Sources and extent of data. (1) To the extent required by CMS, 
risk adjustment data must account for the following:
    (i) Items and services covered under the original Medicare program.
    (ii) Medicare-covered items and services for which Medicare is not 
the primary payer.
    (iii) Other additional or supplemental benefits that the MA 
organization may provide.
    (2) The data must account separately for each provider, supplier, 
physician,

[[Page 23706]]

or other practitioner that would be permitted to bill separately under 
the original Medicare program, even if they participate jointly in the 
same service.
    (d) Other data requirements. (1) MA organizations must submit data 
that conform to CMS' requirements for data equivalent to Medicare fee-
for-service data, when appropriate, and to all relevant national 
standards. CMS may specify abbreviated formats for data submission 
required of MA organizations.
    (2) The data must be submitted electronically to the appropriate 
CMS contractor.
    (3) MA organizations must obtain the risk adjustment data required 
by CMS from the provider, supplier, physician, or other practitioner 
that furnished the item or service.
    (4) MA organizations may include in their contracts with providers, 
suppliers, physicians, and other practitioners, provisions that require 
submission of complete and accurate risk adjustment data as required by 
CMS. These provisions may include financial penalties for failure to 
submit complete data.
    (e) Validation of risk adjustment data. MA organizations and their 
providers and practitioners will be required to submit a sample of 
medical records for the validation of risk adjustment data, as required 
by CMS. There may be penalties for submission of false data.
    (f) Use of data. CMS uses the data obtained under this section to 
determine the risk adjustment factors used to adjust payments, as 
required under Sec. Sec.  422.304(a) and (c). CMS may also use the data 
for other purposes, including updating of risk adjustment models.
    (g) Deadlines for submission of risk adjustment data. Risk 
adjustment factors for each payment year are based on risk adjustment 
data submitted for items and services furnished during the 12-month 
period before the payment year that is specified by CMS. As determined 
by CMS, this 12-month period may include a 6-month data lag that may be 
changed or eliminated as appropriate. CMS may adjust these deadlines, 
as appropriate.
    (1) The annual deadline for risk adjustment data submission is the 
first Friday in September for risk adjustment data reflecting items and 
services furnished during the 12-month period ending the prior June 30, 
and the first Friday in March for data reflecting services furnished 
during the 12-month period ending the prior December 31.
    (2) CMS allows a reconciliation process to account for late data 
submissions. CMS continues to accept risk adjustment data submitted 
after the March deadline until January 31 of the year following the 
payment year. After the payment year is completed, CMS recalculates the 
risk factors for affected individuals to determine if adjustments to 
payments are necessary. Risk adjustment data that are received after 
the annual January 31 late data submission deadline will not be 
accepted for the purposes of reconciliation.

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

    17. 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).

    18. Section 489.3 is amended by revising the definition of 
``physician-owned hospital'' to read as follows:


Sec.  489.3  Definitions.

* * * * *
    Physician-owned hospital means any participating hospital (as 
defined in Sec.  489.24) in which a physician, or an immediate family 
member of a physician (as defined in Sec.  411.351 of this chapter), 
has an ownership or investment interest. The ownership or investment 
interest may be through equity, debt, or other means, and includes an 
interest in an entity that holds an ownership or investment interest in 
the hospital. This definition does not include a hospital with 
physician ownership or investment interests that satisfy the 
requirements at Sec.  411.356(a) or (b) of this chapter.
* * * * *
    19. Section 489.20 is amended by--
    a. Revising paragraph (r)(2).
    b. Revising paragraph (u).
    c. Redesignating paragraphs (v) and (w) as paragraphs (w) and (x), 
respectively.
    d. Adding a new paragraph (v).
    The revisions and addition read as follows:


Sec.  489.20  Basic commitments.

* * * * *
    (r) * * *
    (2) An on-call list of physicians on its medical staff available to 
provide treatment necessary after the initial examination to stabilize 
individuals with emergency medical conditions who are receiving 
services required under Sec.  489.24 in accordance with the resources 
available to the hospital; and
* * * * *
    (u) Except as provided in paragraph (v) of this section, in the 
case of a physician-owned hospital as defined in Sec.  489.3--
    (1) To furnish written notice to all patients at the beginning of 
their hospital stay or outpatient visit that the hospital is a 
physician-owned hospital, in order to assist the patients in making an 
informed decision regarding their care, in accordance with Sec.  
482.13(b)(2) of this subchapter. The notice should disclose, in a 
manner reasonably designed to be understood by all patients, the fact 
that the hospital meets the Federal definition of a physician-owned 
hospital specified in Sec.  489.3 and that the list of the hospital's 
owners or investors who are physicians or immediate family members of 
physicians (as defined at Sec.  411.351 of this chapter) must be 
provided to the patients at the time the request for the list is made 
by or on behalf of the patient. For purposes of this paragraph (u)(1), 
the hospital stay or outpatient visit begins with the provision of a 
package of information regarding scheduled preadmission testing and 
registration for a planned hospital admission for inpatient care or 
outpatient service.
    (2) To require all physicians who are members of the hospital's 
medical staff to agree, as a condition of continued medical staff 
membership or admitting privileges, to disclose, in writing, to all 
patients they refer to the hospital any ownership or investment 
interest in the hospital that is held by themselves or by an immediate 
family member (as defined in Sec.  411.351 of this chapter). Disclosure 
must be required at the time the referral is made.
    (v) The requirements of paragraph (u) of this section do not apply 
to any physician-owned hospital that does not have at least one 
referring physician (as defined at Sec.  411.351 of this chapter) who 
has an ownership or investment interest in the hospital or who has an 
immediate family member who has an ownership or investment interest in 
the hospital, provided that such hospital signs an attestation 
statement to that effect and maintain such a notice in its records.
* * * * *
    20. Section 489.24 is amended by--
    a. Revising paragraph (a)(2).
    b. Revising paragraph (f).
    c. Revising paragraph (j).
    The revisions read as follows:


Sec.  489.24  Special responsibilities of Medicare hospitals in 
emergency cases.

    (a) * * *
    (2) Nonapplicability of provisions of this section. Sanctions under 
this section for an inappropriate transfer during a national emergency 
or for the direction or relocation of an individual to receive medical 
screening at an

[[Page 23707]]

alternate location pursuant to an appropriate State emergency 
preparedness plan or, in the case of a public health emergency that 
involves a pandemic infectious disease, pursuant to a State pandemic 
preparedness plan do not apply to a hospital with a dedicated emergency 
department located in an emergency area during an emergency period, as 
specified in section 1135(g)(1) of the Act. A waiver of these sanctions 
is limited to a 72-hour period beginning upon the implementation of a 
hospital disaster protocol, except that, if a public health emergency 
involves a pandemic infectious disease (such as pandemic influenza), 
the waiver will continue in effect until the termination of the 
applicable declaration of a public health emergency, as provided for by 
section 135(e)(1)(B) of the Act.
* * * * *
    (f) Recipient hospital responsibilities. A participating hospital 
that has specialized capabilities or facilities (including, but not 
limited to, facilities such as burn units, shock-trauma units, neonatal 
intensive case units, or, with respect to rural areas, regional 
referral centers (which, for purposes of this subpart, mean hospitals 
meeting the requirements of referral centers found at Sec.  412.96 of 
this chapter)) may not refuse to accept from a referring hospital 
within the boundaries of the United States an appropriate transfer of 
an individual who requires such specialized capabilities or facilities 
if the receiving hospital has the capacity to treat the individual. 
This provision applies to--
    (1) Any participating hospital with specialized capabilities, 
regardless of whether the hospital has a dedicated emergency 
department; and
    (2) An individual who has been admitted under paragraph (d)(2)(i) 
of this section and who has not been stabilized.
* * * * *
    (j) Availability of on-call physicians. In accordance with the on-
call list requirements specified in Sec.  489.20(r)(2), a hospital must 
have written policies and procedures in place--
    (1) To respond to situations in which a particular specialty is not 
available or the on-call physician cannot respond because of 
circumstances beyond the physician's control; and
    (2) To provide that emergency services are available to meet the 
needs of individuals with emergency medical conditions if a hospital 
elects to--
    (i) Permit on-call physicians to schedule elective surgery during 
the time that they are on call;
    (ii) Permit on-call physicians to have simultaneous on-call duties; 
and
    (iii) Participate in a formal community call plan. Notwithstanding 
participation in a community call plan, hospitals are still required to 
perform medical screening examinations on individuals who present 
seeking treatment and to conduct appropriate transfers. The formal 
community plan must include the following elements:
    (A) A clear delineation of on-call coverage responsibilities; that 
is, when each hospital participating in the plan is responsible for on-
call coverage.
    (B) A description of the specific geographic area to which the plan 
applies.
    (C) A signature by an appropriate representative of each hospital 
participating in the plan.
    (D) Assurances that any local and regional EMS system protocol 
formally includes information on community on-call arrangements.
    (E) Evidence of engagement of the hospitals participating in the 
community call plan in an analysis of the specialty on-call needs of 
the community for which the plan is effective.
    (F) A statement specifying that even if an individual arrives at a 
hospital that is not designated as the on-call hospital, that hospital 
still has an obligation under Sec.  489.24 to provide a medical 
screening examination and stabilizing treatment within its capability, 
and that hospitals participating in the community call plan must abide 
by the regulations under Sec.  489.24 governing appropriate transfers.
    (G) An annual assessment of the community call plan by the 
participating hospitals.
    21. Section 489.53 is amended by revising paragraph (c) to read as 
follows:


Sec.  489.53  Termination by CMS.

* * * * *
    (c) Termination of agreements with physician-owned hospitals. In 
the case of a physician-owned hospital, as defined at Sec.  489.3, CMS 
may terminate the provider agreement if the hospital failed to comply 
with the requirements of Sec.  489.20(u) or (w).
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: April 1, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.

    Dated: April 10, 2008.
Michael O. Leavitt,
Secretary.

    [Editorial Note: The following Addendum and appendixes will not 
appear in the Code of Federal Regulations.]

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, 
and Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2008

I. Summary and Background

    In this Addendum, we are setting forth 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. We are also setting forth the 
proposed rate-of-increase percentages for updating the target 
amounts for certain hospitals and hospital units excluded from the 
IPPS. In general, except for SCHs, MDHs, and hospitals located in 
Puerto Rico, each hospital's payment per discharge under the IPPS is 
based on 100 percent of the Federal national rate, also known as the 
national adjusted standardized amount. This amount reflects the 
national average hospital cost per case from a base year, updated 
for inflation.
    SCHs are paid based on whichever of the following rates yields 
the greatest aggregate payment: The Federal national rate; the 
updated hospital-specific rate based on FY 1982 costs per discharge; 
the updated hospital-specific rate based on FY 1987 costs per 
discharge; or the updated hospital-specific rate based on FY 1996 
costs per discharge.
    Under section 1886(d)(5)(G) of the Act, MDHs historically have 
been paid based on the Federal national rate or, if higher, the 
Federal national rate plus 50 percent of the difference between the 
Federal national rate and the updated hospital-specific rate based 
on FY 1982 or FY 1987 costs per discharge, whichever was higher. 
(MDHs did not have the option to use their FY 1996 hospital-specific 
rate.) 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, an MDH must rebase its hospital-specific 
rates to 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.

[[Page 23708]]

    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 FY 2009. 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 2009. Section IV. of this 
Addendum sets forth our proposed changes for determining the rate-
of-increase limits for certain hospitals excluded from the IPPS for 
FY 2009. The tables to which we refer in the preamble of this 
proposed rule are presented in section V. of this Addendum of this 
proposed rule.

II. Proposed Changes to Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2009

    The basic methodology for determining prospective payment rates 
for hospital inpatient operating costs for FY 2005 and subsequent 
fiscal years is set forth at Sec.  412.64. The basic methodology for 
determining the prospective payment rates for hospital inpatient 
operating costs for hospitals located in Puerto Rico for FY 2005 and 
subsequent fiscal years is set forth at Sec. Sec.  412.211 and 
412.212. Below we discuss the factors used for determining the 
prospective payment rates.
    In summary, the proposed standardized amounts set forth in 
Tables 1A, 1B, and 1C, of section VI. of this Addendum reflect--
    <bullet> Equalization of the standardized amounts for urban and 
other areas at the level computed for large urban hospitals during 
FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) 
of the Act, updated by the applicable percentage increase required 
under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the 
Act.
    <bullet> The labor-related share that is applied to the 
standardized amounts and Puerto Rico-specific standardized amounts 
to give the hospital the highest payment, as provided for under 
sections 1886(d)(3)(E), and 1886(d)(9)(C)(iv) of the Act.
    <bullet> Proposed updates of 3.0 percent for all areas (that is, 
the estimated full market basket percentage increase of 3.0 
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 applicable 
percentage increase by 2.0 percentage points for a hospital that 
fails to submit data, in a form and manner specified by the 
Secretary, relating to the quality of inpatient care furnished by 
the hospital.
    <bullet> A proposed update of 3.0 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 Sec.  412.211(c), which states that we update the 
Puerto Rico-specific standardized amount using the percentage 
increase specified in Sec.  412.64(d)(1), or the percentage increase 
in the market basket index for prospective payment hospitals for all 
areas.
    <bullet> 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.
    <bullet> An adjustment to ensure the wage index update and 
changes are budget neutral, as provided for under section 
1886(d)(3)(E) of the Act.
    <bullet> 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 2008 budget neutrality 
factor and applying a revised factor.
    <bullet> An adjustment to remove the FY 2008 outlier offset and 
apply an offset for FY 2009.
    <bullet> An adjustment to ensure the effects of the rural 
community hospital demonstration required under section 410A of Pub. 
L. 108-173 are budget neutral, as required under section 410A(c)(2) 
of Pub. L. 108-173.
    <bullet> An adjustment to eliminate the effect of coding or 
classification changes that do not reflect real changes in case-mix, 
as discussed below and in section II.D. of the preamble to this 
proposed rule.
    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. For FY 2009, 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 rural floor adopted under section 
1886(d)(3)(E) of the Act to the standardized amounts, beginning with 
FY 2009, we are proposing to apply the imputed rural floor budget 
neutrality adjustment to the wage indices. Beginning in FY 2009, we 
are also proposing 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 proposals concerning the rural floor and the imputed 
rural floor, including the proposal for a within-State budget 
neutrality adjustment, we refer readers to section III.B.2.b. of the 
preamble to this proposed rule.

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) or, for Puerto Rico, adjusted 
target amounts from a base period (section 1886(d)(9)(B)(i) of the 
Act), updated and otherwise adjusted in accordance with the 
provisions of section 1886(d) of the Act. The September 1, 1983 
interim final rule (48 FR 39763) contained a detailed explanation of 
how base-year cost data (from cost reporting periods ending during 
FY 1981) were established 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 (d)(2)(C) of the Act require us to 
update base-year per discharge costs for FY 1984 and then 
standardize the cost data in order to remove the effects of certain 
sources of cost variations among hospitals. These effects include 
case-mix, differences in area wage levels, cost-of-living 
adjustments for Alaska and Hawaii, indirect medical education costs, 
and costs to hospitals serving a disproportionate share of low-
income patients.
    In accordance with section 1886(d)(3)(E) of the Act, the 
Secretary estimates, from time-to-time, the proportion of hospitals' 
costs that are attributable to wages and wage-related costs. In 
general, the standardized amount is divided into labor-related and 
nonlabor-related amounts; only the proportion considered 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 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 2009, we are not proposing to change the national and 
Puerto Rico-specific labor-related and nonlabor-related shares from 
the percentages established for FY 2008. Therefore, the labor-
related share continues to be 69.7 percent for the national 
standardized amounts and 58.7 percent for the Puerto Rico-specific 
standardized amount. Consistent with section 1886(d)(3)(E) of the 
Act, we are applying the wage index to a labor-related share of 62 
percent for all non-Puerto Rico hospitals whose wage indexes are 
less than or equal to 1.0000. For all non-Puerto Rico hospitals 
whose wage indices are greater than 1.0000, we are applying the wage 
index to a labor-related share of 69.7 percent of the national 
standardized amount. For hospitals located in Puerto Rico, we are 
applying a labor-related share of 58.7 percent if its Puerto Rico-
specific wage index is less than or equal to 1.0000. For hospitals 
located in Puerto Rico whose Puerto Rico-specific wage index values 
are greater than 1.0000, we are applying a labor share of 62 
percent.
    The standardized amounts for operating costs appear in Table 1A, 
1B, and 1C of the Addendum to this proposed rule.

2. Computing the Average Standardized Amount

    Section 1886(d)(3)(A)(iv)(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. Accordingly, we are 
calculating FY 2009 national and Puerto Rico

[[Page 23709]]

standardized amounts irrespective of whether a hospital is located 
in an urban or rural location.

3. Updating the Average Standardized Amount

    In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we 
are updating the equalized standardized amount for FY 2008 by the 
full estimated market basket percentage increase for hospitals in 
all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, 
as amended by section 5001(a)(1) of Pub. L. 109-171. The percentage 
change in the market basket reflects the average change in the price 
of goods and services purchased by hospitals to furnish inpatient 
care. The most recent forecast of the hospital market basket 
increase for FY 2009 is 3.0 percent. Thus, for FY 2009, the proposed 
update to the average standardized amount is 3.0 percent for 
hospitals in all areas. The estimated market basket increase of 3.0 
percent is based on the 2008 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 IV.A. of the 
preamble of this proposed rule. The standardized amounts in Tables 
1A through 1C of section V. of the Addendum to this proposed rule 
reflect these differential amounts.
    Section 412.211(c) states that we update the Puerto Rico-
specific standardized amount using the percentage increase specified 
in Sec.  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 estimated to be 3.0 percent.
    Although the update factors for FY 2009 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 
2009 for both IPPS hospitals and hospitals and hospital units 
excluded from the IPPS. Our recommendation on the update factors 
(which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the 
Act) is set forth in Appendix B of this proposed rule.

4. Other Adjustments to the Average Standardized Amount

    As in the past, we are adjusting the FY 2009 standardized amount 
to remove the effects of the FY 2008 geographic reclassifications 
and outlier payments before applying the FY 2009 updates. We then 
applied budget neutrality offsets for outliers and geographic 
reclassifications to the standardized amount based on proposed FY 
2009 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 have satisfied 
these conditions.
    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 included 
outlier payments in the simulations because they may be affected by 
changes in these parameters.
    We are also proposing to adjust the standardized amount this 
year by an estimated amount to ensure that aggregate IPPS payments 
did not exceed the amount of payments that would have been made in 
the absence of the rural community hospital demonstration program, 
as required under section 410A of Pub. L. 108-173. This 
demonstration is required to be budget neutral under section 
410A(c)(2) of Pub. L. 108-173. For FY 2009, we are proposing to no 
longer apply budget neutrality for the imputed rural floor to the 
standardized amount, and to apply it instead to the wage index, as 
discussed in section of II.B.2. of the preamble to this proposed 
rule. For FY 2009, we are also proposing an adjustment to eliminate 
the effect of coding or classification changes that did not reflect 
real changes in case-mix using the Secretary's authority under 
section 1886(d)(3)(A)(vi) of the Act, by the percentage specified in 
section 7 of Pub. L. 110-90.

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 made a budget neutrality adjustment to 
ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act 
is met.
    Section 1886(d)(3)(E) of the Act requires us to update the 
hospital wage index on an annual basis beginning October 1, 1993. 
This provision also requires us to make any updates or adjustments 
to the wage index in a manner that ensures that aggregate payments 
to hospitals are not affected by the change in the wage index. 
Consistent with current policy, for FY 2009, we are adjusting 100 
percent of the wage index factor for occupational mix. We describe 
the occupational mix adjustment in section III.D. of the preamble to 
this proposed rule.
    To comply with the requirement that DRG reclassification and 
recalibration of the relative weights and the updated wage index be 
budget neutral, we used FY 2007 discharge data to simulate payments 
and compared aggregate payments using the FY 2008 relative weights 
and wage indices to aggregate payments using the proposed FY 2009 
relative weights and wage indices. The same methodology was used for 
the FY 2008 budget neutrality adjustment. Based on this comparison, 
we computed a proposed budget neutrality adjustment factor equal to 
0.999525 to be applied to the national standardized amount. We are 
also adjusting the Puerto Rico-specific standardized amount for the 
effect of DRG reclassification and recalibration. We computed a 
proposed budget neutrality adjustment factor of 0.998700 to be 
applied to the Puerto Rico-specific standardized amount. These 
proposed budget neutrality adjustment factors are applied to the 
standardized amounts for FY 2008 without removing the prior year's 
budget neutrality adjustments. In addition, as discussed in section 
IV. of this Addendum, we are applying the same proposed DRG 
reclassification and recalibration budget neutrality factor of 
0.998700 to the hospital-specific rates that would be effective for 
cost reporting periods beginning on or after October 1, 2008.

b. Reclassified Hospitals--Budget Neutrality Adjustment

    Section 1886(d)(8)(B) of the Act provides that, effective with 
discharges occurring on or after October 1, 1988, certain rural 
hospitals are deemed urban. In addition, section 1886(d)(10) of the 
Act provides for the reclassification of hospitals based on 
determinations by the MGCRB. Under section 1886(d)(10) of the Act, a 
hospital may be reclassified for purposes of the wage index.
    Under section 1886(d)(8)(D) of the Act, the Secretary is 
required to adjust the standardized amount to ensure that aggregate 
payments under the IPPS after implementation of the provisions of 
sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal 
to the aggregate prospective payments that would have been made 
absent these provisions. We note that the wage index adjustments 
provided under section 1886(d)(13) of the Act are not budget 
neutral. Section 1886(d)(13)(H) of the Act provides that any 
increase in a wage index under section 1886(d)(13) shall not be 
taken into account ``in applying any budget neutrality adjustment 
with respect to such index'' under section 1886(d)(8)(D) of the Act. 
To calculate the proposed budget neutrality factor for FY 2009, we 
used FY 2007 discharge data to simulate payments, and compared total 
IPPS payments prior to any reclassifications under sections 
1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS 
payments after such reclassifications.

[[Page 23710]]

Based on these simulations, we calculated a proposed adjustment 
factor of 0.992333 to ensure that the effects of these provisions 
are budget neutral, consistent with the statute.
    The proposed adjustment factor is applied to the standardized 
amount after removing the effects of the FY 2008 budget neutrality 
adjustment factor. We note that the FY 2009 adjustment reflects FY 
2009 wage index reclassifications approved by the MGCRB or the 
Administrator. (Section 1886(d)(10)(D)(v) of the Act makes wage 
index reclassifications effective for 3 years. Therefore, the FY 
2009 geographic reclassification could either be the continuation of 
a 3-year reclassification that began in FY 2007 or FY 2008, or a new 
one beginning in FY 2009.)

c. Case-Mix Budget Neutrality Adjustment

    As stated earlier, beginning in FY 2008, we adopted the new MS-
DRG patient classification system for the IPPS to better recognize 
severity of illness in Medicare payment rates. In the FY 2008 IPPS 
final rule with comment period, 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 improved 
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 coding or classification 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. 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 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 
effective October 1, 2007. For FY 2009, section 7 of Pub. L. 110-90 
requires 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 are 
applying 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 is in addition to the 
-0.6 percent adjustment in FY 2008, yielding a combined effect of -
1.5 percent.
    As discussed in more detail in section II.D. of the preamble of 
this proposed rule, in calculating the FY 2008 Puerto Rico 
standardized amount, we made an inadvertent error and applied the 
documentation and coding adjustment established using our authority 
in section 1886(d)(3)(A)(vi) of the Act (which only applies to the 
national standardized amounts) to the Puerto Rico-specific 
standardized amount. We are currently in the process of developing a 
Federal Register notice to remove the -0.6 percent documentation and 
coding adjustment from the FY 2008 Puerto Rico-specific standardized 
amount retroactive to October 1, 2007. As discussed in section II.D. 
of the preamble of this proposed rule, we are not applying the 
documentation and coding adjustment to the Puerto Rico-specific 
standardized amount for FY 2009, but we may consider doing so for 
the FY 2010 Puerto Rico-specific standardized amount in the FY 2010 
rulemaking. In calculating the FY 2009 Puerto Rico-specific 
standardized amount for this proposed rule, we have removed the -0.6 
percent documentation and coding adjustment that was inadvertently 
applied to the FY 2008 Puerto Rico-specific standardized amount.

d. Outliers

    Section 1886(d)(5)(A) of the Act provides for payments in 
addition to the basic prospective payments for ``outlier'' cases 
involving extraordinarily high costs. To qualify for outlier 
payments, a case must have costs greater than the sum of the 
prospective payment rate for the DRG, any IME and DSH payments, any 
new technology add-on payments, and the ``outlier threshold'' or 
``fixed loss'' amount (a dollar amount by which the costs of a case 
must exceed payments in order to qualify for an outlier payment). We 
refer to the sum of the prospective payment rate for the DRG, any 
IME and DSH payments, any new technology add-on payments, and the 
outlier threshold as the outlier ``fixed-loss cost threshold.'' To 
determine whether the costs of a case exceed the fixed-loss cost 
threshold, a hospital's CCR is applied to the total covered charges 
for the case to convert the charges to estimated costs. Payments for 
eligible cases are then made based on a marginal cost factor, which 
is a percentage of the estimated costs above the fixed-loss cost 
threshold. The marginal cost factor for FY 2009 is 80 percent, the 
same marginal cost factor we have used since FY 1995 (59 FR 45367).
    In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier 
payments for any year are projected to be not less than 5 percent 
nor more than 6 percent of total operating DRG payments plus outlier 
payments. Section 1886(d)(3)(B) of the Act requires the Secretary to 
reduce the average standardized amount by a factor to account for 
the estimated proportion of total DRG payments made to outlier 
cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the 
Secretary to reduce the average standardized amount applicable to 
hospitals 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.

(1) Proposed FY 2009 Outlier Fixed-Loss Cost Threshold

    For FY 2009, we are proposing to use the same methodology used 
for FY 2008 (72 FR 47417) to calculate the outlier threshold. 
Similar to the methodology used in the FY 2008 final rule with 
comment period, for FY 2009, we are applying an adjustment factor to 
the CCRs to account for cost and charge inflation (as explained 
below). As we have done in the past, to calculate the proposed FY 
2009 outlier threshold, we simulated payments by applying FY 2009 
rates and policies using cases from the FY 2007 MedPAR files. 
Therefore, in order to determine the proposed FY 2009 outlier 
threshold, we inflate the charges on the MedPAR claims by 2 years, 
from FY 2007 to FY 2009.
    We are proposing to continue using 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 2006 in combination with the first quarter of FY 2007 
(July 1, 2006 through December 31, 2006) to the last quarter of FY 
2007 in combination with the first quarter of FY 2008 (July 1, 2007 
through December 31, 2007). This rate of change was 5.84 percent 
(1.0585) or 12.03 percent (1.1204) over 2 years.
    As we have done in the past, we are proposing to establish the 
proposed FY 2009 outlier threshold using hospital CCRs from the 
December 2007 update to the Provider-Specific File (PSF)--the most 
recent available data at the time of this proposed rule. This file 
includes CCRs that reflected implementation of the changes to the 
policy for determining the applicable CCRs that became effective 
August 8, 2003 (68 FR 34494).
    As discussed in the FY 2007 final rule (71 FR 48150), we worked 
with the Office of Actuary to derive the methodology described below 
to develop the CCR adjustment factor. For FY 2009, we are proposing 
to use the same methodology to calculate the CCR adjustment by using 
the FY 2007 operating cost per discharge increase in combination 
with the actual FY 2007 operating market basket increase determined 
by Global Insight, Inc., as well as the charge inflation factor 
described above to estimate the adjustment to the CCRs. (We note 
that the FY 2007 actual (otherwise referred to as ``final'') 
operating market basket increase reflects historical data whereas 
the published FY 2007 operating market basket update factor was 
based on Global Insight, Inc.'s 2006 second quarter forecast with 
historical data through the first quarter of 2007.) By using the 
operating market basket rate-of-increase and the increase in the 
average cost per discharge from hospital cost reports, we are using 
two different measures of cost inflation. For FY

[[Page 23711]]

2009, we determined the adjustment by taking the percentage increase 
in the operating costs per discharge from FY 2005 to FY 2006 
(1.0538) from the cost report and dividing it by the final operating 
market basket increase from FY 2006 (1.0420). 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 
rate-of-increase and the increase in cost per case from the cost 
report (FY 2003 to FY 2004 percentage increase of operating costs 
per discharge of 1.0629 divided by FY 2004 final operating market 
basket increase of 1.0400, FY 2004 to FY 2005 percentage increase of 
operating costs per discharge of 1.0565 divided by FY 2005 final 
operating market basket increase of 1.0430). For FY 2009, we 
averaged the differentials calculated for FY 2004, FY 2005, and FY 
2006, which resulted in a mean ratio of 1.0154. We multiplied the 3-
year average of 1.0154 by the 2007 operating market basket 
percentage increase of 1.0340, which resulted in an operating cost 
inflation factor of 5.0 percent or 1.05. We then divided the 
operating cost inflation factor by the 1-year average change in 
charges (1.058474) and applied an adjustment factor of 0.9920 to the 
operating CCRs from the PSF.
    As stated in the FY 2008 final rule with comment period, 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 fiscal intermediaries (or, if applicable, the MAC) to 
tentatively settle a cost report from the fiscal year end of a 
hospital's cost reporting period. The average ``age'' of hospitals' 
CCRs from the time the fiscal intermediary or the MAC inserts the 
CCR in the PSF until the beginning of FY 2008 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 2005 to FY 2006 (1.0462) from the cost 
report and dividing it by the final capital market basket increase 
from FY 2006 (1.0090). 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 rate-of-increase and the 
increase in cost per case from the cost report (FY 2003 to FY 2004 
percentage increase of capital costs per discharge of 1.0315 divided 
by FY 2004 final capital market basket increase of 1.0050, FY 2004 
to FY 2005 percentage increase of capital costs per discharge of 
1.0311 divided by FY 2005 final capital market basket increase of 
1.0060). For FY 2009, we averaged the differentials calculated for 
FY 2004, FY 2005, and FY 2006, which resulted in a mean ratio of 
1.0294. We multiplied the 3-year average of 1.0294 by the 2007 
capital market basket percentage increase of 1.0120, which resulted 
in a capital cost inflation factor of 4.17 percent or 1.0417. We 
then divided the capital cost inflation factor by the 1-year average 
change in charges (1.058474) and applied an adjustment factor of 
0.9842 to the capital CCRs from the PSF. We are using the same 
charge inflation factor for the capital CCRs that was used for the 
operating CCRs. The charge inflation factor is based on the overall 
billed charges. Therefore, we believe it is appropriate to apply the 
charge factor to both the operating and capital CCRs.
    For purposes of estimating the proposed outlier threshold for FY 
2009, we assume 3.0 percent case-mix growth in FY 2009 compared with 
our FY 2007 claims data (that is, a 1.2 percent increase in FY 2008 
and an additional 1.8 percent increase in FY 2009). The 3 percent 
case-mix growth was projected by the Office of the Actuary as the 
amount case-mix is expected to increase in response to adoption of 
the MS-DRGs as a result of improvements in documentation and coding 
that do not reflect real changes in patient severity of illness. It 
is necessary to take the 3 percent expected case-mix growth into 
account when calculating the outlier threshold that results in 
outlier payments being 5.1 percent of total payments for FY 2009. If 
we did not take this 3 percent projected case-mix growth into 
account, our estimate of total payments would be too low, and as a 
result, our estimate of the outlier threshold would be too high. 
While we assume 3 percent case-mix growth for all hospitals in our 
outlier threshold calculations, the FY 2009 national standardized 
amounts used to calculate the outlier threshold reflect the 
statutorily mandated documentation and coding adjustment of -0.9 
percent for FY 2009, on top of the -0.6 percent adjustment for FY 
2008.
    Using this methodology, we are proposing an outlier fixed-loss 
cost threshold for FY 2009 equal to the prospective payment rate for 
the DRG, plus any IME and DSH payments, and any add-on payments for 
new technology, plus $21,025.
    As we did in establishing the FY 2008 outlier threshold (72 FR 
47417), in our projection of FY 2009 outlier payments, we are not 
making any adjustments for the possibility that hospitals' CCRs and 
outlier payments may be reconciled upon cost report settlement. We 
continue to believe that, due to the policy implemented in the 
outlier final rule (68 FR 34494, June 9, 2003), CCRs will no longer 
fluctuate significantly and, therefore, few hospitals will actually 
have these ratios reconciled upon cost report settlement. In 
addition, it is difficult to predict the specific hospitals that 
will have CCRs and outlier payments reconciled in any given year. We 
also noted that reconciliation occurs because hospitals' actual CCRs 
for the cost reporting period are different than the interim CCRs 
used to calculate outlier payments when a bill is processed. Our 
simulations assume that CCRs accurately measure hospital costs based 
on information available to us at the time we set the outlier 
threshold. For these reasons, we are not making any assumptions 
about the effects of reconciliation on the outlier threshold 
calculation.
    We also note that there are some factors that contributed to a 
proposed lower fixed loss outlier threshold for FY 2009 compared to 
FY 2008. First, the case-weighted national average operating CCR 
declined by approximately an additional 1 percentage point from the 
March 2007 update (used to calculate the FY 2008 outlier threshold) 
to the December 2007 update of the PSF (used to calculate the 
proposed FY 2009 outlier threshold). In addition, as discussed in 
sections II.C. and II.H. of the preamble of this proposed rule, we 
began a 2-year phase-in of the MS-DRGs in FY 2008, with the DRG 
relative weights based on a 50 percent blend of the CMS DRGs and MS-
DRGs in FY 2008 and based on 100 percent of the MS-DRGs beginning in 
FY 2009. Better recognition of severity of illnesses with the MS-
DRGs means that nonoutlier payments will compensate hospitals for 
the higher costs of some cases that previously received outlier 
payments. As cases are paid more accurately, in order to meet the 
5.1 percent target, we need to decrease the fixed-loss outlier 
threshold so that more cases qualify for outlier payments. In 
addition, as noted previously, in our modeling of the outlier 
threshold, we included a 3-percent adjustment for expected case-mix 
growth between FY 2007 and FY 2009. Together, we believe that the 
above factors cumulatively contributed to a lower proposed fixed-
loss outlier threshold in FY 2009 compared to FY 2008.

(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 are projecting that the proposed thresholds for 
FY 2009 will result in outlier payments that will equal 5.1 percent 
of operating DRG payments and 5.73 percent of capital payments based 
on the Federal rate.
    In accordance with section 1886(d)(3)(B) of the Act, we are 
reducing the FY 2009 standardized amount by the same percentage to 
account for the projected proportion of payments paid as outliers.
    The outlier adjustment factors that are applied to the 
standardized amount for the proposed FY 2009 outlier threshold are 
as follows:

------------------------------------------------------------------------
                                                Operating
                                              standardized     Capital
                                                 amounts    federal rate
------------------------------------------------------------------------
National....................................      0.948928      0.942711
Puerto Rico.................................      0.955988      0.925627
------------------------------------------------------------------------

    Consistent with current policy, we are applying the outlier 
adjustment factors to FY 2009 rates after removing the effects of 
the FY 2008 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

[[Page 23712]]

compared with the outlier fixed-loss cost threshold.
    The outlier final rule (68 FR 34494) eliminated the application 
of the statewide average CCRs for hospitals with CCRs that fell 
below 3 standard deviations from the national mean CCR. However, for 
those hospitals for which the fiscal intermediary or MAC computes 
operating CCRs greater than 1.213 or capital CCRs greater than 
0.148, or hospitals for whom the fiscal intermediary or MAC is 
unable to calculate a CCR (as described at Sec.  412.84(i)(3) of our 
regulations), we still use statewide average CCRs to determine 
whether a hospital qualifies for outlier payments.\27\ Table 8A in 
this Addendum contains the statewide average operating CCRs for 
urban hospitals and for rural hospitals for which the fiscal 
intermediary or MAC is unable to compute a hospital-specific CCR 
within the above range. Effective for discharges occurring on or 
after October 1, 2008, these statewide average ratios would replace 
the ratios published in the IPPS final rule for FY 2008 (72 FR 
48126-48127). Table 8B in this Addendum contains the comparable 
statewide average capital CCRs. Again, the CCRs in Tables 8A and 8B 
would be used during FY 2009 when hospital-specific CCRs based on 
the latest settled cost report are either not available or are 
outside the range noted above. For an explanation of Table 8C, we 
refer readers to section V. of this Addendum.
---------------------------------------------------------------------------

    \27\ These figures represent 3.0 standard deviations from the 
mean of the log distribution of CCRs for all hospitals.
---------------------------------------------------------------------------

    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, reconciliation, and the time value of money. We encourage 
hospitals that are assigned the statewide average operating and/or 
capital CCRs to work with their fiscal intermediaries (or MAC if 
applicable) 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 cost-to-charge ratios, visit the Web 
site: http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.

(3) FY 2007 and FY 2008 Outlier Payments

    In the FY 2008 IPPS final rule (72 FR 47420), we stated that, 
based on available data, we estimated that actual FY 2007 outlier 
payments would be approximately 4.6 percent of actual total DRG 
payments. This estimate was computed based on simulations using the 
FY 2006 MedPAR file (discharge data for FY 2006 bills). That is, the 
estimate of actual outlier payments did not reflect actual FY 2007 
bills, but instead reflected the application of FY 2007 rates and 
policies to available FY 2006 bills.
    Our current estimate, using available FY 2007 bills, is that 
actual outlier payments for FY 2007 were approximately 4.64 percent 
of actual total DRG payments. Thus, the data indicate that, for FY 
2007, the percentage of actual outlier payments relative to actual 
total payments is lower than we projected before FY 2007. Consistent 
with the policy and statutory interpretation we have maintained 
since the inception of the IPPS, we do not plan to make retroactive 
adjustments to outlier payments to ensure that total outlier 
payments for FY 2007 are equal to 5.1 percent of total DRG payments.
    We currently estimate that actual outlier payments for FY 2008 
will be approximately 4.8 percent of actual total DRG payments, 0.3 
percentage points lower than the 5.1 percent we projected in setting 
the outlier policies for FY 2008. This estimate is based on 
simulations using the FY 2007 MedPAR file (discharge data for FY 
2007 bills). We used these data to calculate an estimate of the 
actual outlier percentage for FY 2008 by applying FY 2008 rates and 
policies, including an outlier threshold of $22,185 to available FY 
2007 bills.

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

    Section 410A of Pub. L. 108-173 requires the Secretary to 
establish a demonstration that will modify reimbursement for 
inpatient services for up to 15 small rural hospitals. Section 
410A(c)(2) of Pub. L. 108-173 requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration 
program under this section was not implemented.'' As discussed in 
section IV.K. of the preamble to this proposed rule, we have 
satisfied this requirement by adjusting national IPPS rates by a 
factor that is sufficient to account for the added costs of this 
demonstration. There are currently nine hospitals participating in 
the demonstration program. CMS is currently conducting a 
solicitation for up to six additional hospitals to participate in 
the demonstration program. For this proposed rule, we used data from 
the cost reports of the 9 currently participating hospitals to 
estimate a total cost number for 15 hospitals that could potentially 
participate in the demonstration program in FY 2009. (In the final 
rule, we will know the exact number of hospitals participating in 
the demonstration program, and we will revise our estimates 
accordingly.) We estimate that the average additional annual payment 
that will be made to each participating hospital under the 
demonstration will be approximately $2,134,123. We based this 
estimate on the recent historical experience of the difference 
between inpatient cost and payment for hospitals that are 
participating in the demonstration program. As an estimate of the 
cost for a total of 15 hospitals that may participate, the total 
annual impact of the demonstration program for FY 2009 is projected 
to be $32,011,849. The required adjustment to the Federal rate used 
in calculating Medicare inpatient prospective payments as a result 
of the demonstration is 0.999666.
    In order to achieve budget neutrality, we are adjusting the 
national IPPS rates by an amount sufficient to account for the added 
costs of this demonstration. In other words, we are applying budget 
neutrality across the payment system as a whole rather than merely 
across the participants of this demonstration, consistent with past 
practice. We believe that the language of the statutory budget 
neutrality requirement permits the agency to implement the budget 
neutrality provision in this manner. The statutory language requires 
that ``aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration * * 
* was not implemented,'' but does not identify the range across 
which aggregate payments must be held equal.

5. Proposed FY 2009 Standardized Amount

    The adjusted proposed 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 2009. 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 labor-related share 
applied to the standardized amounts in Table 1A is 69.7 percent, and 
Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) 
and 1886(d)(9)(C)(iv) of the Act, we are applying a labor-related 
share of 62 percent, unless 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 apply a labor-
related share of 62 percent for all hospitals (other than those in 
Puerto Rico) whose wage indexes are less than or equal to 1.0000.
    In addition, Tables 1A and 1B include proposed standardized 
amounts reflecting the full 3.0 percent update for FY 2009, and 
proposed standardized amounts reflecting the 2.0 percentage point 
reduction to the update (a 1.0 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 2009 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 58.7 
percent, or 62 percent, depending on which provides higher payments 
to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended 
by section 403(b) of Pub. L. 108-173, provides

[[Page 23713]]

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 
2008 national average standardized amount. The second and third 
columns show the proposed changes from the FY 2008 standardized 
amounts for hospitals that satisfy the quality data submission 
requirement for receiving the full update (3.0 percent) with the 
different labor-related shares that apply to hospitals. The fourth 
and fifth columns show the proposed changes for hospitals receiving 
the reduced update (1.0 percent) with the different labor-related 
shares that apply to hospitals. The first row of the table shows the 
updated (through FY 2008) average standardized amount after 
restoring the FY 2008 offsets for outlier payments, demonstration 
budget neutrality, the New Jersey imputed floor budget neutrality, 
and the geographic reclassification budget neutrality. The DRG 
reclassification and recalibration and wage index budget neutrality 
factor is cumulative. Therefore, the FY 2008 factor is not removed 
from this table. Also, in order to properly apply the documentation 
and coding adjustment, it was necessary to first remove the FY 2008 
adjustment from the FY 2008 rate in the first row of the table and 
then later in the table to cumulatively apply the sum of the FY 2008 
and FY 2009 adjustments (that is, 1-(.006 + .009)) to the FY 2009 
rate. (For a complete discussion on the documentation and coding 
adjustment, we refer readers to section II.D of the preamble to this 
proposed rule.)

 Comparison of FY 2008 Standardized Amounts to the Proposed FY 2009 Single Standardized Amount With Full Update
                                               and Reduced Update
----------------------------------------------------------------------------------------------------------------
                                                                            Reduced update
                                   Full update (3.0    Full update (3.0     (1.0 percent);      Reduced update
                                    percent); wage      percent); wage       wage index is      (1.0 percent);
                                   index is greater   index is less than     greater than     wage index is less
                                      than 1.0000           1.0000              1.0000            than 1.0000
----------------------------------------------------------------------------------------------------------------
FY 2008 Base Rate, after          Labor: $3,723.07..  Labor: $3,311.77..  Labor: $3,723.07..  Labor: $3,311.77
 removing geographic              Nonlabor:           Nonlabor:           Nonlabor:           Nonlabor:
 reclassification budget           $1,618.50.          $2,029.80.          $1,618.50.          $2,029.80
 neutrality, demonstration
 budget neutrality,
 documentation and coding
 adjustment, NJ imputed floor
 budget neutrality and outlier
 offset (based on the labor and
 market share percentage for FY
 2009).
FY 2009 Update Factor...........  1.030.............  1.030.............  1.010.............  1.010
FY 2009 DRG Recalibrations and    0.999525..........  0.999525..........  0.999525..........  0.999525
 Wage Index Budget Neutrality
 Factor.
FY 2009 Reclassification Budget   0.992333..........  0.992333..........  0.992333..........  0.992333
 Neutrality Factor.
FY 2009 Outlier Factor..........  0.948928..........  0.948928..........  0.948928..........  0.948928
Rural Demonstration Budget        0.999666..........  0.999666..........  0.999666..........  0.999666
 Neutrality Factor.
FY 2009 Documentation and Coding  0.985.............  0.985.............  0.985.............  0.985
 Adjustment and Actual FY 2008
 Adjustment.
Proposed Rate for FY 2009.......  Labor: $3,553.98..  Labor: $3,161.36..  Labor: $3,484.97..  Labor: $3,099.97
                                  Nonlabor:           Nonlabor:           Nonlabor:           Nonlabor:
                                   $1,544.98.          $1,937.60.          $1,514.98.          $1,899.98
----------------------------------------------------------------------------------------------------------------

    Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion 
of the Puerto Rico payment rate is based on the national average 
standardized amounts. The labor-related and nonlabor-related 
portions of the national average standardized amounts for hospitals 
located in Puerto Rico are set forth in Table 1C of this Addendum. 
This table also includes the Puerto Rico standardized amounts. The 
labor-related share applied to the Puerto Rico standardized amount 
is 58.7 percent, or 62 percent, depending on which results in higher 
payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as 
amended by section 403(b) of Pub. L. 108-173, provides that the 
labor-related share for hospitals located in Puerto Rico 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 
proposed labor-related and nonlabor-related shares that we are using 
to calculate the proposed prospective payment rates for hospitals 
located in the 50 States, the District of Columbia, and Puerto Rico 
for FY 2009. This section addresses two types of adjustments to the 
standardized amounts that were made in determining the prospective 
payment rates as described in this Addendum.

1. Proposed Adjustment for Area Wage Levels

    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
national and Puerto Rico prospective payment rates, respectively, to 
account for area differences in hospital wage levels. This 
adjustment is made by multiplying the labor-related portion of the 
adjusted standardized amounts by the appropriate wage index for the 
area in which the hospital is located. In section III. of the 
preamble to this proposed rule, we discuss the data and methodology 
for the FY 2009 wage index.

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 2009, we are proposing to adjust the 
payments for hospitals in Alaska and Hawaii by multiplying the 
nonlabor-related portion of the standardized amount by the 
applicable adjustment factor contained in the table below.

 Table of Cost-of-Living Adjustment Factors: Alaska and Hawaii Hospitals
------------------------------------------------------------------------
                                                          Cost of living
                          Area                              adjustment
                                                              factor
------------------------------------------------------------------------
Alaska:
    City of Anchorage and 80-kilometer (50-mile) radius             1.24
     by road............................................

[[Page 23714]]

 
    City of Fairbanks and 80-kilometer (50-mile) radius             1.24
     by road............................................
    City of Juneau and 80-kilometer (50-mile) radius by             1.24
     road...............................................
    Rest of Alaska......................................            1.25
Hawaii:
    City and County of Honolulu.........................            1.25
    County of Hawaii....................................            1.17
    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.)

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 will apply 
to discharges occurring in FY 2009. 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 2009

    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 2009 equals the Federal rate.
    The prospective payment rate for SCHs for FY 2009 equals the 
higher of the applicable Federal rate, or the hospital-specific rate 
as described below. The prospective payment rate for MDHs for FY 
2009 equals the higher of the Federal rate, or the Federal rate plus 
75 percent of the difference between the Federal rate and the 
hospital-specific rate as described below. The prospective payment 
rate for hospitals located in Puerto Rico for FY 2009 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 is then further 
adjusted if the hospital qualifies for either the IME or DSH 
adjustment. In addition, for hospitals that qualify for a low-volume 
payment adjustment under section 1886(d)(12) of the Act and 42 CFR 
412.101(b), the payment in Step 5 is increased by 25 percent.

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

a. Calculation of Hospital-Specific Rate

    Section 1886(b)(3)(C) of the Act provides that SCHs are paid 
based on whichever of the following rates yields the greatest 
aggregate payment: the Federal rate; the updated hospital-specific 
rate based on FY 1982 costs per discharge; the updated hospital-
specific rate based on FY 1987 costs per discharge; or the updated 
hospital-specific rate based on FY 1996 costs per discharge.
    As discussed previously, MDHs are required to rebase their 
hospital-specific rates to their FY 2002 cost reports if doing so 
results in higher payments. In addition, effective for discharges 
occurring on or after October 1, 2006, MDHs are to be paid based on 
the Federal national rate or, if higher, the Federal national rate 
plus 75 percent (changed from 50 percent) of the difference between 
the Federal national rate and the greater of the updated hospital-
specific rates based on either FY 1982, FY 1987 or FY 2002 costs per 
discharge. Further, MDHs are no longer subject to the 12-percent cap 
on their DSH payment adjustment factor.
    Hospital-specific rates have been determined for each of these 
hospitals based on the FY 1982 costs per discharge, the FY 1987 
costs per discharge, or, for SCHs, the FY 1996 costs per discharge 
and for MDHs, the FY 2002 cost per discharge. For a more detailed 
discussion of the calculation of the hospital-specific rates, we 
refer the reader to the FY 1984 IPPS interim final rule (48 FR 
39772); the April 20, 1990 final rule with comment (55 FR 15150); 
the FY 1991 IPPS final rule (55 FR 35994); and the FY 2001 IPPS 
final rule (65 FR 47082). In addition, for both SCHs and MDHs, the 
hospital-specific rate is adjusted by the budget neutrality 
adjustment factor as discussed in section 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, 2007.

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital-
Specific Rates for FY 2009

    We are proposing to increase the hospital-specific rates by 3.0 
percent (the proposed estimated hospital market basket percentage 
increase) for FY 2009 for those SCHs and MDHs that submit qualifying 
quality data and by 1.0 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 2008, is the 
market basket rate-of-increase for hospitals that submit qualifying 
quality data and the market basket rate-of-increase minus 2 percent 
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 2009, is the market basket rate-of-increase for 
hospitals that submit qualifying quality data and the market basket 
rate-of-increase minus 2 percent for hospitals that fail to submit 
qualifying quality data.

3. General Formula for Calculation of Proposed Prospective Payment 
Rates for Hospitals Located in Puerto Rico Beginning On or After 
October 1, 2008, and Before October 1, 2009

    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).
    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.

[[Page 23715]]

    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 is then further adjusted 
if the hospital qualifies for either the IME or DSH adjustment.

III. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2009

    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 2009, which 
would be effective for discharges occurring on or after October 1, 
2008.
    The 10-year transition period ended with hospital cost reporting 
periods beginning on or after October 1, 2001 (FY 2002). Therefore, 
for cost reporting periods beginning in FY 2002, all hospitals 
(except ``new'' hospitals under Sec.  412.304(c)(2)) are paid based 
on the capital Federal rate. For FY 1992, we computed the standard 
Federal payment rate for capital-related costs under the IPPS by 
updating the FY 1989 Medicare inpatient capital cost per case by an 
actuarial estimate of the increase in Medicare inpatient capital 
costs per case. Each year after FY 1992, we update the capital 
standard Federal rate, as provided at Sec.  412.308(c)(1), to 
account for capital input price increases and other factors. The 
regulations at Sec.  412.308(c)(2) provide that the capital Federal 
rate 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, 
Sec.  412.308(c)(3) requires that the capital Federal rate be 
reduced by an adjustment factor equal to the estimated proportion of 
payments for (regular and special) exceptions under Sec.  412.348. 
Section 412.308(c)(4)(ii) requires that the capital standard Federal 
rate be adjusted so that the effects of the annual DRG 
reclassification and the recalibration of DRG weights and changes in 
the geographic adjustment factor (GAF) are budget neutral.
    For FYs 1992 through 1995, Sec.  412.352 required that the 
capital Federal rate also be adjusted by a budget neutrality factor 
so that aggregate payments for inpatient hospital capital costs were 
projected to equal 90 percent of the payments that would have been 
made for capital-related costs on a reasonable cost basis during the 
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 Sec.  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 Sec.  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 Medicare inpatient capital-related costs over time. With 
the expiration of the budget neutrality provision, the capital cost 
model was only used to estimate the regular exceptions payment 
adjustment and other factors during the transition period. As we 
explained in the FY 2002 IPPS final rule (66 FR 39911), beginning in 
FY 2002, an adjustment for regular exception payments is no longer 
necessary because regular exception payments were only made for cost 
reporting periods beginning on or after October 1, 1991, and before 
October 1, 2001 (see Sec.  412.348(b)). Because payments are no 
longer 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 the use of a blended payment system 
for 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 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 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 (see the March 26, 2004 One-Time Notification (Change Request 
3158)). In addition, section 504 of Pub. L. 108-173 provided that 
the national portion of operating IPPS payments for hospitals 
located in Puerto Rico is equal to 75 percent and the Puerto Rico 
portion of operating IPPS payments is equal to 25 percent for 
discharges occurring on or after October 1, 2004. Consistent with 
that change in operating IPPS payments to hospitals 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 capital rate and 75 percent of the 
capital Federal rate for discharges occurring on or after October 1, 
2004.

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

    In the FY 2008 IPPS final rule with comment period (72 FR 66886 
through 66888), we established a capital Federal rate

[[Page 23716]]

of $426.14 for FY 2008. In the discussion that follows, we explain 
the factors that we are proposing to use to determine the proposed 
FY 2009 capital Federal rate. In particular, we explain why the 
proposed FY 2009 capital Federal rate would decrease approximately 
1.14 percent, compared to the FY 2008 capital Federal rate. However, 
taking into account an estimated increase in Medicare fee-for-
service discharges in FY 2009 as compared to FY 2008, as well as the 
estimated increase in payments due to documentation and coding 
(discussed in section VIII. of Appendix A to this proposed rule), we 
estimate that the increase in aggregate capital payments would be 
negligible during this same period (approximately $6 million). Total 
payments to hospitals under the IPPS are relatively unaffected by 
changes in the capital prospective payments. 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. As noted above, 
aggregate payments under the capital IPPS are projected to increase 
in FY 2009 compared to FY 2008.

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

    Under Sec.  412.308(c)(1), the capital standard Federal rate is 
updated on the basis of an analytical framework that takes into 
account changes in a capital input price index (CIPI) and several 
other policy adjustment factors. Specifically, we have adjusted the 
projected CIPI rate-of-increase as appropriate each year for case-
mix index-related changes, for intensity, and for errors in previous 
CIPI forecasts. The proposed update factor for FY 2009 under that 
framework is 0.7 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 -0.5 percent 
adjustment for the FY 2007 DRG reclassification and recalibration, 
and a forecast error correction of 0.0 percent. As discussed below 
in section III.C. of the Addendum to this proposed rule, 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 2009 CIPI projection in that 
same section of this Addendum. In addition, as also noted below, the 
proposed capital rates would be further adjusted to account for 
documentation and coding improvements under the MS-DRGs discussed in 
section II.D. of the preamble of this proposed rule. Below we 
describe the policy adjustments that we are proposing to apply in 
the update framework for FY 2009.
    The case-mix index is the measure of the average MS-DRG weight 
for cases paid under the IPPS. Because the MS-DRG weight determines 
the prospective payment for each case, any percentage increase in 
the case-mix index corresponds to an equal percentage increase in 
hospital payments.
    The case-mix index can change for any of several reasons:
    <bullet> The average resource use of Medicare patients changes 
(``real'' case-mix change);
    <bullet> Changes in hospital coding of patient records result in 
higher weight MS-DRG assignments (``coding effects''); and
    <bullet> The annual MS-DRG reclassification and recalibration 
changes may not be budget neutral (``reclassification effect'').
    We define real case-mix change as actual changes in the mix (and 
resource requirements) of Medicare patients as opposed to changes in 
coding behavior that result in assignment of cases to higher 
weighted MS-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 the projected increase in case-mix resulting from 
documentation and coding improvements under the recently adopted MS-
DRGs, for FY 2009, we are projecting a 1.0 percent total increase in 
the case-mix index. We estimate that the real case-mix increase will 
also equal 1.0 percent for FY 2009. The net adjustment for change in 
case-mix is the difference between the projected real increase in 
case-mix and the projected total increase in case-mix. Therefore, 
the net adjustment for case-mix change in FY 2009 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 
retain budget neutrality for all case-mix index-related changes 
other than those due to patient severity. Due to the lag time in the 
availability of data, there is a 2-year lag in data used to 
determine the adjustment for the effects of DRG reclassification and 
recalibration. For example, we are adjusting for the effects of the 
FY 2007 DRG reclassification and recalibration as part of our 
proposed update for FY 2009. We estimate that FY 2007 DRG 
reclassification and recalibration resulted in a 0.5 percent change 
in the case-mix when compared with the case-mix index that would 
have resulted if we had not made the reclassification and 
recalibration changes to the DRGs. Therefore, we are proposing to 
make a -0.5 percent adjustment for DRG reclassification in the 
proposed update for FY 2009 to maintain budget neutrality.
    The capital update framework also contains an adjustment for 
forecast error. The input price index forecast is based on 
historical trends and relationships ascertainable at the time the 
update factor is established for the upcoming year. In any given 
year, there may be unanticipated price fluctuations that may result 
in differences between the actual increase in prices and the 
forecast used in calculating the update factors. In setting a 
prospective payment rate under the framework, we make an adjustment 
for forecast error only if our estimate of the change in the capital 
input price index for any year is off by 0.25 percentage points or 
more. There is a 2-year lag between the forecast and the 
availability of data to develop a measurement of the forecast error. 
A forecast error of 0.10 percentage point was calculated for the FY 
2007 update. That is, current historical data indicate that the 
forecasted FY 2007 CIPI (1.1 percent) used in calculating the FY 
2007 update factor slightly understated the actual realized price 
increases (1.2 percent) by 0.10 percentage point. This slight 
underprediction was mostly due to the incorporation of newly 
available source data for fixed asset prices and moveable asset 
prices into the market basket. However, because this estimation of 
the change in the CIPI is less than 0.25 percentage points, it is 
not reflected in the update recommended under this framework. 
Therefore, we are proposing to make a 0.0 percent adjustment for 
forecast error in the update for FY 2009.
    Under the capital IPPS update framework, we also make an 
adjustment for changes in intensity. We calculate this adjustment 
using the same methodology and data that were used in the past under 
the framework for operating IPPS. The intensity factor for the 
operating update framework reflects how hospital services are 
utilized to produce the final product, that is, the discharge. This 
component accounts for changes in the use of quality-enhancing 
services, for changes within DRG severity, and for expected 
modification of practice patterns to remove noncost-effective 
services.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI for 
hospital and related services) and changes in real case-mix. The use 
of total charges in the calculation of the intensity factor makes it 
a total intensity factor; that is, charges for capital services are 
already built into the calculation of the factor. Therefore, we have 
incorporated the intensity adjustment from the operating update 
framework into the capital update framework. Without reliable 
estimates of the proportions of the overall annual intensity 
increases that are due, respectively, to ineffective practice 
patterns and 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.

[[Page 23717]]

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.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI for 
hospital and related services), and changes in real case-mix. As we 
noted above, in accordance with Sec.  412.308(c)(1)(ii), we began 
updating the capital standard Federal rate in FY 1996 using an 
update framework that takes into account, among other things, 
allowable changes in the intensity of hospital services. For FYs 
1996 through 2001, we found that case-mix constant intensity was 
declining, and we established a 0.0 percent adjustment for intensity 
in each of those years. For FYs 2002 and 2003, we found that case-
mix constant intensity was increasing, and we established a 0.3 
percent adjustment and 1.0 percent adjustment for intensity, 
respectively. For FYs 2004 and 2005, we found that the charge data 
appeared to be skewed (as discussed in greater detail below), and we 
established a 0.0 percent adjustment in each of those years. 
Furthermore, we stated that we would continue to apply a 0.0 percent 
adjustment for intensity until any increase in charges can be tied 
to intensity rather than attempts to maximize outlier payments.
    As noted above, our intensity measure is based on a 5-year 
average, and therefore, the intensity adjustment for FY 2009 is 
based on data from the 5-year period beginning with FY 2003 and 
extending through FY 2007. There continues to be a substantial 
increase in hospital charges for three of those 5 years without a 
corresponding increase in the hospital case-mix index. Most 
dramatically, for FY 2003, the change in hospitals' charges is over 
16 percent, which is reflective of the large increases in charges 
that we found in the 4 years prior to FY 2003 and before our 
revisions to the outlier policy in 2003 (discussed below). For FY 
2004 and FY 2005, the change in hospitals' charges is somewhat lower 
in comparison to FY 2003, but is still significantly large. For FY 
2006 and FY 2007, the change in hospitals' charges appears to be 
slightly moderating. However, the change in hospitals' charges for 
FYs 2003 and 2004 and to a somewhat lesser extent FY 2005 remains 
similar to the considerable increase in hospitals' charges that we 
found when examining hospitals' charge data in determining the 
intensity factor in the update recommendations for the past few 
years, as discussed in the FY 2004 IPPS final rule (68 FR 45482), 
the FY 2005 IPPS final rule (69 FR 49285), the FY 2006 IPPS final 
rule (70 FR 47500), the FY 2007 IPPS final rule (72 FR 47500), and 
the FY 2008 IPPS final rule with comment period (72 FR 47426). If 
hospitals were treating new or different types of cases, which would 
result in an appropriate increase in charges per discharge, then we 
would expect hospitals' case-mix to increase proportionally. As we 
discussed most recently in the FY 2008 IPPS final rule with comment 
period (72 FR 47426), because our intensity calculation relies 
heavily upon charge data and we believe that these charge data may 
be inappropriately skewed, we established a 0.0 percent adjustment 
for intensity for FY 2008 just as we did for FYs 2004 through 2007.
    On June 9, 2003, we published in the Federal Register revisions 
to our outlier policy for determining the additional payment for 
extraordinarily high-cost cases (68 FR 34494 through 34515). These 
revised policies were effective on August 8, 2003, and October 1, 
2003. While it does appear that a response to these policy changes 
is beginning to occur, that is, the increase in charges for FYs 2004 
and 2005 are somewhat less than the previous 4 years, they still 
show a significant annual increase in charges without a 
corresponding increase in hospital case-mix. Specifically, the 
increases in charges in FY 2004 and FY 2005 (approximately 12 
percent and 8 percent, respectively), for example, which, while less 
than the increase in the previous 3 years, are still much higher 
than increases in years prior to FY 2001. In addition, these 
increases in charges for FYs 2003, FY 2004, and FY 2005 
significantly exceed the respective case-mix increases for the same 
period. Based on the significant increases in charges for FYs 2003 
through 2005 that remain in the 5-year average used for the 
intensity adjustment, we believe residual effects of hospitals' 
charge practices prior to the implementation of the outlier policy 
revisions established in the June 9, 2003 final rule continue to 
appear in the data, because 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 FY 2003, FY 2004, FY 2005 charge 
data may still be skewed. Although it appears that the change in 
hospitals' charges is more reasonable because the intensity 
adjustment is based on a 5-year average, and although the new 
outlier policy was generally effective in FY 2004, we believe the 
effects of hospitals attempting to maximize outlier payments, while 
lessening costs, continue to skew the charge data.
    Therefore, we are proposing to make a 0.0 percent adjustment for 
intensity for FY 2009. In the past (FYs 1996 through 2001) when we 
found intensity to be declining, we believed a zero (rather than 
negative) intensity adjustment was appropriate. Similarly, we 
believe that it is appropriate to apply a zero intensity adjustment 
for FY 2009 until any increase in charges during the 5-year period 
upon which the intensity adjustment is based can be tied to 
intensity rather than to attempts to maximize outlier payments.
    Above, we described the basis of the components used to develop 
the proposed 0.7 percent capital update factor for all hospitals 
under the capital update framework for FY 2009 as shown in the table 
below.

      CMS Proposed FY 2009 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 2007 Reclassification and Recalibration.........       -0.5
Forecast Error Correction....................................        0.0
                                                              ----------
    Total Update for Hospitals...............................        0.7
------------------------------------------------------------------------

b. Comparison of CMS and MedPAC Update Recommendation

    In its March 2008 Report to Congress, MedPAC did not make a 
specific update recommendation for capital IPPS payments for FY 
2009. However, in that same report, in assessing the adequacy of 
current payments and costs, MedPAC recommended an update to the 
hospital inpatient and outpatient PPS rates equal to the increase in 
the hospital market basket in FY 2009, concurrent with a quality 
incentive program. (MedPAC's Report to the Congress: Medicare 
Payment Policy, March 2008, 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 DRG payments.
    In the FY 2008 IPPS final rule with comment (72 FR 66887), we 
estimated that outlier payments for capital would equal 4.77 percent 
of inpatient capital-related payments based on the capital Federal 
rate in FY 2008. Based on the proposed thresholds as set forth

[[Page 23718]]

in section II.A. of this Addendum, we estimate that proposed outlier 
payments for capital-related costs would equal 5.73 percent for 
inpatient capital-related payments based on the proposed capital 
Federal rate in FY 2009. Therefore, we are proposing to apply an 
outlier adjustment factor of 0.9427 to the capital Federal rate. 
Thus, we estimate that the percentage of capital outlier payments to 
total capital standard payments for FY 2009 will be higher than the 
percentages for FY 2008. This increase is primarily due to the 
proposed decrease to the fixed-loss amount, which is discussed 
section II.A. of this Addendum.
    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 2009 outlier 
adjustment of 0.9427 is a -1.01percent change from the FY 2008 
outlier adjustment of 0.9523. Therefore, the net change in the 
proposed outlier adjustment to the capital Federal rate for FY 2009 
is 0.9899 (0.9427/0.9523). Thus, the proposed outlier adjustment 
decreases the FY 2009 capital Federal rate by 1.01 percent compared 
with the FY 2008 outlier adjustment.

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

    Section 412.308(c)(4)(ii) requires that the capital Federal rate 
be adjusted so that aggregate payments for the fiscal year based on 
the capital Federal rate after any changes resulting from the annual 
DRG reclassification and recalibration and changes in the GAF are 
projected to equal aggregate payments that would have been made on 
the basis of the capital Federal rate without such changes. Because 
we implemented a separate GAF for Puerto Rico, we apply separate 
budget neutrality adjustments for the national GAF and the Puerto 
Rico GAF. We apply the same budget neutrality factor for DRG 
reclassifications and recalibration nationally and for Puerto Rico. 
Separate adjustments were unnecessary for FY 1998 and earlier 
because the GAF for Puerto Rico was implemented in FY 1998.
    In the past, we used the actuarial capital cost model (described 
in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to 
estimate the aggregate payments that would have been made on the 
basis of the capital Federal rate with and without changes in the 
DRG classifications and weights and in the GAF to compute the 
adjustment required to maintain budget neutrality for changes in DRG 
weights and in the GAF. During the transition period, the capital 
cost model was also used to estimate the regular exception payment 
adjustment factor. As we explain in section III.A. of this Addendum, 
beginning in FY 2002, an adjustment for regular exception payments 
is no longer necessary. Therefore, we will 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 2009, we compared 
(separately for the national capital rate and the Puerto Rico 
capital rate) estimated aggregate capital Federal rate payments 
based on the FY 2008 DRG relative weights and the FY 2008 GAF to 
estimated aggregate capital Federal rate payments based on the 
proposed FY 2009 relative weights and the proposed FY 2009 GAFs. We 
established the final FY 2008 budget neutrality factors of 0.9902 
for the national capital rate and 0.9955 for the Puerto Rico capital 
rate. In making the comparison, we set the exceptions reduction 
factor to 1.00. To achieve budget neutrality for the changes in the 
national GAFs, based on calculations using updated data, we are 
proposing to apply an incremental budget neutrality adjustment of 
1.0013 for FY 2009 to the previous cumulative FY 2008 adjustments of 
0.9902, yielding a proposed adjustment of 0.9915, through FY 2009. 
For the Puerto Rico GAFs, we are proposing to apply a proposed 
incremental budget neutrality adjustment of 1.0009 for FY 2009 to 
the previous cumulative FY 2008 adjustment of 0.9955, yielding a 
proposed cumulative adjustment of 0.9965 (calculated with unrounded 
numbers) through FY 2009.
    We then compared estimated aggregate capital Federal rate 
payments based on the FY 2008 DRG relative weights and the proposed 
FY 2009 GAFs to estimated aggregate capital Federal rate payments 
based on the cumulative effects of the proposed FY 2009 DRG relative 
weights and the proposed FY 2009 GAFs. The proposed incremental 
adjustment for proposed DRG classifications and proposed changes in 
relative weights is 0.9994 both nationally and for Puerto Rico. The 
proposed cumulative adjustments for DRG classifications and changes 
in relative weights and for proposed changes in the GAFs through FY 
2009 are 0.9909 nationally and 0.9959 for Puerto Rico. The following 
table summarizes the adjustment factors for each fiscal year:
BILLING CODE 4120-01-P

[[Page 23719]]

[GRAPHIC][TIFF OMITTED]TP30AP08.021

BILLING CODE 4120-01-C
    The methodology used to determine the recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor is similar 
to the methodology used in establishing budget neutrality 
adjustments under the PPS for operating costs. One difference is 
that, under the operating PPS, the budget neutrality adjustments for 
the effect of geographic reclassifications are determined separately 
from the effects of other changes in the hospital wage index and the 
DRG relative weights. Under the capital PPS, there is a single DRG/
GAF budget neutrality adjustment factor (the national capital rate 
and the Puerto Rico capital rate are determined separately) for 
changes in the GAF (including geographic reclassification) and the 
DRG relative weights. In addition, there is no adjustment for the 
effects that geographic reclassification has on the other payment 
parameters, such as the payments for serving low-income patients or 
indirect medical education payments.
    In the FY 2008 IPPS correction notice (72 FR 57636), we 
calculated a GAF/DRG budget neutrality factor of 0.9996 for FY 2008. 
For FY 2009, we are proposing to establish a GAF/DRG budget 
neutrality factor of 1.0007. The GAF/DRG budget neutrality factors 
are

[[Page 23720]]

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 2008 to FY 
2009 is 1.0007. The cumulative change in the proposed capital 
Federal rate due to this proposed adjustment is 0.9909 (the product 
of the incremental factors for FYs 1994 though 2008 and the proposed 
incremental factor of 1.0007 for FY 2009). (We note that averages of 
the incremental factors that were in effect during FYs 2004 and 
2005, respectively, were used in the calculation of the proposed 
cumulative adjustment of 0.9909 for FY 2009.)
    The proposed factor accounts for DRG reclassifications and 
recalibration and for changes in the GAFs. It also incorporates the 
effects on the proposed GAFs of FY 2009 geographic reclassification 
decisions made by the MGCRB compared to FY 2008 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 Sec.  412.348 
relative to total capital PPS payments. In estimating the proportion 
of regular exception payments to total capital PPS payments during 
the transition period, we used the actuarial capital cost model 
originally developed for determining budget neutrality (described in 
Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to 
determine the exceptions payment adjustment factor, which was 
applied to both the Federal and hospital-specific capital rates.
    An adjustment for regular exception payments is no longer 
necessary in determining the FY 2009 capital Federal rate because, 
in accordance with Sec.  412.348(b), regular exception payments were 
only made for cost reporting periods beginning on or after October 
1, 1991 and before October 1, 2001. Accordingly, as we explained in 
the FY 2002 IPPS final rule (66 FR 39949), in FY 2002 and subsequent 
fiscal years, no payments are made under the regular exceptions 
provision. However, in accordance with Sec.  412.308(c), we still 
need to compute a budget neutrality adjustment for special exception 
payments under Sec.  412.348(g). We describe our methodology for 
determining the exceptions adjustment used in calculating the FY 
2008 capital Federal rate below.
    Under the special exceptions provision specified at Sec.  
412.348(g)(1), eligible hospitals include SCHs, urban hospitals with 
at least 100 beds that have a disproportionate share percentage of 
at least 20.2 percent or qualify for DSH payments under Sec.  
412.106(c)(2), and hospitals with a combined Medicare and Medicaid 
inpatient utilization of at least 70 percent. An eligible hospital 
may receive special exceptions payments if it meets the following 
criteria: (1) A project need requirement as described at Sec.  
412.348(g)(2), which, in the case of certain urban hospitals, 
includes an excess capacity test as described at Sec.  
412.348(g)(4); (2) an age of assets test as described at Sec.  
412.348(g)(3); and (3) a project size requirement as described at 
Sec.  412.348(g)(5).
    Based on information compiled from our fiscal intermediaries, 
six hospitals have qualified for special exceptions payments under 
Sec.  412.348(g). Because we have cost reports ending in FY 2005 for 
all of these hospitals, we calculated the adjustment based on actual 
cost experience. Using data from cost reports ending in FY 2005 from 
the December 2007 update of the HCRIS data, we divided the capital 
special exceptions payment amounts for the six hospitals that 
qualified for special exceptions by the total capital PPS payment 
amounts (including special exception payments) for all hospitals. 
Based on the data from cost reports ending in FY 2005, this ratio is 
rounded to 0.0002. We also computed the ratios for FY 2004 and FY 
2003, which both round to 0.0003. Since the ratios are trending 
downward, we are proposing an adjustment of 0.0002. Because special 
exceptions are budget neutral, we are proposing to offset the 
proposed capital Federal rate by 0.02 percent for special exceptions 
payments for FY 2009. Therefore, the proposed exceptions adjustment 
factor is equal to 0.9998 (1-0.0002) to account for special 
exceptions payments in FY 2009.
    In the FY 2008 IPPS final rule with comment period (72 FR 
47430), we estimated that total (special) exceptions payments for FY 
2008 would equal 0.03 percent of aggregate payments based on the 
capital Federal rate. Therefore, we applied an exceptions adjustment 
factor of 0.9997 (1 - 0.0003) to determine the FY 2008 capital 
Federal rate. As we stated above, we estimate that exceptions 
payments in FY 2009 would equal 0.02 percent of aggregate payments 
based on the proposed FY 2009 capital Federal rate. Therefore, we 
are proposing to apply an exceptions payment adjustment factor of 
0.9998 to the proposed capital Federal rate for FY 2009. The 
proposed exceptions adjustment factor for FY 2009 is slightly lower 
than the factor used in determining the FY 2008 capital Federal rate 
in the FY 2008 IPPS final rule. The exceptions reduction factors are 
not built permanently into the capital rates; that is, the factors 
are not applied cumulatively in determining the capital Federal 
rate. Therefore, the net change in the proposed exceptions 
adjustment factor used in determining the proposed FY 2009 capital 
Federal rate is 1.0001 (0.9998/0.9997).

5. Proposed Capital Standard Federal Rate for FY 2009

    In the FY 2008 IPPS final rule with comment period (72 FR 
66888), we established a capital Federal rate of $426.14 for all 
hospitals for FY 2008. We are proposing to establish an update of 
0.7 percent in determining the proposed FY 2009 capital Federal rate 
for all hospitals. However, under the statutory authority at section 
1886(d)(3)(A)(vi) of the Act, and as specified in section 7 of Pub. 
L. 110-90, we are proposing an additional 0.9 percent reduction to 
the proposed standardized amounts for both capital and operating 
Federal payment rates in FY 2009. The proposed 0.9 percent reduction 
is based on our Actuary's analysis of the effect of changes in 
coding or classification of discharges that do not reflect real 
changes in case-mix in light of the adoption of the MS-DRGs. 
Although the proposed 0.9 percent reduction is outside the 
established process for developing the proposed capital Federal 
payment rate, it nevertheless is a factor in the final prospective 
payment rate to hospitals for capital-related costs. For that 
reason, the proposed national capital Federal payment rate proposed 
in this proposed rule was determined by applying the proposed 0.9 
percent reduction. (As discussed below in section II.A.6. of this 
Addendum, we are not proposing to apply the proposed 0.9 percent 
reduction in developing the proposed FY 2009 Puerto Rico-specific 
capital rate.) As a result of the proposed 0.70 percent update and 
other proposed budget neutrality factors discussed above, we are 
proposing to establish a capital Federal rate of $421.29 for FY 
2009. The proposed capital Federal rate for FY 2009 was calculated 
as follows:
    <bullet> The proposed FY 2009 update factor is 1.0070, that is, 
the update is 0.70 percent.
    <bullet> The proposed FY 2009 budget neutrality adjustment 
factor that is applied to the capital standard Federal payment rate 
for changes in the DRG relative weights and in the GAFs is 1.0007.
    <bullet> The proposed FY 2009 outlier adjustment factor is 
0.9427.
    <bullet> The proposed FY 2009 (special) exceptions payment 
adjustment factor is 0.9998.
    <bullet> The proposed FY 2009 reduction for improvements in 
documentation and coding under the MS-DRGs is 0.9 percent.
    Because the proposed capital Federal rate has already been 
adjusted for differences in case-mix, wages, cost-of-living, 
indirect medical education costs, and payments to hospitals serving 
a disproportionate share of low-income patients, we are not 
proposing to make additional adjustments in the proposed capital 
standard Federal rate for these factors, other than the budget 
neutrality factor for changes in the DRG relative weights and the 
GAFs.
    We are providing the following chart that shows how each of the 
proposed factors and adjustments for FY 2009 affected the 
computation of the proposed FY 2009 capital Federal rate in 
comparison to the FY 2008 capital Federal rate. The proposed FY 2009 
update factor has the effect of increasing the proposed capital 
Federal rate by 0.70 percent compared to the FY 2008 capital Federal 
rate. The proposed GAF/DRG budget neutrality factor has the effect 
of increasing the proposed capital Federal rate by 0.07 percent. The 
proposed FY 2009 outlier adjustment factor has the effect of 
decreasing the proposed capital Federal rate by 1.01 percent 
compared to the FY 2008 capital Federal rate. The proposed FY 2009 
exceptions payment adjustment factor has the effect of increasing 
the proposed capital Federal rate by 0.01 percent. The proposed 
adjustment for improvements in documentation and coding

[[Page 23721]]

under the MS-DRGs has the effect of decreasing the proposed FY 2009 
capital Federal rate by 0.9 percent as compared to the FY 2008 
capital Federal rate. The combined effect of all the proposed 
changes decreases the proposed capital Federal rate by 1.14 percent 
compared to the FY 2008 capital Federal rate.

  Comparison of Factors and Adjustments: FY 2008 Capital Federal Rate and Proposed FY 2009 Capital Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                                    Proposed FY                   Percent change
                                                      FY 2008        2009 \4\         Change            \5\
----------------------------------------------------------------------------------------------------------------
Update Factor \1\...............................          1.0090          1.0070          1.0070            0.70
GAF/DRG Adjustment Factor \1\...................          0.9996          1.0007          1.0007            0.07
Outlier Adjustment Factor \2\...................          0.9523          0.9427          0.9899           -1.01
Exceptions Adjustment Factor \2\................          0.9997          0.9998          1.0001            0.01
MS-DRG Coding and Documentation Improvements              0.9940          0.9910          0.9910           -0.90
 Adjustment Factor \3\..........................
Capital Federal Rate............................         $426.14         $421.29          0.9886           -1.14
----------------------------------------------------------------------------------------------------------------
\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 2008 to FY 2009 resulting from the application of the
  proposed 1.0007 GAF/DRG budget neutrality factor for FY 2009 is 1.0007.
\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 net change resulting from the application of the proposed FY 2009 outlier adjustment factor is
  0.9427/0.9523, or 0.9899.
\3\ Proposed adjustment to FY 2009 IPPS rates to account for documentation and coding improvements expected to
  result from the adoption of the MS-DRGs, as discussed above in section III.D. of the Addendum to this proposed
  rule.
\4\ Proposed factors for FY 2009, as discussed above in section III. of this Addendum.
\5\ Percent change of individual factors may not sum due to rounding.

6. Proposed Special Capital Rate for Puerto Rico Hospitals

    Section 412.374 provides for the use of a blended payment system 
for payments to 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, while the capital 
Federal rate is derived from the costs of all acute care hospitals 
participating in the IPPS (including Puerto Rico).
    To adjust hospitals' capital payments for geographic variations 
in capital costs, we apply a GAF to both portions of the blended 
capital rate. The GAF is calculated using the operating IPPS wage 
index, and varies depending on the labor market area or rural area 
in which the hospital is located. We use the Puerto Rico wage index 
to determine the GAF for the Puerto Rico part of the capital-blended 
rate and the national wage index to determine the GAF for the 
national part of the blended capital rate.
    Because we implemented a separate GAF for Puerto Rico in FY 
1998, we also apply separate budget neutrality adjustments for the 
national GAF and for the Puerto Rico GAF. However, we apply the same 
budget neutrality factor for DRG reclassifications and recalibration 
nationally and for Puerto Rico. As we stated above in section 
III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget 
neutrality factor is 1.0009, while the DRG adjustment is 0.9994, for 
a combined proposed cumulative adjustment of 1.0004.
    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 2008, before application of the GAF, the special capital 
rate for hospitals located in Puerto Rico was $201.67 for discharges 
occurring on or after October 1, 2007, through September 30, 2008 
(72 FR 66888). However, as discussed in greater detail in section 
II.D. of the preamble of this proposed rule, we are revising this 
rate in a forthcoming correction notice that will be retroactive to 
October 1, 2007, to remove the application of the 0.6 percent 
documentation and coding adjustment for FY 2008, consistent with the 
correction to the Puerto Rico specific standardized amount for FY 
2008. The 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. Although 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, we have historically made 
changes to the capital PPS consistent with those changes made to the 
IPPS. Thus, we are removing the documentation and coding adjustment 
from the FY 2008 Puerto Rico-specific portion of the blended capital 
payment rate, consistent with its removal from the Puerto Rico-
specific standardized amount under the IPPS for operating costs. 
Furthermore, we are not proposing to apply the 0.9 percent 
documentation and coding adjustment to the proposed FY 2009 Puerto 
Rico-specific portion of the blended capital payment. However, as 
also discussed in section II.D. of the preamble of this proposed 
rule, we may propose to apply such an adjustment to the Puerto Rico 
operating and capital rates in the future. With the changes we are 
proposing to make to the other factors used to determine the capital 
rate, the proposed FY 2009 special capital rate for hospitals in 
Puerto Rico is $197.19.

B. Calculation of the Proposed Inpatient Capital-Related 
Prospective Payments for FY 2009

    Because the 10-year capital PPS transition period ended in FY 
2001, all hospitals (except ``new'' hospitals under Sec.  412.324(b) 
and under Sec.  412.304(c)(2)) are paid based on 100 percent of the 
capital Federal rate in FY 2007. The applicable capital Federal rate 
was determined by making the following adjustments:
    <bullet> For outliers, by dividing the capital standard Federal 
rate by the outlier reduction factor for that fiscal year; and
    <bullet> For the payment adjustments applicable to the hospital, 
by multiplying the hospital's GAF, disproportionate share adjustment 
factor, and IME adjustment factor, when appropriate.
    For purposes of calculating payments for each discharge during 
FY 2009, the capital standard Federal rate would be adjusted as 
follows: (Standard Federal Rate) x (DRG weight) x (GAF) x (COLA for 
hospitals located in Alaska and Hawaii) x (1 + Disproportionate 
Share Adjustment Factor + IME Adjustment Factor, if applicable). The 
result is the adjusted capital Federal rate. (As discussed above and 
in section V. of the preamble of this proposed rule, we eliminated 
the large urban add-on adjustment in existing regulations at Sec.  
412.316, beginning in FY 2008.)
    Hospitals also may receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year. 
Section 412.312(c) provides for a single

[[Page 23722]]

set of thresholds to identify outlier cases for both inpatient 
operating and inpatient capital-related payments. The proposed 
outlier thresholds for FY 2009 are in section II.A. of this 
Addendum. For FY 2009, a case qualifies as a cost outlier if the 
cost for the case plus the IME and DSH payments is greater than the 
prospective payment rate for the DRG plus the proposed fixed-loss 
amount of $21,025.
    An eligible hospital may also qualify for a special exceptions 
payment under Sec.  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 Sec.  
412.348(g)(2), which in the case of certain urban hospitals includes 
an excess capacity test as described at Sec.  412.348(g)(4); and (2) 
a project size requirement as described at Sec.  412.348(g)(5). 
Eligible hospitals include SCHs, urban hospitals with at least 100 
beds that have a DSH patient percentage of at least 20.2 percent or 
qualify for DSH payments under Sec.  412.106(c)(2), and hospitals 
that have a combined Medicare and Medicaid inpatient utilization of 
at least 70 percent. Under Sec.  412.348(g)(8), the amount of a 
special exceptions payment is determined by comparing the cumulative 
payments made to the hospital under the capital PPS to the 
cumulative minimum payment level. This amount is offset by: (1) Any 
amount by which a hospital's cumulative capital payments exceed its 
cumulative minimum payment levels applicable under the regular 
exceptions process for cost reporting periods beginning during which 
the hospital has been subject to the capital PPS; and (2) any amount 
by which a hospital's current year operating and capital payments 
(excluding 75 percent of operating DSH payments) exceed its 
operating and capital costs. Under Sec.  412.348(g)(6), the minimum 
payment level is 70 percent for all eligible hospitals.
    During the transition period, new hospitals (as defined under 
Sec.  412.300) were exempt from the capital IPPS for their first 2 
years of operation and were paid 85 percent of their reasonable 
costs during that period. Effective with the third year of operation 
through the remainder of the transition period, under Sec.  
412.324(b), we paid the hospitals under the appropriate transition 
methodology (if the hold-harmless methodology were applicable, the 
hold-harmless payment for assets in use during the base period would 
extend for 8 years, even if the hold-harmless payments extend beyond 
the normal transition period).
    Under Sec.  412.304(c)(2), for cost reporting periods beginning 
on or after October 1, 2002, we pay a new hospital 85 percent of its 
reasonable costs during the first 2 years of operation unless it 
elects to receive payment based on 100 percent of the capital 
Federal rate. Effective with the third year of operation, we pay the 
hospital based on 100 percent of the capital Federal rate (that is, 
the same methodology used to pay all other hospitals subject to the 
capital PPS).

C. Capital Input Price Index

1. Background

    Like the operating input price index, the capital input price 
index (CIPI) is a fixed-weight price index that measures the price 
changes associated with capital costs during a given year. The CIPI 
differs from the operating input price index in one important 
aspect--the CIPI reflects the vintage nature of capital, which is 
the acquisition and use of capital over time. Capital expenses in 
any given year are determined by the stock of capital in that year 
(that is, capital that remains on hand from all current and prior 
capital acquisitions). An index measuring capital price changes 
needs to reflect this vintage nature of capital. Therefore, the CIPI 
was developed to capture the vintage nature of capital by using a 
weighted-average of past capital purchase prices up to and including 
the current year.
    We periodically update the base year for the operating and 
capital input prices to reflect the changing composition of inputs 
for operating and capital expenses. The CIPI was last rebased to FY 
2002 in the FY 2006 IPPS final rule (70 FR 47387).

2. Forecast of the CIPI for FY 2009

    Based on the latest forecast by Global Insight, Inc. (first 
quarter of 2008), we are forecasting the CIPI to increase 1.2 
percent in FY 2009. This reflects a projected 1.9 percent increase 
in vintage-weighted depreciation prices (building and fixed 
equipment, and movable equipment), and a 2.9 percent increase in 
other capital expense prices in FY 2009, partially offset by 2.8 
percent decline in vintage-weighted interest expenses in FY 2009. 
The weighted average of these three factors produces the 1.2 percent 
increase for the CIPI as a whole in FY 2009.

IV. Proposed Changes to Payment Rates for Excluded Hospitals and 
Hospital Units: 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 Sec.  413.40(a)) was set for each 
hospital or hospital unit based on the hospital's own cost 
experience in its base year. The target amount was multiplied by the 
Medicare discharges and applied as an aggregate upper limit (the 
ceiling as defined in Sec.  413.40(a)) on total inpatient operating 
costs for a hospital's cost reporting period. Prior to October 1, 
1997, these payment provisions applied consistently to all 
categories of excluded providers (rehabilitation hospitals and units 
(now referred to as IRFs), psychiatric hospitals and units (now 
referred to as IPFs), LTCHs, children's hospitals, and cancer 
hospitals).
    Payment for services furnished in children's hospitals and 
cancer hospitals that are excluded from the IPPS continues to be 
subject to the rate-of-increase ceiling based on the hospital's own 
historical cost experience. (We note that, in accordance with Sec.  
403.752(a), RNHCIs are also subject to the rate-of-increase limits 
established under Sec.  413.40 of the regulations.)
    We are proposing that the FY 2009 rate-of-increase percentage 
for cancer and children's hospitals and RNHCIs is the percentage 
increase in the FY 2009 IPPS operating market basket, estimated to 
be 3.0 percent. Consistent with our historical approach, if more 
recent data are available for the final rule, we will use those data 
to calculate the IPPS operating market basket. For this proposed 
rule, we are proposing to calculate the IPPS operating market basket 
for FY 2009 using the most recent data available. For cancer and 
children's hospitals and RNHCIs, the proposed FY 2009 rate-of-
increase percentage that is applied to FY 2008 target amounts in 
order to calculate the proposed FY 2009 target amounts is based on 
Global Insight, Inc.'s 2008 forecast of the IPPS operating market 
basket increase, in accordance with the applicable regulations at 42 
CFR 413.40.
    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 the various transitioning periods 
provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have 
ended. For cost reporting periods beginning on or after October 1, 
2002, all IRFs are paid 100 percent of the adjusted Federal rate 
under the IRF PPS. Therefore, for cost reporting periods beginning 
on or after October 1, 2002, no portion of an IRF PPS payment is 
subject to 42 CFR part 413. Similarly, for cost reporting periods 
beginning on or after October 1, 2006, all LTCHs are paid 100 
percent of the adjusted Federal prospective payment rate under the 
LTCH PPS. Therefore, for cost reporting periods beginning on or 
after October 1, 2006, no portion of the LTCH PPS payment is subject 
to 42 CFR part 413. Likewise, for cost reporting periods beginning 
on or after January 1, 2008, all IPFs are paid 100 percent of the 
Federal per diem amount under the IPF PPS. Therefore, for cost 
reporting periods beginning on or after January 1, 2008, no portion 
of an IPF PPS payment is subject to 42 CFR part 413.

V. Tables

    This section contains the tables referred to throughout the 
preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 
1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4D, 4D-1, 4D-2, 4E, 4F, 4G, 4H, 4J, 
5, 6A, 6B, 6C, 6D, 6E, 6F, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 
are presented below. The following tables discussed in section II. 
of the preamble of this proposed rule are available only through the 
Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/: 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.--
Complication and Comorbidity (CC).

[[Page 23723]]

    The tables presented in this section of the Addendum are as 
follows:

Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If 
Wage Index Is Greater Than 1)
Table 1B.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage 
Index Is Less Than or Equal To 1)
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D.--Capital Standard Federal Payment Rate
Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal 
Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 
2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage 
Data); and 3-Year Average of Hospital Average Hourly Wages
Table 3A.--FY 2009 and 3-Year Average Hourly Wage for Urban Areas by 
CBSA
Table 3B.--FY 2009 and 3-Year Average Hourly Wage for Rural Areas by 
CBSA
Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Urban Areas by CBSA and by State--FY 2009
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Rural Areas by CBSA and by State--FY 2009
Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Hospitals That Are Reclassified by CBSA and by State--FY 2009
Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009
Table 4D-2.--Urban Areas with Hospitals Receiving the Statewide 
Rural Floor or Imputed Floor Wage Index--FY 2009
Table 4E.--Urban CBSAs and Constituent Counties--FY 2009
Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment 
Factor (GAF) by CBSA--FY 2009
Table 4J.--Out-Migration Adjustment--FY 2009
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 2007 MedPAR Update--December 2007 GROUPER V25.0 
MS-DRGs
Table 7B.--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay: FY 2007 MedPAR Update--December 2007 GROUPER V26.0 
MS-DRGs
Table 8A.--Proposed Statewide Average Operating Cost-to-Charge 
Ratios-- March 2008
Table 8B.--Proposed Statewide Average Capital Cost-to-Charge 
Ratios--March 2008
Table 8C.--Proposed Statewide Average Total Cost-to-Charge Ratios 
for LTCHs--March 2008
Table 9A.--Hospital Reclassifications and Redesignations--FY 2009
Table 9C.--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2009
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 2008
Table 11.--Proposed FY 2009 MS-LTC-DRGs, Proposed Relative Weights, 
Proposed Geometric Average Length of Stay, and Proposed Short-Stay 
Outlier Threshold

   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
   [69.7 Percent Labor Share/30.3 Percent Nonlabor Share if Wage Index
                             Greater Than 1]
------------------------------------------------------------------------
      Full update (3.0 percent)          Reduced update (1.0 percent)
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
     $3,553.98          $1,544.98         $3,484.97         $1,514.98
------------------------------------------------------------------------


   Table 1B.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
  [62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Less
                           Than or Equal to 1]
------------------------------------------------------------------------
      Full update (3.0 percent)          Reduced update (1.0 percent)
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
     $3,161.36          $1,937.60         $3,099.97         $1,899.98
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                                 Rates if wage index    Rates if wage index less
                                                                   greater than 1          than or equal to 1
                                                             ---------------------------------------------------
                                                                 Labor       Nonlabor      Labor       Nonlabor
----------------------------------------------------------------------------------------------------------------
National....................................................    $3,553.98    $1,544.98    $3,161.36    $1,937.60
Puerto Rico.................................................     1,501.82       920.46     1,421.88     1,000.40
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                                 Rate
------------------------------------------------------------------------
National....................................................     $421.29
Puerto Rico.................................................      197.19
------------------------------------------------------------------------


[[Page 23724]]


 Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal Year 2009; Hospital
  Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data) and 2009 (2005 Wage Data); and 3-Year Average of Hospital
                                                                  Average Hourly Wages
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                              Average         Average         Average         Average
                      Provider No.                        Case-mix index   FY 2009 wage   hourly wage FY  hourly wage FY  hourly wage FY   hourly wage**
                                                                \2\            index           2007            2008          2009 \1\        (3 years)
--------------------------------------------------------------------------------------------------------------------------------------------------------
010001..................................................          1.5513          0.8397         22.1989         23.2195         24.7672         23.3821
010005..................................................          1.1192          0.8636         23.6022         23.0203         25.7755         24.1406
010006..................................................          1.4819          0.7883         23.4975         23.7502         25.0258         24.0951
010007..................................................          1.0611          0.7647         19.9329         21.3492         22.0185         21.1334
010008..................................................          1.0242          0.7821         17.9533         22.0793         23.2562         20.8430
010009..................................................          0.9973          0.8636         23.5626         25.9011         25.8405         25.1048
010010..................................................          1.0945          0.8786         27.0385         22.8602         24.8375         24.7458
010011..................................................          1.6762          0.8786         27.6658         27.4668         27.1978         27.4380
010012..................................................          1.1633          0.9524         24.4059         25.5767         26.4968         25.4682
010015..................................................          1.0453          0.7693         22.3383         27.0806         23.6811         24.1695
010016..................................................          1.5794          0.8786         24.6488         26.8611         28.9705         26.8024
010018..................................................          1.4886          0.8786         23.7048         24.8974         26.9498         25.1709
010019..................................................          1.2556          0.7883         22.8766         23.3460         25.0154         23.7418
010021..................................................          1.2285          0.7677         19.7367         21.0624         21.7592         20.8458
010022..................................................          0.9940          0.9760         25.8404         27.4318         28.7520         27.3475
010023..................................................          1.7665          0.8192         25.4272         26.1739         27.0693         26.2901
010024..................................................          1.5997          0.8192         22.0819         25.0715         26.6617         24.5911
010025..................................................          1.2929          0.8495         22.7635         23.6186         23.8602         23.4229
010027..................................................          0.7391          0.7662         16.4682         17.0513         18.2507         17.2827
010029..................................................          1.5947          0.8495         23.9007         25.0468         24.3605         24.4407
010032..................................................          0.8805          0.7972         19.3311         18.5545         20.8446         19.6445
010033..................................................          2.1342          0.8786         27.4181         29.1471         29.2005         28.6046
010034..................................................          1.0166          0.8192         17.7457         19.1549         21.2713         19.3572
010035..................................................          1.2478          0.8786         24.2425         24.2746         26.5285         25.0065
010036..................................................          1.1526          0.7647         21.5796         24.2887         23.7923         23.2285
010038..................................................          1.3336          0.8054         23.7039         27.0752         28.9624         26.4786
010039..................................................          1.6454          0.8987         26.9919         28.6462         29.8012         28.4927
010040..................................................          1.6515          0.8052         24.3207         24.7657         25.9851         25.0414
010043..................................................          1.0854          0.8786         21.9774         23.9121         25.3624         23.7097
010044..................................................          1.0626          0.7647         22.5009         24.4276         23.4009         23.4233
010045..................................................          1.1529          0.7869         20.4927         23.1695         23.5160         22.3334
010046..................................................          1.5241          0.8052         23.4219         25.9105         25.4444         24.8777
010047..................................................          0.8836          0.7774         26.4851         19.7542         21.7347         22.0981
010049..................................................          1.1411          0.7662         21.7888         22.4248         23.1186         22.4564
010050..................................................          1.0831          0.8786         22.9620         24.4060         25.3663         24.2272
010051..................................................          0.8989          0.8695         18.7701         18.0305         20.0755         18.9088
010052..................................................          0.8813          0.8192         25.9233         36.3638         23.4990         28.7904
010054..................................................          1.1310          0.8636         23.3624         24.4810         25.4189         24.4485
010055..................................................          1.5957          0.8322         22.5396         22.4145         25.3295         23.4244
010056..................................................          1.5856          0.8786         23.7398         24.5754         25.7272         24.7305
010058..................................................          1.0206          0.8786         19.5092         17.0150         31.1856         21.2663
010059..................................................          1.0080          0.8636         23.0012         24.8199         27.8607         25.3457
010061..................................................          0.9842          0.8740         24.1185         25.2454         25.5878         24.9798
010062..................................................          1.0319          0.7718         21.4805         21.7112         22.9481         22.0341
010064..................................................          1.7124          0.8786         24.8155         27.6149         26.6313         26.3101
010065..................................................          1.5119          0.8786         23.0477         24.3346         24.5833         24.0058
010066..................................................          0.8885          0.7647         19.8692         25.4612         25.6055         23.6384
010068..................................................             ***               *         22.7156         24.4145               *         23.5620
010069..................................................          0.9721          0.7647         23.1243         23.6272         27.3424         24.6217
010072..................................................             ***               *         24.4989               *               *         24.4989
010073..................................................          0.9451          0.7647         18.3963         19.0046         20.7832         19.3949
010078..................................................          1.6130          0.8054         23.5279         24.3828         25.2879         24.4148
010079..................................................          1.2409          0.8987         22.7337         22.3034         23.1015         22.7293
010083..................................................          1.1817          0.8115         22.4279         24.0036         25.0403         23.8754
010084..................................................             ***               *         26.3238         26.5079         27.5054         26.7172
010085..................................................          1.3040          0.8636         24.2609         23.6280         24.0460         23.9691
010086..................................................          1.0270          0.7647         22.2096         21.5584         26.8993         23.3292
010087..................................................          2.2105          0.7809         22.4318         24.8320         26.2401         24.3812
010089..................................................          1.2944          0.8786         25.0811         26.2628         25.9704         25.7574
010090..................................................          1.7257          0.8030         26.0494         26.3957         25.6095         26.0158
010091..................................................          0.9075          0.7693         23.1310         22.5272         23.6554         23.1156
010092..................................................          1.4953          0.8695         26.6796         26.9959         28.5598         27.4270
010095..................................................          0.8389          0.8695         16.5250         17.0024         17.8242         17.1161
010097..................................................          0.7528          0.8192         19.4511         19.2481         18.4215         18.9973
010099..................................................          0.9928          0.7647         20.8383         20.6736         22.3677         21.2837
010100..................................................          1.7251          0.8115         23.8919         25.1460         25.4338         24.8850
010101..................................................          1.1737          0.8786         24.2575         25.0974         26.2731         25.2372

[[Page 23725]]

 
010102..................................................          0.9506          0.8192         25.6158         26.9859         26.6935         26.4289
010103..................................................          1.8628          0.8786         27.8272         28.9636         30.4015         29.0796
010104..................................................          1.8548          0.8786         27.6471         28.3126         30.4938         28.7438
010108..................................................          1.0595          0.8192         24.6740         25.4325         26.8882         25.7625
010109..................................................          0.9572          0.8098         17.6733         21.0449         21.9296         20.0804
010110..................................................          0.7382          0.7862         26.0038         19.8738         22.1164         22.5113
010112..................................................          0.9794          0.7647         17.1833         20.4027         21.3150         19.6839
010113..................................................          1.6320          0.7809         22.3282         24.7170         25.0689         24.0138
010114..................................................          1.4032          0.8786         25.6152         25.7090         25.3646         25.5596
010118..................................................          1.2125          0.8192         21.4630         22.7191         25.3678         23.1085
010120..................................................          1.0320          0.7647         20.9019         22.1868         22.8170         21.9915
010125..................................................          1.0385          0.8123         21.5123         22.8911         23.6542         22.7013
010126..................................................          1.1498          0.8192         23.9327         24.4957         25.7234         24.7205
010128..................................................          0.9062          0.7693         23.6647         24.9881         25.9417         24.9328
010129..................................................          1.0676          0.7781         22.1574         21.8502         24.4806         22.8945
010130..................................................          1.0051          0.8786         23.7528         24.5644         25.2775         24.5383
010131..................................................          1.3760          0.8987         26.4297         27.2707         28.0468         27.2971
010137..................................................          1.2318          0.8786         27.5782         28.5843         30.4347         28.8905
010138..................................................          0.6210          0.7713         16.7602         14.5551         15.0814         15.4264
010139..................................................          1.5846          0.8786         26.8726         28.1473         29.3543         28.1531
010143..................................................          1.2041          0.8636         26.2762         24.0674         25.0859         25.0921
010144..................................................          1.7285          0.7809         22.5133         22.3916         23.8581         22.9469
010145..................................................          1.4494          0.8695         24.5092         25.8293         27.3277         25.8981
010146..................................................          1.1251          0.8054         22.6586         22.6879         23.7803         23.0525
010148..................................................          0.8893          0.7647         23.9246         23.5714         25.0949         24.1955
010149..................................................          1.2271          0.8192         24.4805         25.4354         26.8895         25.7355
010150..................................................          0.9968          0.8192         23.6080         24.4098         25.0060         24.3378
010152..................................................          1.2632          0.7809         22.4075         23.7803         26.0777         24.1152
010157..................................................          1.1630          0.7883         23.3828         24.2206         27.1156         24.7415
010158..................................................          1.2536          0.7883         23.5533         25.5905         26.2350         25.0899
010162..................................................             ***               *         33.8777               *               *         33.8777
010163..................................................             ***               *               *         34.0325               *         34.0325
010164..................................................          1.2261          0.8786               *         23.2447         25.6659         24.4751
010165..................................................             ***               *               *         28.8040               *         28.8040
010166..................................................             ***               *               *         29.7256               *         29.7256
010167..................................................          1.6912          0.8786               *               *               *               *
010168..................................................          1.3124          0.9061               *               *               *               *
020001..................................................          1.7281          1.1884         35.4232         36.5298         38.1754         36.7192
020004..................................................             ***               *         31.8004               *               *         31.8004
020006..................................................          1.2847          1.1884         34.3752         37.0211         37.2838         36.2129
020008..................................................          1.2046          1.1884         36.1250         39.3432         40.6758         38.7262
020012..................................................          1.3619          1.1884         32.5975         33.9375         36.1891         34.2975
020014..................................................          1.0617          1.1884         29.4472         30.9722         30.6325         30.3727
020017..................................................          2.0201          1.1884         35.4119         35.8804         38.2137         36.5154
020018..................................................          0.9475          1.9292               *               *               *               *
020019..................................................          0.9038               *               *               *               *               *
020024..................................................          1.1768          1.1884         29.5195         38.6934         39.9916         35.5845
020026..................................................          1.5400          1.9292               *               *               *               *
020027..................................................          0.9585          1.9292               *               *               *               *
030001..................................................          1.5351          1.0271         32.4791         33.4178         35.9045         33.8225
030002..................................................          2.1087          1.0271         30.2200         31.0818         32.9061         31.4265
030006..................................................          1.7187          0.9442         27.0599         27.7421         29.1218         28.0025
030007..................................................          1.4597          1.1305         31.1928         33.7213         35.5193         33.5056
030009..................................................             ***               *         26.5408               *               *         26.5408
030010..................................................          1.4417          0.9442         28.5684         30.6261         31.8606         30.4135
030011..................................................          1.5335          0.9442         28.1423         28.8203         30.2062         29.0981
030012..................................................          1.4301          1.0198         27.3895         29.1042         31.3041         29.3702
030013..................................................          1.5318          0.9903         27.0111         31.2815         31.9135         30.1305
030014..................................................          1.5815          1.0271         29.6582         29.8296         30.6276         30.0779
030016..................................................          1.2770          1.0271         29.1980         30.7896         31.1854         30.4653
030017..................................................          2.0581          1.0271         30.6007         34.4852         34.8458         33.3763
030018..................................................          1.3639          1.0271         29.4566         31.8056         31.7220         31.0137
030019..................................................          1.3016          1.0271         29.5921         30.1934         33.6528         31.0565
030022..................................................          1.8063          1.0271         30.5710         30.3746         35.0728         31.9469
030023..................................................          1.8138          1.1652         34.2142         35.8287         37.5481         35.8798
030024..................................................          2.1440          1.0271         31.9247         33.1797         35.6078         33.6344
030030..................................................          1.6952          1.0271         32.0994         34.4166         36.4747         34.2670

[[Page 23726]]

 
030033..................................................          1.3116          1.1305         28.7508         29.9383         32.0342         30.2702
030036..................................................          1.5415          1.0271         30.9834         33.0523         36.2020         33.6063
030037..................................................          1.9894          1.0271         31.2877         34.1079         35.1314         33.3937
030038..................................................          1.6433          1.0271         29.9314         31.7238         31.2906         31.0104
030040..................................................             ***               *         27.5322               *               *         27.5322
030043..................................................          1.2301          0.8857         26.5834         27.3856         28.3147         27.4531
030055..................................................          1.4731          1.0011         27.1473         27.1621         30.9311         28.4812
030060..................................................          1.1614               *         24.8373               *               *         24.8373
030061..................................................          1.6370          1.0271         28.0696         28.1337         33.0826         29.7496
030062..................................................          1.2360          0.8857         26.6880         28.9587         29.9331         28.5898
030064..................................................          2.0334          0.9442         28.3853         29.8226         31.6603         30.0071
030065..................................................          1.6347          1.0271         29.5883         31.0817         31.4568         30.7651
030067..................................................          1.0057          0.9155         20.7591         27.4497         27.0766         25.0396
030068..................................................          1.1245          0.8857         23.1394         23.8792         26.0276         24.3896
030069..................................................          1.4761          1.1254         30.2224         29.7802         30.7696         30.2553
030071..................................................          1.0045          1.4448               *               *               *               *
030073..................................................          1.1300          1.4448               *               *               *               *
030074..................................................          0.9181          1.4448               *               *               *               *
030077..................................................          0.8053          1.4448               *               *               *               *
030078..................................................          1.1355          1.4448               *               *               *               *
030080..................................................             ***               *         27.1360         28.6568         30.7660         28.9576
030083..................................................          1.3493          1.0271         27.4983         33.5302         35.8488         32.0946
030084..................................................          1.0175          1.4448               *               *               *               *
030085..................................................          1.6306          0.9442         26.8364         28.1388         29.0750         28.0469
030087..................................................          1.7040          1.0271         29.5962         31.2331         31.1070         30.6895
030088..................................................          1.3727          1.0271         27.8604         29.9758         30.5716         29.5054
030089..................................................          1.5952          1.0271         28.9068         30.1591         31.3148         30.1497
030092..................................................          1.5055          1.0271         31.7512         30.6343         30.4361         30.8516
030093..................................................          1.3209          1.0271         26.4430         27.8821         33.0699         29.2816
030094..................................................          1.5460          1.0271         31.5422         33.4050         34.2007         33.1194
030099..................................................          0.9137          0.8857         27.1402         26.9227         24.9115         26.3285
030100..................................................          2.0982          0.9442         31.5628         34.7532         35.0944         33.8057
030101..................................................          1.4909          1.1388         27.8302         30.6764         33.2110         30.6802
030102..................................................          2.4535          1.0271         31.6285         33.6247         36.9492         34.0941
030103..................................................          1.7698          1.0271         31.7322         32.2833         33.9387         32.6963
030105..................................................          2.3493          1.0271         31.2970         32.7449         33.9846         32.7833
030106..................................................          1.5634          1.0271         32.9840         36.4667         40.1625         36.8304
030107..................................................          1.9107          1.0271         35.6197         35.5386         35.4524         35.5298
030108..................................................          2.0613          1.0271               *         29.9395         34.8483         32.9293
030109..................................................             ***               *         16.5906               *               *         16.5906
030110..................................................          1.6838          1.0271         31.4852         29.7949         36.2124         32.4772
030111..................................................          1.0463          0.9442               *         33.3711         28.5133         30.2230
030112..................................................          2.0028          1.0271               *         36.6601         33.4776         34.6249
030113..................................................          0.9099          1.4448               *               *               *               *
030114..................................................          1.4838          0.9442               *               *         28.8439         28.8439
030115..................................................          1.4714          1.0271               *               *         32.5857         32.5857
030117..................................................          1.2494          0.9817               *               *               *               *
030118..................................................          1.1423          1.0198               *               *               *               *
030119..................................................          1.2774          1.0271               *               *               *               *
030120..................................................          0.8689          1.0271               *               *               *               *
030121..................................................          1.0784          1.0271               *               *               *               *
040001..................................................          1.0747          0.9131         22.9327         22.9948         24.4950         23.4592
040002..................................................          1.1735          0.7641         21.2020         25.0000         24.0479         23.3250
040004..................................................          1.6814          0.9131         27.1741         28.1117         29.2695         28.2056
040007..................................................          1.7434          0.8754         40.1291         29.1941         27.4839         32.0643
040010..................................................          1.4746          0.9131         24.2315         26.5287         28.2363         26.3909
040011..................................................          1.0296          0.7641         21.0967         22.2431         22.6320         22.0004
040014..................................................          1.3517          0.8650         26.4777         28.9855         34.8259         29.4945
040015..................................................          1.1207          0.7641         20.4279         20.1061         22.3145         20.9794
040016..................................................          1.7125          0.8754         25.8056         26.5911         26.4787         26.3029
040017..................................................          1.1221          0.8952         21.9147         23.8768         24.3768         23.3605
040018..................................................          1.1123          0.7843         24.0026         25.6751         26.2511         25.2931
040019..................................................          1.0410          0.8909         23.8706         24.9113         26.4915         25.0680
040020..................................................          1.6290          0.8909         22.6497         23.9470         26.1519         24.2422
040021..................................................          1.5502          0.8754         25.4046         26.1853         27.6779         26.3611
040022..................................................          1.4648          0.9131         29.5000         27.9902         30.0234         29.1589
040026..................................................          1.5430          0.9146         27.7931         29.5299         31.8579         29.7126

[[Page 23727]]

 
040027..................................................          1.5239          0.8477         21.4252         23.8220         25.7922         23.6373
040029..................................................          1.4258          0.8754         24.8409         25.1479         27.8865         25.9688
040036..................................................          1.6268          0.8754         27.6234         29.7150         30.4885         29.2730
040039..................................................          1.2296          0.8291         21.2712         21.4819         22.9798         21.9027
040041..................................................          1.1562          0.8650         23.7787         26.4964         26.4417         25.5529
040042..................................................          1.2893          0.9329         21.1716         19.8709         23.1648         21.3821
040047..................................................          1.0408          0.7758         22.4249         23.0358         23.3547         22.9631
040050..................................................          1.1948          0.7641         17.6906         18.5119         19.6944         18.6284
040051..................................................          0.9470          0.7641         21.3342         22.0394         22.1983         21.8575
040054..................................................             ***               *         18.0509         19.5353               *         18.7591
040055..................................................          1.5598          0.7843         23.0448         24.9164         26.0132         24.6243
040062..................................................          1.6247          0.7843         23.8994         25.2303         25.6541         24.9287
040067..................................................          1.1145          0.7648         19.0471         18.9872         20.9688         19.6151
040069..................................................          1.0608          0.8909         24.8060         24.9996         23.3108         24.3661
040071..................................................          1.5798          0.8650         25.4680         25.2840         26.6629         25.8031
040072..................................................          1.1274          0.7641         22.4741         22.1058         22.9668         22.5262
040074..................................................          1.2633          0.8754         25.2699         26.2661         27.3878         26.2955
040076..................................................          0.9952          0.8650         23.5742         23.0954         24.7891         23.8273
040078..................................................          1.6712          0.8650         23.5915         26.1937         25.6870         25.0529
040080..................................................          1.0467          0.8291         24.1921         24.8760         26.5895         25.2945
040081..................................................          0.8888          0.7998         16.8437         17.2536         18.4756         17.5296
040084..................................................          1.2389          0.8754         27.7626         26.6449         28.1552         27.5095
040085..................................................          1.0085          0.8909         22.9916         25.7215         26.6972         25.1591
040088..................................................          1.6650          0.7789         22.4860         23.6276         24.7107         23.6212
040091..................................................          1.1951          0.8093         24.2398         23.1913         22.3295         23.2265
040100..................................................             ***               *         21.3051         22.6131         24.5448         22.8466
040114..................................................          1.8332          0.8754         26.7581         27.7928         28.5682         27.7154
040118..................................................          1.5334          0.8291         26.0388         26.8908         26.5770         26.5251
040119..................................................          1.3884          0.8650         24.3680         24.2419         25.6769         24.7942
040126..................................................             ***               *         15.6985         17.3715               *         16.4167
040132..................................................             ***               *               *         22.0054         21.8131         21.8928
040134..................................................          2.3449          0.8754         31.9325         32.2832         34.9636         33.0707
040137..................................................          1.3582          0.8754         25.9979         27.7360         27.7619         27.1679
040138..................................................          1.5085          0.9131         27.8584         28.3342         33.0048         29.8698
040141..................................................          0.7864          0.9131         26.1041         30.3475         33.8758         29.9321
040142..................................................          1.5543          0.9146         21.4222         23.8620         23.1293         22.9022
040143..................................................             ***               *         37.1976               *               *         37.1976
040144..................................................             ***               *         21.4008               *               *         21.4008
040145..................................................          1.7933          0.8291               *         24.4367         20.3865         22.2702
040146..................................................             ***               *               *         33.7876               *         33.7876
040147..................................................          1.7491          0.8754               *               *         35.7643         35.7643
040148..................................................          1.3585          0.8754               *               *               *               *
050002..................................................          1.4597          1.5288         35.5184         41.7336         43.1732         40.2432
050006..................................................          1.5912          1.2730         33.5751         37.1639         41.7694         37.1459
050007..................................................          1.4363          1.5025         43.4440         45.8773         46.3257         45.2428
050008..................................................          1.4460          1.4905         49.3167         46.8706         50.9532         49.0479
050009..................................................          1.6477          1.3974         43.0584         46.2186         49.7145         46.4654
050013..................................................          1.8267          1.3974         35.7591         43.5623         43.4884         40.8362
050014..................................................          1.2659          1.2710         36.0305         37.4135         39.4733         37.6850
050015..................................................          1.6268               *         32.2188               *               *         32.2188
050016..................................................          1.3208          1.1925         24.5768         31.0653         34.4877         30.1759
050017..................................................          2.0225          1.2827         39.6653         42.2200         44.3892         42.1245
050018..................................................          1.2702          1.1916         23.3204         31.8310         43.5594         30.7984
050022..................................................          1.5850          1.1822         31.6467         33.0592         36.6332         33.8292
050024..................................................          1.1169          1.1822         29.4062         33.4334         33.5179         32.1616
050025..................................................          1.7936          1.1822         33.5466         32.7476         36.4068         34.2656
050026..................................................          1.5921          1.1822         31.5250         33.1277         35.0276         33.2678
050028..................................................          1.2946          1.1822         27.3826         28.5736         28.1194         28.0466
050030..................................................          1.2276          1.1822         27.2945         30.9014         33.5634         30.5981
050036..................................................          1.6000          1.1822         33.8000         36.0905         37.8493         35.9795
050038..................................................          1.6319          1.5766         44.2265         48.7483         55.2150         49.5117
050039..................................................          1.6727          1.1822         35.2630         36.6943         34.9232         35.5973
050040..................................................          1.3922          1.1916         35.8322         35.7054         38.1639         36.6252
050042..................................................          1.4804          1.2730         37.3760         40.3326         40.4361         39.4000
050043..................................................          1.6147          1.5288         45.4887         48.2283         50.5011         48.0790
050045..................................................          1.3307          1.1822         25.0150         27.0676         28.5930         26.9305
050046..................................................          1.1963          1.1822         26.1926         29.1125         31.8120         29.0132

[[Page 23728]]

 
050047..................................................          1.7553          1.4905         55.9367         45.1675         48.5921         49.7760
050054..................................................          1.1791          1.1822         21.3650         24.0338         27.1306         24.3249
050055..................................................          1.3418          1.4905         42.9516         44.2926         48.2759         45.1972
050056..................................................          1.4226          1.1916         30.6126         32.7693         34.7937         32.7247
050057..................................................          1.6897          1.1822         30.0236         31.7467         33.7545         31.8592
050058..................................................          1.6320          1.1916         33.1409         37.2538         39.1657         36.5431
050060..................................................          1.5084          1.1822         29.9762         32.0196         34.1151         31.9978
050063..................................................          1.4482          1.1916         34.0906         36.3085         36.6271         35.6915
050065..................................................             ***               *         34.9110         38.2421         42.0052         38.4607
050067..................................................          1.2075          1.1963         38.8070         40.1393         41.8949         40.2601
050069..................................................          1.7361          1.1822         34.6353         35.3850         38.1313         36.1111
050070..................................................          1.3124          1.5025         47.4099         46.4009         49.3910         47.8284
050071..................................................          1.4512          1.5766         50.7602         49.6495         52.5202         51.0422
050072..................................................          1.4096          1.5278         49.4344         50.0343         51.9174         50.5640
050073..................................................          1.2488          1.5278         49.9730         49.0069         50.6478         49.8748
050075..................................................          1.3747          1.5288         54.4089         49.8290         51.5366         51.6907
050076..................................................          1.8168          1.5278         52.3788         50.2039         51.0338         51.1894
050077..................................................          1.5379          1.1822         34.8660         36.5384         37.4961         36.4378
050078..................................................          1.2512          1.1916         32.0133         30.4274         37.1909         33.1204
050079..................................................          1.5736          1.5278         47.3449         48.8994         48.2983         48.1333
050082..................................................          1.6600          1.1822         38.2878         37.8905         42.1694         39.4148
050084..................................................          1.5667          1.1954         35.5196         39.5748         41.0288         38.7442
050089..................................................          1.3670          1.1822         33.9593         36.4018         39.2412         36.5180
050090..................................................          1.2562          1.4879         33.8953         37.7421         41.5994         37.7203
050091..................................................          1.0354          1.1916         32.1301         37.1223         40.1032         36.4125
050093..................................................          1.5575          1.1822         36.9481         36.8486         37.7213         37.1762
050095..................................................             ***               *               *               *         44.2364         44.2364
050096..................................................          1.2641          1.1916         34.9237         33.1322         33.3800         33.8096
050099..................................................          1.5398          1.1822         33.4174         32.0650         34.3480         33.2470
050100..................................................          1.8205          1.1822         31.4404         33.3959         34.2814         33.0478
050101..................................................          1.3210          1.5278         42.4589         47.9327         48.7447         46.4291
050102..................................................          1.3903          1.1822         32.0617         32.8434         33.2811         32.8150
050103..................................................          1.5437          1.1916         34.0935         35.6773         37.5528         35.8192
050104..................................................          1.4136          1.1916         32.3043         33.6204         37.1418         34.4090
050107..................................................          1.5287          1.1822         32.5846         33.5687         36.6966         34.2821
050108..................................................          1.8628          1.2827         38.8672         42.0131         43.0409         41.3295
050110..................................................          1.2335          1.1822         26.8408         28.0670         30.9036         28.6069
050111..................................................          1.1657          1.1916         28.7875         31.8766         31.9371         30.8306
050112..................................................          1.5363          1.1916         37.7281         38.9483         39.9904         38.9358
050113..................................................          1.1706          1.5025         39.4882         42.8884         46.3447         42.8008
050114..................................................             ***               *         34.0309         35.7274         37.5895         35.8060
050115..................................................          1.4716          1.1822         28.8051         32.5257         33.8575         31.7873
050116..................................................          1.6387          1.1916         36.8825         37.6018         39.1213         37.9136
050117..................................................             ***               *         34.2020         35.0531               *         34.3889
050118..................................................          1.2470          1.1963         39.9683         41.6701         41.8166         41.1955
050121..................................................          1.2657          1.1822         30.6105         34.6244         35.1123         33.4898
050122..................................................          1.6278          1.1954         33.9812         34.0259         36.8803         34.9559
050124..................................................          1.2976          1.1916         30.2522         29.9944         31.7666         30.6975
050125..................................................          1.4819          1.5766         44.9523         47.7578         53.6251         49.3187
050126..................................................          1.5255          1.1916         31.7619         32.6686         30.6587         31.6279
050127..................................................          1.2888          1.2827         32.0355         40.7610         42.5307         37.9357
050128..................................................          1.4865          1.1822         31.1308         33.4233         34.2327         32.9837
050129..................................................          1.8869          1.1822         34.7359         36.9887         40.7010         37.4287
050131..................................................          1.4641          1.5278         45.3152         47.5257         50.5592         48.0185
050132..................................................          1.4120          1.1916         35.9199         39.6807         39.5311         38.3266
050133..................................................          1.5874          1.2710         31.9527         33.1814         34.7446         33.5182
050135..................................................          1.0174          1.1916         25.1813         25.3209         25.4416         25.3286
050136..................................................          1.3870          1.4879         43.3747         46.6619         52.9752         47.9218
050137..................................................          1.5096          1.1916         39.1496         40.2457         45.3315         41.8810
050138..................................................          1.4788          1.1916         45.3727         40.6343         46.7946         44.1215
050139..................................................          1.3979          1.1916         37.8986         38.7385         44.3290         40.6568
050140..................................................          1.3188          1.1822         40.9725         39.4954         44.5658         41.7792
050144..................................................             ***               *         33.6662         38.2424         40.4728         37.3677
050145..................................................          1.5409          1.4671         42.2921         48.0796         49.2634         46.7040
050146..................................................          1.8140               *               *               *               *               *
050148..................................................          1.0935               *         28.2305               *               *         28.2305
050149..................................................          1.5423          1.1916         35.8821         37.3616         43.3419         39.0535

[[Page 23729]]

 
050150..................................................          1.2344          1.2710         33.6583         37.9946         43.5908         38.2550
050152..................................................          1.4480          1.4905         46.1553         51.6567         54.7138         50.9486
050153..................................................          1.4515          1.5766         42.8955         47.6374         50.4838         47.2422
050155..................................................             ***               *         16.9516         16.7756               *         16.8520
050158..................................................          1.3682          1.1916         35.7805         39.9160         42.7838         39.6127
050159..................................................          1.2951          1.1822         32.5704         34.6915         35.0123         34.1437
050167..................................................          1.4830          1.1954         31.4798         34.0418         38.0704         34.4888
050168..................................................          1.5682          1.1822         37.9784         40.5973         40.8318         39.8615
050169..................................................          1.5146          1.1916         29.4693         31.4115         33.1105         31.4624
050173..................................................          1.3454          1.1822         29.0576         31.6717         32.3240         30.9921
050174..................................................          1.5492          1.4879         44.4199         48.1740         53.7062         48.9658
050175..................................................             ***               *         33.3061         35.0152               *         34.1608
050177..................................................             ***               *         24.0717               *               *         24.0717
050179..................................................          1.1909          1.1963         30.4973         31.6651         34.6529         32.3080
050180..................................................          1.5822          1.5278         42.0358         45.7099         48.7392         45.6253
050188..................................................          1.5411          1.5766         41.0943         43.7381         45.8470         43.4416
050189..................................................          1.0400          1.4671         30.1155         28.7580         31.5787         30.2839
050191..................................................          1.5029          1.1916         37.7805         37.8756         42.0018         39.2858
050192..................................................          0.9799          1.1822         27.1400         27.8386         27.4599         27.4784
050193..................................................          1.2329          1.1822         33.9520         29.0623         36.7215         32.9051
050194..................................................          1.3496          1.5758         44.7107         49.0030         49.8490         47.9003
050195..................................................          1.5733          1.5288         48.8595         53.5583         57.6511         53.3853
050196..................................................          1.0787          1.1822         34.0956         32.8293         41.1280         35.9355
050197..................................................          1.9800          1.5758         50.0728         52.9998         55.2982         52.8587
050204..................................................          1.4038          1.1916         32.0121         35.3954         38.8654         35.4348
050205..................................................          1.3872          1.1916         29.3334         30.6322         30.6087         30.1774
050207..................................................             ***               *         30.0062         31.3431               *         30.6661
050211..................................................          1.3077          1.5288         35.0515         35.0289         42.9220         37.8234
050214..................................................             ***               *         25.4647               *               *         25.4647
050215..................................................             ***               *         48.8112         50.7578               *         49.8014
050219..................................................          1.3346          1.1916         26.4143         25.8378         26.7043         26.3093
050222..................................................          1.6635          1.1822         32.3882         33.7510         35.4673         33.9374
050224..................................................          1.6644          1.1822         32.5010         35.7280         37.2306         35.2444
050225..................................................          1.3992          1.1822         34.0836         35.1227         37.5227         35.6603
050226..................................................          1.5964          1.1822         32.4411         35.4597         36.5328         34.8249
050228..................................................          1.3082          1.4905         43.7939         47.1430         49.9023         46.9935
050230..................................................          1.5485          1.1822         34.0600         35.8490         38.8880         36.2981
050231..................................................          1.7120          1.1916         32.1813         33.7139         37.0216         34.3576
050232..................................................          1.7085          1.1925         26.3004         34.3242         35.5078         32.2261
050234..................................................          1.2780          1.1822         32.3726         34.8308         37.7096         34.9915
050235..................................................          1.4885          1.1916         30.5405         37.0858         39.1708         35.6922
050236..................................................          1.4514          1.1822         33.0686         32.6462         34.4239         33.3573
050238..................................................          1.5286          1.1916         33.3346         34.0823         35.1235         34.2447
050239..................................................          1.6781          1.1916         33.1148         35.9041         36.3232         35.1511
050240..................................................             ***               *         36.1154         40.7427               *         38.4427
050242..................................................          1.3854          1.5758         46.4844         50.9882         53.7118         50.5362
050243..................................................          1.5755          1.1822         32.9385         36.1209         37.8510         35.6823
050245..................................................          1.3731          1.1822         27.3866         33.2556         34.5668         31.8473
050248..................................................          1.1239          1.4671               *         40.4941         46.0285         43.3497
050251..................................................             ***               *         27.8452               *               *         27.8452
050253..................................................             ***               *         23.5381               *               *         23.5381
050254..................................................          1.2803          1.2827         31.2386         33.0865         33.5043         32.6688
050256..................................................             ***               *         29.6793         32.7159         32.6816         31.5748
050257..................................................          0.9389          1.1822         20.1829         24.0737         29.2635         24.4838
050261..................................................          1.2967          1.1822         29.2150         30.8704         33.7180         31.3396
050262..................................................          2.2067          1.1916         39.9946         41.4835         43.7672         41.7544
050264..................................................          1.3674          1.5288         47.7024         43.4181         48.0876         46.3588
050270..................................................             ***               *         33.6855         36.0111               *         34.8609
050272..................................................          1.4019          1.1822         29.4671         30.9290         31.5894         30.7391
050276..................................................          1.1193          1.5278         41.1406         43.7943         47.2414         44.0832
050277..................................................          1.1820          1.1916         35.4443         35.0079               *         35.2189
050278..................................................          1.5456          1.1916         31.8712         34.3798         38.5649         35.0167
050279..................................................          1.1978          1.1822         29.7118         31.6738         32.1678         31.1945
050280..................................................          1.7360          1.2730         38.8341         41.3912         43.5214         41.2937
050281..................................................          1.4053          1.1916         29.4882         31.6639         31.0678         30.7699
050283..................................................          1.6153          1.5288         44.3122         43.6855         44.8602         44.2950
050289..................................................          1.6158          1.5025         44.2814         50.1762         52.0875         49.0216

[[Page 23730]]

 
050290..................................................          1.7575          1.1916         37.3563         40.6192         42.0066         39.9556
050291..................................................          1.9821          1.4879         38.4365         41.2100         43.2395         41.1200
050292..................................................          1.0615          1.1822         26.9786         27.3365         30.9112         28.4996
050295..................................................          1.4386          1.1822         34.7382         38.4256         39.5132         37.7732
050296..................................................          1.1373          1.5758         39.9842         42.5405         44.8105         42.4568
050298..................................................          1.2078          1.1839         30.2022         33.7864         33.6925         32.5818
050299..................................................             ***               *         35.1249         32.3707               *         33.6024
050300..................................................          1.4161          1.1822         30.2874         33.6821         37.1244         33.7458
050301..................................................          1.2490          1.4497         35.9491         37.1103         36.3661         36.4668
050305..................................................          1.4137          1.5288         44.9681         48.5339         52.8531         48.7916
050308..................................................          1.5368          1.5766         43.7413         46.4180         49.0086         46.4303
050309..................................................          1.4523          1.2827         38.2659         40.1499         41.1612         39.8863
050312..................................................             ***               *         36.8498               *               *         36.8498
050313..................................................          1.2021          1.1954         35.0478         37.5024         37.8834         36.8450
050315..................................................          1.3141          1.1822         33.2038         32.5538         37.3526         34.4352
050320..................................................          1.2624          1.5288         45.7686         46.2071         50.6670         47.5834
050324..................................................          1.7781          1.1822         34.5503         36.3474         37.1854         36.0605
050325..................................................          1.1860          1.1855         31.3730         37.0441         34.0333         34.2474
050327..................................................          1.6676          1.1822         33.9507         35.9349         36.9523         35.6196
050329..................................................          1.2676          1.1822         23.2927         33.0390         36.7650         31.1927
050333..................................................          1.0488          1.1822         19.6352         18.6534         32.2010         21.9629
050334..................................................          1.5881          1.4671         43.9656         47.2968         50.9796         47.4795
050335..................................................          1.3834          1.1963         30.9928         34.7192         37.2324         34.3853
050336..................................................          1.2384          1.1954         30.4664         31.5480         33.0304         31.7345
050342..................................................          1.2489          1.1822         29.2244         30.4226         29.8368         29.8437
050348..................................................          1.7714          1.1822         31.5156         32.7107         33.5253         32.6280
050349..................................................          0.9688          1.1822         24.4863         25.4266         23.1089         24.2535
050350..................................................          1.4256          1.1916         31.0136         31.7908         34.0896         32.2951
050351..................................................          1.5307          1.1916         30.6599         33.3064         35.0010         33.0083
050352..................................................          1.3551          1.2827         36.7673         37.0807         38.6234         37.4921
050353..................................................          1.5204          1.1916         29.4215         30.4206         37.1683         32.2253
050357..................................................          1.5056          1.1822         32.6763         36.2089         38.9202         35.9956
050359..................................................          1.1869          1.1822         29.8345         31.3391         30.3963         30.5262
050360..................................................          1.5234          1.5278         47.4497         52.3811         53.4113         51.1213
050366..................................................          1.1511          1.1837         33.6714         37.1527         41.8302         37.3699
050367..................................................          1.4838          1.5278         38.6330         40.1904         40.0423         39.6594
050369..................................................          1.4765          1.1916         30.6439         32.2467         33.3330         32.1001
050373..................................................          1.4477          1.1916         35.1380         34.3737         37.6802         35.7093
050376..................................................          1.7774          1.1916         34.3539         35.2837         36.6487         35.4753
050378..................................................          1.0502          1.1916         37.9904         40.1923         42.0465         40.0787
050380..................................................          1.6776          1.5766         46.0276         49.4258         52.5752         49.4098
050382..................................................          1.4478          1.1916         30.4014         32.6683         32.9220         31.9903
050385..................................................          1.2993          1.4879         36.8107         36.4188         36.5610         36.5948
050390..................................................          1.1220          1.1822         27.3183         27.9359         33.0438         29.3100
050391..................................................             ***               *         17.2141               *               *         17.2141
050393..................................................          1.3848          1.1916         34.1743         35.6356         35.1855         35.0078
050394..................................................          1.6185          1.1822         27.4861         32.1894         32.1720         30.6682
050396..................................................          1.5625          1.1822         32.4918         37.3972         38.9901         36.2041
050397..................................................          0.8787          1.1822         28.3671         29.6825         31.1603         29.8101
050407..................................................          1.1900          1.4905         42.2748         44.6839         47.5560         44.8602
050411..................................................          1.3207          1.1916         38.8294         38.6328         44.7079         40.9918
050414..................................................          1.3194          1.2827         38.7585         41.8688         45.0472         42.0484
050417..................................................          1.3093          1.1822         32.9341         36.1222         37.0117         35.4225
050420..................................................             ***               *         35.2869         39.9237               *         37.6935
050423..................................................          1.0114          1.1822         28.3768         31.9751         32.4104         31.1452
050424..................................................          1.9524          1.1822         34.5680         36.6091         37.5218         36.2762
050425..................................................          1.3696          1.2827         49.2245         46.6628         45.7794         47.0234
050426..................................................          1.4616          1.1822         33.2031         34.9855         37.6483         35.2291
050430..................................................          0.9394          1.1822         23.9045         24.5327         25.9363         24.7203
050432..................................................             ***               *         33.1876         35.2416               *         34.2247
050433..................................................             ***               *         21.3573         21.1287         23.0629         21.6609
050434..................................................          0.9988          1.1822         32.6255         33.7794         35.4799         33.9524
050435..................................................          1.1984          1.1822         30.6530         33.0372         35.7401         33.2043
050438..................................................          1.5503          1.1916         36.3026         36.2044         38.2823         36.9424
050441..................................................          1.9553          1.5766         44.5694         46.6160         49.2095         46.8421
050444..................................................          1.4083          1.2202         34.6313         37.6821         39.3915         37.5291
050447..................................................          2.2656          1.1822         26.7960         29.0780         27.1252         27.7351

[[Page 23731]]

 
050448..................................................          1.2948          1.1822         30.6201         32.7748         32.6666         31.9996
050454..................................................          1.9380          1.4905         38.5833         40.2811         43.3674         40.8320
050455..................................................          1.5610          1.1822         30.4606         34.5445         35.0200         33.3430
050456..................................................             ***               *         21.6261         27.7659         27.9693         25.0702
050457..................................................          1.5970          1.4905         47.8947         50.0282         53.3144         50.4334
050464..................................................          1.7391          1.1963         38.3058         41.6235         42.6660         40.8465
050468..................................................          1.7714          1.1916         31.1111         35.7409         37.3361         34.8277
050469..................................................             ***               *         30.6502               *               *         30.6502
050470..................................................             ***               *         27.8678         31.0466         32.5012         30.5202
050471..................................................          1.7119          1.1916         35.4768         36.8680         36.4887         36.2903
050476..................................................          1.4110          1.4497         38.7856         41.1042         40.5395         40.1623
050477..................................................             ***               *         37.7668         40.1566               *         39.0877
050478..................................................          1.0325          1.1822         40.2558         41.1668         41.5592         41.0379
050481..................................................          1.5130          1.1916         36.1394         38.8650         42.8499         39.2898
050485..................................................          1.6505          1.1916         36.1488         34.6219         34.7050         35.1967
050488..................................................          1.4378          1.5288         42.6854         45.0630         47.1937         45.0874
050491..................................................             ***               *         34.3598               *               *         34.3598
050492..................................................          1.3241          1.1822         28.0826         30.7718         32.6577         30.4668
050494..................................................          1.4344          1.2710         38.1177         40.6384         42.3086         40.3782
050496..................................................          1.6970          1.5278         48.2468         51.6363         51.1433         50.4172
050498..................................................          1.3475          1.2827         37.1667         41.0350         42.2469         40.1486
050502..................................................          1.6482          1.1916         28.7046         31.8872         32.9773         31.1609
050503..................................................          1.5152          1.1822         34.0994         37.3605         37.7183         36.4438
050506..................................................          1.5249          1.1925         37.7420         39.8586         40.6497         39.4417
050510..................................................          1.3370          1.5278         52.5376         49.4533         51.3691         51.0324
050512..................................................          1.4990          1.5288         50.9264         48.8057         50.1599         49.9366
050515..................................................          1.3185          1.1822         38.9542         40.2957         41.0328         40.1925
050516..................................................          1.5093          1.2827         39.8161         43.0249         45.5247         42.8485
050517..................................................          1.2967          1.1822         20.0213         22.4096         29.3674         23.6394
050523..................................................          1.2869          1.5278         40.6535         43.4579         46.9830         43.8643
050526..................................................          1.1843          1.1822         28.1997         33.3964         35.5437         32.2787
050528..................................................          1.1507          1.1822         31.4941         36.2908         38.3022         35.4339
050531..................................................          1.0520          1.1916         27.1974         28.3348         28.4865         28.0127
050534..................................................          1.4315          1.1822         33.1666         36.6447         38.1859         36.0367
050535..................................................             ***               *         34.6143         37.8174               *         36.2328
050537..................................................          1.4828          1.2827         34.9931         38.2145         40.1908         37.8814
050541..................................................          1.4378          1.5758         52.5908         48.0867         51.5270         50.6366
050543..................................................          0.7526          1.1822         29.4443         24.4913         32.8347         28.6007
050545..................................................          0.7226          1.1916         31.3080         35.3209               *         33.2475
050546..................................................          0.6945          1.1822         33.2245         36.5099               *         34.9356
050547..................................................          1.0205          1.4879         34.8401         33.8036               *         34.2850
050548..................................................          0.6180          1.1822         39.2234         41.1075               *         40.1570
050549..................................................          1.6510          1.1822         35.2792         38.3927         40.6759         38.1001
050550..................................................             ***               *         30.9612         34.9476         39.2133         34.7849
050551..................................................          1.3452          1.1822         34.0467         37.2506         37.6198         36.3778
050552..................................................          0.9428          1.1916         33.0711         33.9810         35.3466         34.1389
050557..................................................          1.5993          1.1963         33.3654         35.7023         38.6871         35.9147
050561..................................................          1.4093          1.1916         38.0196         38.2543         39.1298         38.5223
050567..................................................          1.5110          1.1822         35.7063         37.6384         39.0084         37.5231
050568..................................................          1.2464          1.1822         25.2337         26.0908         26.7719         26.0576
050569..................................................          1.3207               *         31.6785               *               *         31.6785
050570..................................................          1.5519          1.1822         34.5161         38.4373         40.6719         37.8603
050571..................................................             ***               *         34.7627         39.0649               *         36.9575
050573..................................................          1.5662          1.1822         34.7279         35.2842         36.8535         35.6371
050575..................................................          1.3192          1.1916         25.1457         23.7990         22.1000         23.5654
050577..................................................             ***               *         32.3744               *               *         32.3744
050578..................................................          1.4310          1.1916         35.2390         31.3639         43.4883         36.9415
050579..................................................             ***               *         42.5081               *               *         42.5081
050580..................................................          1.1517          1.1822         31.5806         34.1531         35.0950         33.6230
050581..................................................          1.4139          1.1916         34.0136         37.7567         40.0883         37.3040
050583..................................................          1.6442          1.1822         34.5747         37.4450         40.5818         37.4769
050584..................................................          1.4508          1.1839         30.3434         30.7839         31.9887         31.0588
050585..................................................             ***               *         22.2521               *               *         22.2521
050586..................................................          1.3101          1.1822         26.4782         31.3513         31.1898         29.6927
050588..................................................          1.3759          1.1916         32.7556         37.7387         39.4229         36.6367
050589..................................................          1.2424          1.1822         34.5100         37.6886         37.2032         36.5093
050590..................................................          1.2814          1.2827         38.4971         41.7519         44.2900         41.5361

[[Page 23732]]

 
050591..................................................             ***               *         30.6106         34.7133               *         32.5892
050592..................................................             ***               *         27.3606         31.8053         32.2351         30.0884
050594..................................................             ***               *         36.5256         42.0788               *         39.2148
050597..................................................          1.2983          1.1916         28.8294         31.5625         32.8964         31.1668
050599..................................................          1.8547          1.2827         32.7835         34.7187         36.6122         34.7394
050601..................................................          1.5329          1.1916         36.0572         39.7717         43.2367         39.7359
050603..................................................          1.4506          1.1822         34.0275         35.0279         35.4778         34.9101
050604..................................................          1.3664          1.5766         55.0821         49.4446         49.6225         50.8907
050608..................................................          1.2665          1.1822         30.4169         31.2909         30.7266         30.8122
050609..................................................          1.2511          1.1822         41.7208         39.7397         42.4128         41.2383
050613..................................................             ***               *         42.8108         42.9930               *         42.8892
050615..................................................             ***               *         35.9547         39.1299               *         37.5269
050616..................................................          1.4930          1.1822         37.7284         37.1200         40.8621         38.5549
050618..................................................          1.0232          1.1822         31.3182         33.1472         34.9156         33.1400
050624..................................................          1.3457          1.1916         33.9594         35.9346         39.2531         36.4371
050625..................................................          1.7610          1.1916         38.6591         41.0439         44.8446         41.6090
050633..................................................          1.2411          1.1925         36.8302         38.4916         40.7347         38.7394
050636..................................................          1.2748          1.1822         32.5576         33.0718         35.4525         33.7338
050641..................................................          1.3434          1.1916         39.6921         32.3586         32.0483         34.3171
050644..................................................          1.0499          1.1916         28.8237         30.7981         33.2746         30.9581
050660..................................................          1.7555               *               *               *               *               *
050662..................................................          0.7264          1.5766         33.2446         38.3017               *         35.5809
050663..................................................          1.4166          1.1916         27.7334         17.7035         17.8180         19.8971
050667..................................................          0.9359          1.3974         24.2771         25.9161         25.8444         25.2820
050668..................................................          1.2668          1.4905         56.6555         51.6049         52.6968         53.2587
050674..................................................          1.2833          1.2827         48.0893         47.0720         48.6658         47.9616
050677..................................................          1.3833          1.1916         38.5770         39.2161         40.7889         39.6370
050678..................................................          1.3254          1.1822         32.4473         33.7633         35.8378         34.1139
050680..................................................          1.2900          1.5278         38.2871         37.9856         39.0346         38.4541
050682..................................................          0.8353          1.1822         17.9077         22.2193         22.3883         20.9013
050684..................................................          1.1150          1.1822         27.5256         28.8378         33.5883         30.1544
050686..................................................          1.5945          1.1822         41.0188         39.7757         41.3815         40.7110
050688..................................................          1.2103          1.5766         44.1510         49.4062         53.2703         49.0705
050689..................................................          1.5822          1.5278         45.0951         48.8533         48.9898         47.6626
050690..................................................          1.3422          1.4879         50.9094         49.0226         51.7590         50.5850
050693..................................................          1.3899          1.1822         34.5797         39.6838         42.8232         38.9551
050694..................................................          1.0517          1.1822         30.7858         32.1065         34.8458         32.6630
050695..................................................             ***               *         39.6004         49.0340               *         44.6756
050696..................................................          2.2640          1.1916         37.3837         39.8963         39.4330         38.9118
050697..................................................          1.1055          1.2730         16.6605         22.1441         26.7588         21.2675
050699..................................................             ***               *         28.9083         21.5725         28.8973         26.4337
050701..................................................          1.3490          1.1822         31.9529         34.9876         37.2811         34.8704
050704..................................................          1.0435          1.1916         29.7740         31.6097         32.1995         31.2008
050707..................................................             ***               *         35.7311         43.5555         44.0218         40.8918
050708..................................................          1.4932          1.1822         30.5860         31.8442         28.3051         30.2199
050709..................................................          1.4478          1.1822         26.8549         24.5621         29.5339         27.1486
050710..................................................          1.2058          1.1822         45.8022         44.2482         46.2957         45.4488
050713..................................................             ***               *         21.1273         21.4825               *         21.2886
050714..................................................          1.4054          1.5818         31.9527         34.1542         42.9756         36.5738
050717..................................................          1.5439          1.1916         39.3227         38.8773         37.0867         38.4090
050718..................................................             ***               *         25.5140         31.9622               *         28.5587
050720..................................................          0.9656          1.1822         29.4726         30.3595         32.1156         30.5944
050722..................................................          0.9138          1.1822         31.4867         33.7991         35.6698         33.7766
050723..................................................          1.3255          1.1916         38.5446         38.7140         41.1633         39.6081
050724..................................................          2.0000          1.1822         31.6910         35.2344         35.0980         34.1972
050725..................................................          0.8736          1.1916         24.3100         30.0580         28.8366         27.6830
050726..................................................          1.5371          1.1963         30.6479         28.6361         30.6054         29.9355
050727..................................................          1.3473          1.1916         33.9118         32.7783         33.0915         33.2499
050728..................................................             ***               *         39.3581         41.8263               *         40.4993
050729..................................................             ***               *         36.5432         38.1882               *         37.4033
050730..................................................             ***               *         37.0629         39.2046               *         38.1210
050732..................................................          2.3278          1.1822               *         33.6831         34.3456         34.0196
050733..................................................          1.5906          1.2730               *         40.1517         40.6287         40.3877
050734..................................................             ***               *               *         31.2883               *         31.2883
050735..................................................          1.3963          1.1916               *               *         36.6052         36.6052
050736..................................................          1.2104          1.1916               *               *         41.8905         41.8905
050737..................................................          1.4996          1.1916               *               *         38.0395         38.0395

[[Page 23733]]

 
050738..................................................          1.5052          1.1916               *               *         43.9225         43.9225
050739..................................................          1.6284          1.1916               *               *         57.2436         57.2436
050740..................................................          1.4538          1.1916               *               *         54.0328         54.0328
050741..................................................          1.4520          1.1916               *               *         51.1485         51.1485
050742..................................................          1.4454          1.1916               *               *         39.0793         39.0793
050744..................................................          1.7412          1.1822               *               *         48.4913         48.4913
050745..................................................          1.3450          1.1822               *               *         42.5490         42.5490
050746..................................................          1.8196          1.1822               *               *         43.1981         43.1981
050747..................................................          1.5410          1.1822               *               *         44.5852         44.5852
050748..................................................          1.1344          1.1954               *               *         42.9957         42.9957
050749..................................................          1.3856          1.1822               *               *         28.1978         28.1978
050750..................................................             ***               *               *               *         33.9880         33.9880
050751..................................................          2.9380          1.1916               *               *         29.5465         29.5465
050752..................................................          1.4092          1.1916               *               *         39.8004         39.8004
050753..................................................          1.6850          1.1916               *               *               *               *
050754..................................................          1.1933          1.5025               *               *               *               *
050755..................................................          1.3602          1.1916               *               *               *               *
050757..................................................          1.5947          1.1822               *               *               *               *
050758..................................................          1.3399          1.1822               *               *               *               *
050759..................................................          2.1683          1.1822               *               *               *               *
060001..................................................          1.5186          1.0070         29.6191         31.0018         32.4200         30.9988
060003..................................................          1.4098          1.0409         29.4809         31.3616         31.8621         30.9372
060004..................................................          1.1053          1.0561         32.4609         32.0095         34.8408         33.1185
060006..................................................          1.3131          0.9303         25.2139         27.2057         26.8067         26.4045
060008..................................................          1.2609          0.9303         23.0947         26.5175         27.2059         25.5276
060009..................................................          1.4736          1.0561         31.5210         32.4208         34.0129         32.6683
060010..................................................          1.5411          0.9734         27.1916         29.5304         30.6402         29.1093
060011..................................................          1.5219          1.0561         35.1573         32.1001         34.4158         33.8458
060012..................................................          1.5548          0.9738         27.3885         28.7724         29.4348         28.5090
060013..................................................          1.5942          0.9303         26.8675         27.9145         28.0786         27.6090
060014..................................................          1.8805          1.0561         31.0542         31.9389         33.0340         32.0056
060015..................................................          1.8679          1.0561         32.5285         32.2927         36.3270         33.6071
060016..................................................          1.1848          0.9303         26.5427         27.1430         28.3040         27.3080
060018..................................................          1.2897          0.9303         24.1086         25.3897         26.5770         25.3463
060020..................................................          1.5516          0.9303         24.5992         25.9147         26.7340         25.7382
060022..................................................          1.6011          0.9738         28.2944         29.3379         31.9353         29.8727
060023..................................................          1.6260          1.0409         29.5760         31.1556         32.7901         31.1705
060024..................................................          1.8688          1.0561         30.0279         31.5411         32.8183         31.5099
060027..................................................          1.5941          1.0409         29.6121         30.9212         31.6117         30.7134
060028..................................................          1.4266          1.0561         31.6900         32.1656         33.4942         32.4479
060030..................................................          1.4302          0.9734         27.8642         29.9513         31.2907         29.7046
060031..................................................          1.5357          1.0409         27.8345         29.3907         30.8385         29.3398
060032..................................................          1.4900          1.0561         31.0686         32.7383         34.6417         32.7827
060034..................................................          1.7145          1.0561         30.9359         32.1252         33.3625         32.1070
060036..................................................          1.0946          0.9303         20.3226         22.8256         20.9359         21.3443
060041..................................................          0.9254          0.9303         24.6142         25.9710         31.4722         27.2226
060043..................................................          0.9724          0.9303         18.2143         21.9955         23.3899         21.1620
060044..................................................          1.1929          0.9303         26.5611         24.8352         29.4060         26.8390
060049..................................................          1.4157          0.9581         29.3724         30.2192         32.1570         30.6358
060054..................................................          1.4812          0.9925         24.3389         25.0980         24.6714         24.6993
060064..................................................          1.7013          1.0561         32.3681         33.2428         37.2384         33.8162
060065..................................................          1.4081          1.0561         32.4735         33.8538         34.9177         33.7649
060071..................................................          1.1347          0.9303         27.6657         28.1762         31.5370         29.2648
060075..................................................          1.3842          0.9925         32.2545         37.6023         35.8069         35.2179
060076..................................................          1.2641          0.9303         26.5631         30.7808         31.6033         29.6210
060096..................................................          1.6188          1.0409         32.1310         37.8243         38.2230         36.0395
060100..................................................          1.7198          1.0561         32.6104         33.2145         33.5326         33.1192
060103..................................................          1.3654          1.0409         31.6314         32.9690         33.7519         32.8044
060104..................................................          1.4279          1.0561         32.4232         35.4409         37.1405         34.8954
060107..................................................          1.5071          1.0561         26.8388         28.0660         30.3986         28.4350
060112..................................................          1.6339          1.0561         34.9272         34.7116         35.1275         34.9373
060113..................................................          1.4241          1.0561               *         32.6073         35.2074         33.9039
060114..................................................          1.3878          1.0561               *         34.8536         35.3035         35.0938
060115..................................................          0.8560          0.9303               *               *               *               *
060116..................................................          1.2796          1.0409               *               *         33.1528         33.1528
060117..................................................          1.4396          0.9303               *               *         28.3098         28.3098
060118..................................................          1.4247          0.9303               *               *               *               *

[[Page 23734]]

 
060119..................................................          2.0319          0.9734               *               *               *               *
070001..................................................          1.5932          1.2038         35.8958         37.0403         37.9403         36.9862
070002..................................................          1.8116          1.1897         33.4398         34.7636         36.4240         34.8862
070003..................................................          1.1297          1.1897         34.1352         35.6320         36.0505         35.2926
070004..................................................          1.1791          1.1897         29.4448         29.9557         31.2093         30.2307
070005..................................................          1.4770          1.2038         33.7813         34.9404         36.5469         35.0801
070006..................................................          1.3529          1.2391         37.9148         39.3935         41.2133         39.5140
070007..................................................          1.2875          1.1897         35.9617         36.2914         36.8054         36.3570
070008..................................................          1.2515          1.1897         28.5506         30.7305         35.4942         31.5216
070009..................................................          1.3430          1.1897         32.9299         35.5670         36.6355         34.9997
070010..................................................          1.6851          1.2391         35.3730         36.7227         38.6086         36.9439
070011..................................................          1.4127          1.1897         31.8987         31.6843         34.1325         32.5714
070012..................................................          1.4106          1.1897         29.4216         31.9345         33.2459         31.5134
070015..................................................          1.4333          1.2391         35.3385         37.3454         39.9225         37.5863
070016..................................................          1.4989          1.2038         31.4930         33.2391         34.1238         32.9404
070017..................................................          1.3644          1.2038         34.0490         35.6456         37.5821         35.7978
070018..................................................          1.3783          1.2391         39.7515         41.8460         42.4745         41.4021
070019..................................................          1.3857          1.2038         34.5125         33.7246         35.8591         34.6869
070020..................................................          1.2985          1.1897         33.6453         32.9714         35.6515         34.1183
070021..................................................          1.1854          1.1897         36.9241         38.5623         39.7761         38.4026
070022..................................................          1.6626          1.2038         39.0462         40.2283         41.4692         40.2883
070024..................................................          1.3628          1.1897         35.2323         34.7419         36.8976         35.6415
070025..................................................          1.7385          1.1897         32.4085         34.5887         36.1293         34.3741
070027..................................................          1.4463          1.1897         29.8513         30.4433         33.5960         31.3085
070028..................................................          1.5690          1.2391         35.1966         38.0855         43.1846         38.7150
070029..................................................          1.2883          1.1897         30.9299         31.0662         32.8478         31.6076
070031..................................................          1.2891          1.2038         30.1915         30.4054         30.5906         30.4009
070033..................................................          1.4498          1.2391         40.1594         41.7955         44.6692         42.2677
070034..................................................          1.4240          1.2391         38.3965         40.1685         42.4078         40.3330
070035..................................................          1.2479          1.1897         30.7440         32.2766         33.4024         32.1114
070036..................................................          1.6115          1.1897         38.3413         42.3391         43.6345         41.4903
070038..................................................          0.8866          1.2038         25.7914         35.8053         29.9492         29.4507
070039..................................................          0.9487          1.2038         36.1369         34.7219         32.7121         34.7190
070040..................................................          1.0777          1.1897               *               *               *               *
080001..................................................          1.6391          1.0799         32.0105         33.5310         34.9490         33.5152
080002..................................................             ***               *         29.6800         31.3391         33.0378         31.3601
080003..................................................          1.6226          1.0799         30.7697         34.3048         30.5113         31.8516
080004..................................................          1.5578          1.0645         30.1094         32.2443         34.3823         32.3013
080006..................................................          1.3096          1.0304         27.4749         28.8862         31.0299         29.2083
080007..................................................          1.4835          1.0909         30.1100         31.1645         33.4764         31.6259
090001..................................................          1.7487          1.1018         36.6577         38.3043         40.1629         38.3535
090003..................................................          1.2254          1.0670         31.0419         32.1960         32.8939         31.9877
090004..................................................          1.9209          1.1018         35.6964         37.3798         38.5646         37.2403
090005..................................................          1.4073          1.0670         33.0178         33.7448         35.2850         34.0306
090006..................................................          1.3917          1.0670         29.4912         31.3562         32.3448         31.0266
090008..................................................          1.2958          1.0670         32.0745         33.7471         36.6606         34.0292
090011..................................................          2.0065          1.1018         36.7579         38.0654         39.0086         37.9688
100001..................................................          1.4956          0.9092         26.4631         27.2809         27.8509         27.2111
100002..................................................          1.4292          1.0025         27.2350         28.7068         30.6650         28.8632
100006..................................................          1.6260          0.9189         29.1505         28.3673         28.9654         28.8205
100007..................................................          1.5846          0.9189         28.5702         29.0472         30.3800         29.3589
100008..................................................          1.6979          0.9865         29.1705         30.3392         32.1650         30.5829
100009..................................................          1.3613          0.9865         27.4424         27.8618         30.0468         28.3830
100012..................................................          1.6154          0.9502         28.4600         29.8353         30.8602         29.7781
100014..................................................          1.4551          0.9073         25.1524         27.4019         27.4048         26.6903
100015..................................................          1.2730          0.8993         26.0916         27.2483         28.6813         27.3086
100017..................................................          1.6234          0.9073         27.9654         28.2402         29.8685         28.7071
100018..................................................          1.6116          0.9820         30.2423         30.6545         32.8609         31.2755
100019..................................................          1.6071          0.9401         28.6630         30.3008         31.4521         30.1350
100020..................................................             ***               *         27.1257               *               *         27.1257
100022..................................................          1.6470          1.0025         32.8088         36.7912         36.3330         35.3146
100023..................................................          1.5384          0.9073         25.2652         25.4270         27.1008         26.0111
100024..................................................          1.2924          0.9865         29.1894         29.5423         29.8902         29.5369
100025..................................................          1.7145          0.8633         23.3843         26.7013         27.1652         25.7513
100026..................................................          1.5761          0.8633         23.4730         26.0147         27.3027         25.6436
100027..................................................             ***               *         18.9432               *               *         18.9432
100028..................................................          1.3554          0.9401         27.7497         27.5664         28.7776         28.0281

[[Page 23735]]

 
100029..................................................          1.2121          0.9865         28.8842         30.5382         31.5979         30.3873
100030..................................................          1.3539          0.9189         24.6314         25.3513         26.3096         25.4476
100032..................................................          1.6723          0.8993         26.8162         26.9275         27.8918         27.2236
100034..................................................          1.7942          0.9865         28.1280         27.2915         28.9362         28.1268
100035..................................................          1.6017          0.9757         29.4803         30.2382         32.5568         30.7182
100038..................................................          1.7177          1.0025         31.3403         31.6657         32.8363         31.9625
100039..................................................          1.5743          1.0025         28.2531         29.3699         29.0221         28.8790
100040..................................................          1.7008          0.9092         26.2429         27.2835         28.3342         27.2945
100043..................................................          1.4134          0.8993         26.4221         27.0054         26.8400         26.7591
100044..................................................          1.5389          0.9905         30.3659         33.1141         34.3895         32.6318
100045..................................................          1.3128          0.9073         29.7375         26.5413         25.5601         27.1971
100046..................................................          1.4584          0.8993         26.9469         26.7702         27.7856         27.1801
100047..................................................          1.6986          0.9648         26.7674         29.9729         31.4038         29.3525
100048..................................................          0.9293          0.8633         19.3226         20.2657         21.7684         20.4248
100049..................................................          1.2227          0.8715         24.0385         24.5571         27.6295         25.3718
100050..................................................          1.1486          0.9865         21.5101         25.3354         23.5194         23.4888
100051..................................................          1.3882          0.9189         28.0946         28.6225         30.1464         29.0839
100052..................................................          1.4592          0.8715         23.6796         23.4036         25.1096         24.0877
100053..................................................          1.3335          0.9865         28.5118         31.7415         31.9242         30.6741
100054..................................................          1.4058          0.8703         28.7646         30.5515         30.9825         30.1173
100055..................................................          1.4682          0.8993         25.6243         27.3826         29.6999         27.4746
100057..................................................          1.4366          0.9189         24.8010         26.3134         27.7025         26.3249
100061..................................................          1.5221          0.9865         31.4413         30.4528         31.9154         31.2647
100062..................................................          1.6289          0.8633         25.1280         25.9597         26.3043         25.8131
100063..................................................          1.2914          0.8993         25.5097         26.4139         27.0754         26.3647
100067..................................................          1.4240          0.8993         26.8628         27.4762         27.5486         27.3159
100068..................................................          1.6629          0.9073         26.1341         27.6576         27.6975         27.1712
100069..................................................          1.5199          0.8993         25.7450         27.2108         29.0462         27.3031
100070..................................................          1.6948          0.9757         26.8461         29.2005         29.1098         28.3496
100071..................................................          1.3016          0.8993         26.3768         25.3667         25.1867         25.6298
100072..................................................          1.3899          0.9073         25.7962         27.1889         27.6927         26.8986
100073..................................................          1.7604          1.0025         30.5845         29.4165         31.0379         30.3564
100075..................................................          1.5137          0.8993         25.7612         27.6534         26.7551         26.7473
100076..................................................          1.2093          0.9865         23.4551         24.0412         24.0262         23.8474
100077..................................................          1.3908          0.9648         30.6925         30.7564         27.9764         29.8150
100079..................................................          1.4454               *               *               *               *               *
100080..................................................          1.6170          1.0025         28.2188         29.5346         31.0487         29.6112
100081..................................................          0.9435          0.8633         16.9756         19.5711         19.7407         18.7147
100084..................................................          1.7063          0.9189         27.4947         32.7503         30.6285         30.2189
100086..................................................          1.3909          1.0025         28.5971         29.9072         31.3169         29.9261
100087..................................................          1.8447          0.9757         29.5823         30.5938         32.1290         30.7622
100088..................................................          1.5784          0.9092         26.7574         28.2825         29.5464         28.3236
100090..................................................          1.4708          0.9092         26.5703         27.6175         28.9548         27.7918
100092..................................................          1.5273          0.9401         27.8341         26.6315         28.6765         27.7162
100093..................................................          1.7183          0.8633         21.6438         22.5555         23.4836         22.5921
100099..................................................          1.0283          0.8715         25.8454         26.2395         28.0669         26.7407
100102..................................................          1.1035          0.8758         26.1015         27.8551         29.0373         27.7069
100105..................................................          1.5837          0.9741         29.9745         30.9915         30.8907         30.6081
100106..................................................          1.0497          0.8633         24.7650         24.8098         25.6284         25.0615
100107..................................................          1.1889          0.9502         27.4760         30.5764         31.2927         29.8950
100108..................................................          0.8653          0.8633         21.3540         22.6270         22.8139         22.2176
100109..................................................          1.2509          0.9073         25.5669         26.2446         26.7361         26.2234
100110..................................................          1.5739          0.9189         29.4788         29.5985         30.3729         29.8429
100113..................................................          1.9724          0.9427         28.0440         29.2429         30.5837         29.3004
100114..................................................          1.7025          0.9865         29.2862         30.2544         32.3934         30.6145
100117..................................................          1.2439          0.9092         27.7198         28.4928         30.0549         28.8365
100118..................................................          1.3879          0.8633         27.6438         27.0981         28.3179         27.7197
100121..................................................          1.1178          0.8715         26.2990         27.9353         24.9371         26.3668
100122..................................................          1.2316          0.8703         24.6285         26.7175         27.6162         26.3632
100124..................................................          1.1998          0.8633         24.0333         24.8880         26.2310         25.0380
100125..................................................          1.2235          0.9865         29.7750         31.7749         33.3469         31.6838
100126..................................................          1.3212          0.8993         29.6247         28.3213         28.9151         28.9566
100127..................................................          1.5761          0.8993         26.0923         27.4632         27.0669         26.8835
100128..................................................          2.1341          0.8993         29.2566         30.0324         30.3690         29.9099
100130..................................................          1.1458          1.0025         26.0268         28.3651         30.9735         28.5262
100131..................................................          1.4707          0.9865         27.8164         29.7647         30.9586         29.6460
100132..................................................          1.2889          0.8993         26.0526         27.8180         27.6613         27.2139

[[Page 23736]]

 
100134..................................................          0.8985          0.8633         20.7367         21.6544         22.9624         21.8248
100135..................................................          1.6390          0.8981         26.7030         29.1856         29.8423         28.5445
100137..................................................          1.3328          0.8715         24.8519         26.8391         28.2969         26.7255
100139..................................................          0.8641          0.9427         18.2197         21.1310         21.4420         20.1386
100140..................................................          1.1161          0.9092         26.1352         27.8352         28.5466         27.5007
100142..................................................          1.1395          0.8633         24.8853         25.6999         26.8978         25.8482
100150..................................................          1.2603          0.9865         26.8492         27.7740         29.3690         27.9646
100151..................................................          1.7355          0.9092         30.6447         29.7267         31.3820         30.5873
100154..................................................          1.6098          0.9865         28.2506         29.7332         31.3618         29.8234
100156..................................................          1.1428          0.9427         27.5706         28.3927         28.3041         28.1071
100157..................................................          1.5705          0.8993         29.7455         30.3086         30.3339         30.1497
100160..................................................          1.2508          0.9865         30.7454         30.6902         32.3113         31.2761
100161..................................................          1.5295          0.9189         28.0545         29.5673         30.8955         29.5189
100166..................................................          1.5059          0.9757         28.8685         30.1811         31.9053         30.2720
100167..................................................          1.2272          1.0025         30.2166         31.7813         32.4711         31.5289
100168..................................................          1.5608          1.0025         27.6739         27.0938         28.0517         27.6177
100172..................................................             ***               *         20.7857         22.2183         20.5502         21.2381
100173..................................................          1.6082          0.8993         26.5436         28.6402         30.2470         28.5123
100175..................................................          0.9474          0.8633         23.9665         25.0913         26.1711         25.0707
100176..................................................          1.8223          1.0025         30.7087         33.3181         35.5821         33.1514
100177..................................................          1.3295          0.9401         28.0089         29.6284         31.0063         29.5570
100179..................................................          1.7392          0.9092         29.1111         29.2795         30.5213         29.6480
100180..................................................          1.5114          0.8993         29.9238         31.0099         31.5463         30.8513
100181..................................................          1.1566          0.9865         24.3708         23.9656         26.0656         24.7884
100183..................................................          1.2816          0.9865         29.0270         30.5042         32.9863         30.7987
100187..................................................          1.3637          0.9865         27.8144         30.7705         31.6639         30.0560
100189..................................................          1.3348          1.0025         28.8320         29.9376         30.5491         29.8033
100191..................................................          1.3365          0.8993         28.3710         29.4533         30.9183         29.5986
100200..................................................          1.3715          1.0025         28.7694         29.6400         29.0719         29.1618
100204..................................................          1.5799          0.9427         27.4763         27.2819         29.9311         28.2769
100206..................................................          1.2774          0.8993         27.0295         27.7551         28.8609         27.8936
100209..................................................          1.5193          0.9865         26.8473         28.5336         29.0435         28.1481
100210..................................................          1.5671          1.0025         29.8515         32.0830         32.4538         31.4634
100211..................................................          1.2490          0.8993         24.7533         26.2859         28.8303         26.5619
100212..................................................          1.4634          0.8633         26.1846         27.7960         29.2475         27.7618
100213..................................................          1.5367          0.9757         27.9283         29.5218         30.2251         29.2000
100217..................................................          1.3065          0.9741         27.3989         27.7683         30.3301         28.4907
100220..................................................          1.6181          0.9502         28.3868         29.3601         30.8265         29.5174
100223..................................................          1.5286          0.8703         25.0332         26.1115         27.6756         26.3160
100224..................................................          1.2624          1.0025         26.6446         28.0455         29.1992         27.9615
100225..................................................          1.3079          1.0025         28.5259         30.8782         32.6890         30.6971
100226..................................................          1.3028          0.9092         28.8165         28.8791         30.2828         29.3578
100228..................................................          1.3954          1.0025         28.1396         30.1635         31.0195         29.7490
100230..................................................          1.3499          1.0025         29.8493         31.9448         34.6099         32.1778
100231..................................................          1.7092          0.8633         25.7037         26.6773         28.3633         26.9108
100232..................................................          1.2640          0.9092         28.5537         28.3892         29.3783         28.7734
100234..................................................          1.3320          1.0025         27.4456         28.8835         29.7800         28.7289
100236..................................................          1.4357          0.9648         28.9955         28.3017         30.5701         29.2818
100237..................................................          1.8545          1.0025         31.7848         33.1536         33.9606         32.9295
100238..................................................          1.5484          0.8993         30.1094         31.4198         31.6331         31.0862
100239..................................................          1.3821          0.8993         28.6893         29.0650         30.3212         29.3632
100240..................................................          0.9591          0.9865         27.3523         29.7000         31.0943         29.4319
100242..................................................          1.5092          0.8633         25.6083         26.1988         27.8149         26.5486
100243..................................................          1.4703          0.8993         27.4534         28.3894         29.8294         28.5415
100244..................................................          1.4338          0.9502         26.6876         28.2881         29.8266         28.3031
100246..................................................          1.5457          0.9905         29.3310         30.1061         30.0261         29.8298
100248..................................................          1.5452          0.8993         28.8082         30.2133         32.4702         30.5161
100249..................................................          1.2896          0.8993         24.9876         26.4676         28.5107         26.7077
100252..................................................          1.1632          0.9741         27.8256         27.1639         29.1429         28.0419
100253..................................................          1.3893          1.0025         27.4927         28.7770         28.5597         28.3018
100254..................................................          1.4934          0.8981         26.1406         27.4900         28.5240         27.3995
100255..................................................          1.3025          0.8993         26.5571         27.3866         29.5157         27.8451
100256..................................................          1.7382          0.8993         30.3081         30.2093         33.3907         31.2430
100258..................................................          1.5591          1.0025         31.2203         33.8630         35.2197         33.4797
100259..................................................          1.2682          0.8993         27.4809         29.0612         29.9274         28.8444
100260..................................................          1.3830          0.9905         26.7129         28.2301         29.4885         28.1387
100264..................................................          1.4156          0.8993         26.8216         28.0370         30.1956         28.3177

[[Page 23737]]

 
100265..................................................          1.3296          0.8993         25.7432         26.3326         26.6920         26.2976
100266..................................................          1.3896          0.8633         23.0208         24.2517         25.6366         24.3555
100267..................................................          1.2811          0.9757         28.7259         28.9674         30.6033         29.4523
100268..................................................          1.1771          1.0025         29.0668         30.5750         33.6114         31.0650
100269..................................................          1.3742          1.0025         26.6047         27.8407         28.3722         27.6319
100271..................................................          2.0607               *               *               *               *               *
100275..................................................          1.3310          1.0025         26.8943         28.7797         31.0459         28.9926
100276..................................................          1.2874          1.0025         29.7606         30.5720         31.7050         30.6750
100277..................................................          1.5574          0.9865         20.4791         24.1122         25.5878         23.9890
100279..................................................          1.4040          0.9502         28.6383         29.2257         31.1921         29.7250
100281..................................................          1.3929          1.0025         29.6698         30.9131         32.8807         31.2127
100284..................................................          1.0632          0.9865         22.3134         25.2637         21.4401         22.7441
100285..................................................          1.2639          1.0025               *         41.9481         34.7963         39.4585
100286..................................................          1.5465          0.9820         28.3645         25.8085         26.5795         26.8126
100287..................................................          1.3877          1.0025         28.1051         29.7536         30.3059         29.3361
100288..................................................          1.7404          1.0025         28.7902         31.0506         32.9558         30.8729
100289..................................................          1.6231          1.0025         29.6376         31.9011         31.4701         31.0127
100290..................................................          1.2302          0.9215         27.1011         28.7111         29.7566         28.5282
100291..................................................          1.3483          0.9401         28.4722         28.1515         28.3762         28.3296
100292..................................................          1.3753          0.8633         26.7063         27.7644         28.5799         27.7205
100293..................................................             ***               *         32.7963               *               *         32.7963
100294..................................................             ***               *         30.7557               *               *         30.7557
100295..................................................             ***               *         26.1983               *               *         26.1983
100296..................................................          1.3271          0.9865               *         29.3870         31.1449         30.2840
100297..................................................             ***               *               *         32.1536               *         32.1536
100298..................................................          0.8450          0.8981               *         19.0297         21.9226         20.3569
100299..................................................          1.2918          0.9757               *         34.3697         31.6820         33.1821
100300..................................................             ***               *               *               *         33.1669         33.1669
100302..................................................          1.1546          0.9189               *               *               *               *
110001..................................................          1.3724          0.8740         26.4338         26.5640         27.4189         26.8009
110002..................................................          1.3136          0.9760         26.4715         26.2228         28.9001         27.2273
110003..................................................          1.3119          0.7840         22.7066         24.2097         25.0083         23.9366
110004..................................................          1.3686          0.8880         24.9978         25.1846         27.2513         25.7796
110005..................................................          1.2944          0.9760         28.1209         27.2826         29.5994         28.4189
110006..................................................          1.5596          0.9589         28.3839               *         32.3714         30.3778
110007..................................................          1.5907          0.8770         26.6396         26.3133         28.0665         27.0191
110008..................................................          1.3589          0.9760         29.2947         30.9757         31.8366         30.6980
110010..................................................          2.1741          0.9760         31.7185         33.2396         33.9818         32.9905
110011..................................................          1.2809          0.9760         28.0598         28.5892         30.3526         29.0303
110015..................................................          1.0815          0.9760         28.1274         28.8796         30.5004         29.2479
110016..................................................          1.2537          0.8495         22.7263         24.3563         25.9193         24.3226
110018..................................................          1.1989          0.9760         26.8016         30.1849         30.9429         29.3022
110020..................................................          1.2987          0.9760         28.3822         27.5559         29.4629         28.5809
110023..................................................          1.3269          0.9760         29.8061         29.3282         29.2001         29.4297
110024..................................................          1.4712          0.8943         27.0225         27.3357         28.5637         27.6412
110025..................................................          1.4799          1.0139         31.0703         30.2845         32.6731         31.3350
110026..................................................          1.0963          0.7840         21.8018         22.8820         24.3858         23.0082
110027..................................................          1.0459          0.7840         22.6058         25.5291         25.6536         24.4936
110028..................................................          1.7426          0.9604         30.4641         31.4568         32.8679         31.5933
110029..................................................          1.7563          0.9760         27.3618         29.2134         30.0367         28.8932
110030..................................................          1.3857          0.9760         29.6841         29.9531         32.0250         30.6320
110031..................................................          1.2793          0.9760         27.1989         29.5533         30.7447         29.1990
110032..................................................          1.2564          0.7840         23.2586         25.1896         24.4949         24.3026
110033..................................................          1.7263          0.9760         30.3415         32.4178         32.7019         31.8557
110034..................................................          1.7739          0.9604         27.2338         28.7915         29.6801         28.5541
110035..................................................          1.7859          0.9760         28.9408         30.1852         31.5705         30.2749
110036..................................................          1.8235          0.8943         26.6664         27.2280         28.4022         27.4638
110038..................................................          1.5488          0.8397         22.2720         22.9685         23.3659         22.8669
110039..................................................          1.3716          0.9604         26.3503         26.2485         28.4347         26.8945
110040..................................................          1.1123          0.9760         20.9487         23.9526         21.5761         22.1590
110041..................................................          1.2061          0.9760         24.8864         26.1948         27.6593         26.2845
110042..................................................          1.0795          0.9760         34.9954         33.4391         34.5117         34.3025
110043..................................................          1.7560          0.8943         27.8477         28.8551         30.3702         28.9989
110044..................................................          1.2146          0.7840         23.3039         24.3772         27.0418         24.8928
110045..................................................          1.0279          0.9760         24.4275         27.7619         28.2217         26.7950
110046..................................................          1.1453          0.9760         26.7464               *         28.6264         27.6790
110050..................................................          1.0857          0.8499         27.5985         27.0651         27.1525         27.2626

[[Page 23738]]

 
110051..................................................          1.1244          0.7840         20.1756         21.4898         22.1488         21.3080
110054..................................................          1.4223          0.9760         28.9254         29.4691         31.5780         30.0224
110059..................................................          1.1567          0.7840         23.2137         24.7838         24.9265         24.3029
110064..................................................          1.5836          0.9061         24.1219         26.9363         28.7283         26.5861
110069..................................................          1.3437          0.9618         26.2085         29.9098         30.6443         28.9853
110071..................................................          1.1205          0.7840         21.3963         21.2041         23.6494         22.1661
110073..................................................          1.0228          0.7840         18.5753         23.3571         23.0067         21.5478
110074..................................................          1.4894          0.9589         27.9190         31.0062         30.3996         29.7348
110075..................................................          1.3134          0.8841         23.7585         24.8244         26.1068         24.8944
110076..................................................          1.4843          0.9760         28.7871         29.4344         31.0636         29.7176
110078..................................................          1.9462          0.9760         29.9625         30.5196         31.1064         30.5424
110079..................................................          1.5678          0.9760         26.8412         27.3274         29.0882         27.7224
110080..................................................             ***               *         18.4714               *               *         18.4714
110082..................................................          1.9672          0.9760         30.8320         30.1072         31.1407         30.6976
110083..................................................          1.9525          0.9760         30.4287         34.0610         34.5768         33.0335
110086..................................................          1.2641          0.7840         21.6898         22.9959         23.4762         22.7087
110087..................................................          1.4285          0.9760         28.1633         31.0403         32.8007         30.7266
110089..................................................          1.1392          0.7840         23.9026         24.3327         26.0096         24.7677
110091..................................................          1.2915          0.9760         29.5337         27.0994         28.0609         28.1665
110092..................................................          1.1137          0.7840         20.8911         21.4168         22.8591         21.7047
110095..................................................          1.4622          0.8397         26.3075         28.0526         27.9005         27.4450
110100..................................................          0.9787          0.8630         16.2575         20.8201         20.0633         18.9182
110101..................................................          0.9836          0.7907         19.4257         21.0983         23.8601         21.3923
110104..................................................          1.2036          0.7840         20.3777         21.8966         22.2585         21.5748
110105..................................................          1.3643          0.7840         23.1405         23.4010         23.7738         23.4420
110107..................................................          1.9504          0.9815         28.9352         30.1027         31.5754         30.2370
110109..................................................          1.0213          0.7840         23.0376         21.6023         21.6011         22.0502
110111..................................................          1.1524          0.9604         25.1270         25.7084         27.2234         26.0060
110112..................................................          1.0413          0.8397         22.7672         26.4089         24.2924         24.5380
110113..................................................          0.9563          0.9604         21.3417         22.0793         22.0479         21.8312
110115..................................................          1.7706          0.9760         31.5074         32.7927         33.3880         32.5794
110121..................................................          1.0024          0.8397         26.2336         23.4571         24.5645         24.7827
110122..................................................          1.5445          0.8397         25.1934         25.4439         26.3052         25.6427
110124..................................................          1.0887          0.7840         22.9212         22.9571         24.8540         23.5883
110125..................................................          1.2577          0.9618         23.7834         24.7347         26.4991         24.9905
110128..................................................          1.2891          0.8841         25.7839         25.4190         24.5272         25.2129
110129..................................................          1.5763          0.9061         25.9625         30.0444         29.7304         28.5402
110130..................................................          0.9171          0.7840         19.1284         20.4349         21.7084         20.4154
110132..................................................          1.0348          0.7840         20.2502         21.2642         21.6033         21.0527
110135..................................................          1.2731          0.7840         22.5346         24.0945         25.1022         23.9470
110136..................................................             ***               *         18.8212               *               *         18.8212
110142..................................................          0.9807          0.8025         21.3935         21.6286         22.2156         21.7484
110143..................................................          1.4253          0.9760         28.6583         29.9139         30.9590         29.8777
110146..................................................          1.0832          0.9112         27.0987         29.0193         30.1159         28.7418
110149..................................................             ***               *         28.4040               *               *         28.4040
110150..................................................          1.2994          0.9760         25.3742         26.9884         27.7908         26.7261
110153..................................................          1.1210          0.9618         25.7467         29.3305         30.2424         28.4006
110161..................................................          1.5555          0.9760         30.4885         31.5001         31.9981         31.3389
110163..................................................          1.4520          0.8770         28.2169         27.7679         29.5674         28.5127
110164..................................................          1.7038          0.9815         28.8946         30.0145         31.2804         30.1111
110165..................................................          1.4333          0.9760         27.0977         28.7902         28.7898         28.2209
110168..................................................          1.7664          0.9760         28.5700         29.7774         30.8727         29.7602
110172..................................................          1.4736          0.9760         31.1234         31.3999         33.0426         31.8709
110177..................................................          1.9238          0.9604         28.8356         29.7079         30.5507         29.7260
110183..................................................          1.2868          0.9760         28.6208         28.3505         29.6606         28.9003
110184..................................................          1.2634          0.9760         28.3545         29.4071         30.2897         29.4131
110186..................................................          1.3171          0.9061         27.4925         28.2880         29.6479         28.4857
110187..................................................          1.2029          0.9760         25.2139         26.9638         31.0150         27.7895
110189..................................................          1.1025          0.9760         26.1418         26.2799         27.4200         26.6304
110190..................................................          1.0867          0.8081         23.3204         24.5224         29.4199         25.5710
110191..................................................          1.3278          0.9760         27.7760         30.9481         28.7481         29.1019
110192..................................................          1.4139          0.9760         28.8267         30.0843         31.6605         30.2562
110193..................................................             ***               *         27.9161               *               *         27.9161
110194..................................................          0.8957          0.7840         19.1920         21.0826         20.5257         20.2837
110198..................................................          1.3546          0.9760         31.0557         32.8171         34.0021         32.6125
110200..................................................          2.0256          0.9061         24.9236         27.2974         29.4610         27.3150
110201..................................................          1.4532          0.9815         31.0841         32.0967         33.4267         32.2165

[[Page 23739]]

 
110203..................................................          0.9588          0.9760         29.7888         32.3441         32.0585         31.3300
110205..................................................          1.1768          0.8347         22.0207         23.9738         26.1963         24.0311
110209..................................................          0.6196          0.7840         21.1534         21.2428         22.4539         21.6327
110212..................................................          1.2087          0.8163               *               *               *               *
110214..................................................             ***               *         37.1450               *               *         37.1450
110215..................................................          1.3584          0.9760         27.5566         29.5238         30.1770         29.1787
110219..................................................          1.4002          0.9760         28.8814         32.2603         33.4462         31.6155
110220..................................................             ***               *         37.5741               *               *         37.5741
110221..................................................             ***               *         28.0500               *               *         28.0500
110222..................................................             ***               *         35.6189               *               *         35.6189
110223..................................................             ***               *               *         25.3071               *         25.3071
110224..................................................             ***               *               *         33.6464               *         33.6464
110225..................................................          1.2065          0.9760               *         29.5373         28.9757         29.2212
110226..................................................          1.1952          0.9760               *               *         32.1814         32.1814
110228..................................................          0.8800          0.9760               *               *               *               *
110229..................................................          1.2950          0.9760               *               *               *               *
110230..................................................          1.3685          0.7840               *               *               *               *
120001..................................................          1.7874          1.1608         34.1385         39.6348         39.0344         37.5738
120002..................................................          1.2448          1.1219         32.3784         34.1709         37.7249         34.7927
120004..................................................          1.2549          1.1608         30.0668         31.3555         32.5141         31.3602
120005..................................................          1.2949          1.1219         31.1985         33.6942         35.1716         33.3840
120006..................................................          1.2614          1.1608         31.6785         34.2231         35.7058         33.9086
120007..................................................          1.6360          1.1608         30.2473         30.8773         35.0167         31.9560
120010..................................................          1.9848          1.1608         29.5714         30.8526         34.3338         31.4351
120011..................................................          1.4966          1.1608         37.1792         39.1941         44.0519         40.3992
120014..................................................          1.3531          1.1219         30.3463         30.9839         34.2101         31.8841
120019..................................................          1.1710          1.1219         30.4257         33.0114         36.1586         33.2188
120022..................................................          1.8673          1.1608         29.9527         32.5326         34.9024         32.4610
120026..................................................          1.4190          1.1608         32.4566         34.2244         35.8383         34.2218
120027..................................................          1.3261          1.1608         28.7905         29.5825         31.8146         30.1238
120028..................................................          1.2595          1.1608         32.4847         34.0451         34.6327         33.7338
120029..................................................             ***               *               *         44.6382               *         44.6382
130002..................................................          1.4057          0.9100         24.7871         24.7266         24.3491         24.6130
130003..................................................          1.4692          0.9560         28.6158         28.6136         29.8774         29.0074
130006..................................................          1.7566          0.9290         27.2158         28.0048         28.8325         28.0328
130007..................................................          1.7298          0.9290         28.7246         30.4958         31.2250         30.1204
130013..................................................          1.3634          0.9290         30.9609         36.1570         33.8909         33.6903
130014..................................................          1.2442          0.9290         27.2543         27.5936         28.2815         27.7157
130018..................................................          1.7489          0.9327         27.3439         28.4041         30.2030         28.6009
130024..................................................          1.1981          0.8272         23.6212         24.8035         25.3184         24.5765
130025..................................................          1.2309          0.7597         21.1998         22.7962         23.8581         22.6625
130028..................................................          1.4347          0.9103         27.2195         28.4934         29.3360         28.3737
130049..................................................          1.5627          1.0315         27.3597         29.0185         29.7190         28.7360
130062..................................................             ***               *         25.6467         29.1925         28.3416         27.9024
130063..................................................          1.4068          0.9290         26.0955         27.7607         27.7664         27.1825
130065..................................................          1.9441          0.9327         21.9792         30.4547         25.8977         26.3095
130066..................................................          2.0484          0.9504               *         28.9883         28.1483         28.5227
130067..................................................          2.5439               *               *         21.3867         26.8243         23.8814
140001..................................................          1.1235          0.8797         22.3001         22.2003         23.2221         22.5895
140002..................................................          1.3464          0.8993         27.0165         27.4779         29.1084         27.9303
140007..................................................          1.4044          1.0334         30.7378         31.4024         32.4342         31.5521
140008..................................................          1.4402          1.0334         29.1767         31.8008         32.7592         31.2208
140010\3\...............................................          1.4980          1.0334         31.8806         40.1360         39.3702         36.3250
140B10\3\...............................................             ***               *               *         40.1360         39.3702         39.7545
140011..................................................          1.2146          0.8428         23.8575         25.8864         26.2125         25.4083
140012..................................................          1.3120          1.0334         29.0336         31.8213         31.9498         30.8913
140013..................................................          1.4671          0.9043         23.9269         25.0951         26.4178         25.1250
140015..................................................          1.3506          0.8993         24.4687         24.6409         25.2491         24.8022
140018..................................................          1.3731          1.0334         26.3533         30.7398         31.5604         29.4466
140019..................................................          0.9139          0.8428         21.3438         22.3179         22.2899         21.9787
140026..................................................          1.1531          0.8743         25.9669         26.0493         28.1690         26.7518
140029..................................................          1.5837          1.0334         30.2688         36.7722         36.3824         34.4448
140030..................................................          1.5087          1.0334         30.2776         31.6822         32.1110         31.3500
140032..................................................          1.2668          0.8993         26.7310         27.5367         28.5229         27.5996
140033..................................................             ***               *         27.9993         29.5256         31.4328         29.1997
140034..................................................          1.1683          0.8993         24.0470         24.4653         26.7233         25.0924
140040..................................................          1.2236          0.9043         23.2293         24.5589         28.4995         25.3375

[[Page 23740]]

 
140043..................................................          1.2647          0.8606         27.3469         29.8633         31.3736         29.5994
140046..................................................          1.4727          0.8993         24.7334         25.6230         25.7906         25.3934
140048..................................................          1.2788          1.0334         29.3877         30.6686         31.6262         30.5704
140049..................................................          1.5369          1.0334         29.0976         30.8617         32.0217         30.6556
140051..................................................          1.5614          1.0334         30.9696         32.1730         32.7506         31.9766
140052..................................................          1.3408          0.8993         25.9617         26.9907         26.7896         26.5759
140053..................................................          1.7853          0.9133         27.4518         28.4513         29.9472         28.5957
140054..................................................          1.4862          1.0334         33.1406         34.2378         34.5342         33.9734
140058..................................................          1.2320          0.8993         24.6058         25.2568         26.5660         25.4975
140059..................................................          1.0669          0.8993         22.6743         21.6230         22.8588         22.3764
140062..................................................          1.3719          1.0334         34.1230         36.8271         36.6461         35.8580
140063..................................................          1.4103          1.0334         28.6559         30.5465         31.1242         30.0979
140064..................................................          1.2191          0.9043         23.8639         25.7551         26.6231         25.4620
140065..................................................          1.4143          1.0334         30.1856         31.5510         32.4631         31.3610
140066..................................................          1.1167          0.8993         22.1524         22.0225         23.6295         22.6003
140067..................................................          1.8104          0.9043         28.3506         29.8982         30.6882         29.6686
140068..................................................          1.2321          1.0334         28.3938         26.7166         31.3440         28.7631
140075..................................................          1.2712          1.0334         26.2626         35.9507         33.6844         31.5469
140077..................................................          0.9374          0.8993         20.3999         21.6468         22.5061         21.5537
140080..................................................          1.4286          1.0334         28.8791         29.9067         30.3760         29.7135
140082..................................................          1.6302          1.0334         28.3429         31.0516         32.0539         30.4270
140083..................................................          0.9706          1.0334         26.8919         27.2189         26.1622         26.6852
140084..................................................          1.2689          1.0334         30.5036         30.7251         31.3281         30.8596
140088..................................................          1.8601          1.0334         30.5450         32.6866         34.0556         32.5121
140089..................................................          1.2292          0.8428         24.1066         24.9120         26.6942         25.2540
140091..................................................          1.7570          0.9353         27.8536         28.2095         29.4099         28.5130
140093..................................................          1.2251          0.9711         28.3298         28.6709         31.2955         29.5310
140094..................................................          1.0614          1.0334         27.3841         28.7647         28.8596         28.3324
140095..................................................          1.2067          1.0334         28.7617         29.7385         29.9452         29.4617
140100..................................................          1.4165          1.0334         41.3374         37.2961         37.3023         38.5940
140101..................................................          1.2742          1.0334         29.4081         28.9723         31.0048         29.8038
140103..................................................          1.1919          1.0334         23.6406         24.0926         25.3608         24.3942
140105..................................................             ***               *         29.5274         29.6590         30.7135         29.8404
140110..................................................          1.1348          1.0334         28.6364         30.3432         31.3460         30.1323
140113..................................................          1.5825          0.9353         29.5452         30.2542         31.6124         30.5020
140114..................................................          1.5001          1.0334         28.2151         29.8316         31.1390         29.7616
140115..................................................          1.2630          1.0334         26.0383         25.4576         26.2578         25.9061
140116..................................................          1.3668          1.0341         34.5537         34.3876         34.1356         34.3550
140117..................................................          1.5097          1.0334         27.7201         30.9679         28.5785         29.0528
140118..................................................          1.4623          1.0334         32.5518         33.1987         33.6634         33.1346
140119..................................................          1.8095          1.0334         34.2118         32.2185         34.3896         33.5609
140120..................................................          1.3098          0.9043         23.9724         25.9275         26.2398         25.4006
140122..................................................          1.5055          1.0334         30.5653         30.2888         32.4728         31.1094
140124..................................................          1.2504          1.0334         35.7563         38.2191         38.8956         37.6290
140125..................................................          1.1586          0.8993         22.7571         26.5801         27.6333         25.6694
140127..................................................          1.6283          0.9520         25.6668         27.8363         29.3326         27.6412
140130..................................................          1.2280          1.0334         32.6209         32.5425         34.5053         33.2090
140133..................................................          1.4054          1.0334         31.0269         30.3259         32.8907         31.4186
140135..................................................          1.4168          0.8840         23.3196         24.6645         25.9046         24.6639
140137..................................................          1.0555          0.8993         23.4174         31.4349               *         26.5232
140143..................................................          1.1818          1.0334         27.4499         26.1126         27.0294         26.8354
140145..................................................          1.0941          0.8993         26.0875         25.2040         26.9326         26.0849
140147..................................................          1.0800          0.8428         21.0686         21.1817         22.1026         21.4534
140148..................................................          1.6364          0.9133         25.5677         27.0038         28.9453         27.2136
140150..................................................          1.6423          1.0334         52.0970         35.5951         45.8193         44.1226
140151..................................................          0.7986          1.0334         27.0312         26.0825         27.3539         26.8313
140152..................................................             ***               *         30.2209         29.8647         32.2789         30.7789
140155..................................................          1.3176          1.0334         29.5734         32.7960         35.0804         32.3959
140158..................................................          1.3565          1.0334         27.3721         30.4445         32.1130         30.0627
140160..................................................          1.1748          0.9756         25.8684         27.6905         28.9023         27.4932
140161..................................................          1.1449          0.8596         25.2898         28.8266         28.8132         27.6822
140162..................................................          1.5506          0.9520         29.4121         32.1810         33.0967         31.5165
140164..................................................          1.7462          0.8993         24.6009         25.9726         27.3117         26.0022
140166..................................................          1.1830          0.8428         26.4800         26.2875         27.2398         26.6846
140167..................................................          1.1518          0.8428         22.8703         24.9904         24.2733         24.0635
140172..................................................          1.3856          1.0334         32.1220         33.0926         33.4586         32.9106
140174..................................................          1.5880          1.0334         30.5905         31.2231         34.2433         32.0655

[[Page 23741]]

 
140176..................................................          1.2311          1.0341         32.9794         32.6145         33.2116         32.9375
140177..................................................          0.9832          1.0334         26.4340         25.5725         26.0709         26.0349
140179..................................................          1.3098          1.0334         29.3657         30.2944         31.3599         30.3150
140180..................................................          1.1869          1.0334         27.8887         29.1352         29.7982         28.9361
140181..................................................          1.1559          1.0334         25.0226         27.6835         27.3815         26.6876
140182..................................................          1.4662          1.0334         30.1755         32.8972         26.4085         29.5346
140184..................................................          1.3087          0.8428         25.2327         26.6104         27.5837         26.4843
140185..................................................          1.4359          0.8993         25.2423         26.5398         27.9409         26.5570
140186..................................................          1.4967          1.0334         29.8022         30.7212         41.2521         33.4222
140187..................................................          1.5073          0.8993         24.8332         25.5873         26.9246         25.7702
140189..................................................          1.1619          0.8428         22.5965         24.7013         29.1349         25.4810
140191..................................................          1.3271          1.0334         28.5836         31.9943         29.7497         30.0468
140197..................................................          1.0759          1.0334         24.0463         24.9103         24.8700         24.5943
140200..................................................          1.5134          1.0334         28.8435         30.6641         31.3692         30.2724
140202..................................................          1.4541          1.0334         32.7915         32.9433         34.3762         33.4137
140206..................................................          1.2021          1.0334         29.7953         29.6275         31.1376         30.1671
140207..................................................          1.1245          1.0334         26.0535         28.2262         31.6793         28.4326
140208..................................................          1.6424          1.0334         29.5380         31.4035         26.1728         28.8260
140209..................................................          1.5750          0.9043         26.3230         29.7965         27.4032         27.7656
140210..................................................          1.0667          0.8428         20.6954         19.2053         22.2507         20.7150
140211..................................................          1.3317          1.0334         30.3286         31.4539         34.5893         32.1847
140213..................................................          1.2466          1.0334         31.6926         32.1031         33.3902         32.4246
140217..................................................          1.4736          1.0334         32.1277         32.9404         33.2151         32.8054
140223..................................................          1.4965          1.0334         31.7267         33.5083         34.6969         33.3189
140224..................................................          1.3728          1.0334         29.6181         31.2237         30.1050         30.3035
140228..................................................          1.4758          0.9862         27.9456         28.2855         28.7440         28.3351
140231..................................................          1.4738          1.0334         30.0236         34.8291         35.2199         33.3358
140233..................................................          1.6742          0.9862         29.7093         31.5168         32.3348         31.1982
140234..................................................          1.0951          0.8743         24.5476         25.7353         25.7647         25.3480
140239..................................................          1.5089          0.9862         31.1879         31.0918         33.7241         31.9840
140240..................................................          1.4543          1.0334         31.5637         32.7986         28.0966         30.7320
140242..................................................          1.5121          1.0334         34.6120         35.2351         36.6696         35.4606
140250..................................................          1.2451          1.0334         29.6305         31.2533         32.9392         31.3008
140251..................................................          1.3749          1.0334         28.0622         28.3598         29.5921         28.6552
140252..................................................          1.4509          1.0334         34.4268         35.8762         36.1503         35.4953
140258..................................................          1.5542          1.0334         34.2333         33.0093         34.5667         33.9309
140275..................................................          1.3633          0.8606         27.8186         28.5064         26.7377         27.6728
140276..................................................          1.9223          1.0334         31.6359         32.1048         32.7052         32.1538
140280..................................................          1.4877          0.8606         24.9401         26.6536         26.9815         26.2013
140281..................................................          1.7853          1.0334         33.3903         35.6589         37.5673         35.5869
140286..................................................          1.2031          1.0334         30.3237         32.0048         32.2227         31.5106
140288..................................................          1.4810          1.0334         31.5197         31.5944         32.5446         31.8981
140289..................................................          1.2801          0.8993         23.8452         25.6847         26.0851         25.2075
140290..................................................          1.3716          1.0334         31.8135         32.5247         35.9647         33.4767
140291..................................................          1.5227          1.0334         31.9052         33.8706         32.7857         32.8705
140292..................................................          1.1466          1.0334         28.5094         30.6917         32.4476         30.3851
140294..................................................          1.1034          0.8428         24.0750         26.1595         26.9772         25.8209
140300..................................................          1.1745          1.0334         35.1494         42.5240         37.1204         38.1961
140301..................................................          1.0712          1.0334         49.9507         39.4295         38.0581         40.7701
140303..................................................          2.1328          1.0334         29.6470               *         32.2920         30.8365
150001..................................................          1.1896          0.9827         28.9075         31.8089         32.9797         31.2747
150002..................................................          1.4747          1.0328         26.6222         27.6481         28.1057         27.6106
150003..................................................          1.5897          0.8960         26.7585         26.9771         29.0575         27.6017
150004..................................................          1.4569          1.0328         28.7336         30.9626         31.6781         30.3933
150005..................................................          1.2612          0.9827         29.5371         30.5367         31.6148         30.6086
150006..................................................          1.3702          0.9353         25.6265         27.1364         28.3389         27.0718
150007..................................................          1.4525          0.9254         29.4971         30.0500         31.0369         30.2270
150008..................................................          1.4479          1.0328         27.5703         27.0525         29.1473         27.9333
150009..................................................          1.4395          0.9238         25.4496         25.7616         26.1499         25.7891
150010..................................................          1.5221          0.9254         27.2272         28.4118         28.2599         27.9486
150011..................................................          1.3308          0.9707         25.3178         26.7686         27.7857         26.5785
150012..................................................          1.5537          0.9644         30.0348         31.2282         30.4819         30.5840
150015..................................................          1.3616          0.9320         28.0931         27.3811         30.1474         28.5072
150017..................................................          1.8267          0.9004         26.3973         26.3379         27.1249         26.6388
150018..................................................          1.5912          0.9353         27.3689         29.1137         30.0478         28.9018
150021..................................................          1.8098          0.9004         28.9196         30.0030         31.1140         30.0142
150022..................................................          1.0584          0.8637         23.1041         23.8971         26.8394         24.4351

[[Page 23742]]

 
150023..................................................          1.5869          0.9707         26.9095         27.7520         30.3560         28.3734
150024..................................................          1.4757          0.9827         28.1655         28.4170         30.6133         29.0364
150026..................................................          1.3515          0.9353         28.6517         30.4967         31.9378         30.4512
150029..................................................          1.3421          0.9644         28.7187         29.9307         29.7461         29.4587
150030..................................................          1.1963          0.9707         29.1493         29.3588         31.1964         29.9386
150033..................................................          1.4204          0.9827         28.6838         29.7744         33.1990         30.5371
150034..................................................          1.4624          1.0328         28.6429         28.0434         30.0027         28.9357
150035..................................................          1.5482          0.9320         26.9700         27.8904         29.2014         28.0374
150037..................................................          1.2521          0.9827         31.0935         29.0161         30.4623         30.1390
150038..................................................          1.1402          0.9827         29.3156         33.0112         31.9539         31.4556
150042..................................................          1.3656          0.8791         22.8786         25.1403         25.2440         24.4073
150044..................................................          1.4443          0.9238         25.2137         25.2685         25.9260         25.4830
150045..................................................          1.0453          0.9004         26.9818         27.5340         29.4308         27.9971
150046..................................................          1.5575          0.9130         24.5593         26.5876         27.6210         26.2766
150047..................................................          1.7059          0.9004         25.5194         25.8497         27.1835         26.1904
150048..................................................          1.4375          0.9583         27.1233         28.1525         29.5578         28.3255
150051..................................................          1.6111          0.9707         26.5655         28.9157         30.3742         28.6837
150056..................................................          1.9795          0.9827         28.8727         29.3500         30.5758         29.6152
150057..................................................          2.0656          0.9827         28.9529         30.3287         29.1268         29.4500
150058..................................................          1.6334          0.9644         29.1444         29.1255         31.7536         30.0001
150059..................................................          1.4852          0.9827         31.4987         31.3362         36.2553         33.0486
150061..................................................          1.1299          0.8479         21.3711         22.6746         23.2415         22.4414
150064..................................................          1.2404          0.8479         25.4987         28.7978         28.9419         27.8440
150065..................................................          1.2493          0.9707         27.9283         30.2053         30.8254         29.6617
150069..................................................          1.1831          0.9583         26.2028         26.0909         27.0720         26.4651
150072..................................................          1.1283          0.8584         21.2120         21.7644         23.0612         21.9963
150074..................................................          1.4309          0.9827         25.9321         28.5655         29.4124         28.0120
150075..................................................          1.1406          0.9004         25.1568         25.7245         26.5972         25.8595
150076..................................................          1.2974          0.9353         29.3249         30.1120         29.2703         29.5697
150082..................................................          1.5914          0.8525         28.3494         26.4544         28.1280         27.6224
150084..................................................          1.8344          0.9827         31.1720         33.1784         34.8522         33.0904
150086..................................................          1.2227          0.9583         25.1992         26.6745         27.2568         26.4089
150088..................................................          1.2980          0.9707         27.2103         29.1509         30.2378         28.8855
150089..................................................          1.5552          0.8479         24.7233         24.8045         26.7270         25.4200
150090..................................................          1.5584          1.0328         30.4835         30.6412         30.8754         30.6754
150091..................................................          1.1569          0.9004         30.4234         32.1627         33.0402         31.9030
150097..................................................          1.1855          0.9827         27.7468         29.1359         29.4776         28.7947
150100..................................................          1.6039          0.8525         25.7997         26.9724         27.6326         26.7725
150101..................................................          1.0840          0.9004         29.0301         30.5475         31.6018         30.3780
150102..................................................          1.0268          0.9320         25.7424         25.8742         25.4704         25.6892
150104..................................................          1.1443          0.9827         28.2552         28.7788         30.8970         29.3100
150109..................................................          1.5465          0.8960         25.3367         26.8464         28.7412         26.9892
150112..................................................          1.4960          0.9707         28.0068         29.8540         31.7711         29.8902
150113..................................................          1.2097          0.9707         24.7960         25.9814         26.9088         25.9097
150115..................................................          1.3474          0.8479         22.0747         22.5793         22.3560         22.3407
150125..................................................          1.5500          1.0328         27.6535         29.3596         31.2081         29.4320
150126..................................................          1.3476          1.0328         28.9454         29.4300         32.5356         30.2297
150128..................................................          1.4329          0.9827         28.7810         29.5008         31.1046         29.8290
150129..................................................          1.1906          0.9827         29.7398         31.4317         32.9621         31.3709
150132..................................................             ***               *         27.6560               *               *         27.6560
150133..................................................          1.2148          0.9353         25.1322         24.2538         23.0651         24.1076
150134..................................................             ***               *         26.3249         21.6740         27.3963         24.7453
150146..................................................          1.1296          0.9547         29.5256         30.3343         31.8743         30.6315
150147..................................................          1.4431          1.0328         27.2339         26.1646         28.9248         27.6245
150149..................................................          0.9337          0.8525         23.7026         24.9629         25.3324         24.7398
150150..................................................          1.3583          0.9004         27.0542         26.7700         26.5963         26.7808
150153..................................................          2.3079          0.9827         32.1022         35.0617         37.3920         35.1885
150154..................................................          2.4814          0.9827         29.8514         29.8894         30.5758         30.1310
150155..................................................             ***               *         45.0121               *               *         45.0121
150156..................................................             ***               *         25.9681               *               *         25.9681
150157..................................................          1.7719          0.9827               *         32.3106         32.9148         32.6153
150158..................................................          1.2495          0.9827               *               *         30.4337         30.4337
150159..................................................             ***               *               *               *         27.5574         27.5574
150160..................................................          2.0971          0.9827               *               *         28.6108         28.6108
150161..................................................          1.6006          0.9827               *               *               *               *
150162..................................................          1.8254          0.9827               *               *               *               *
150163..................................................          1.0174          0.9238               *               *               *               *

[[Page 23743]]

 
150164..................................................          1.1402          0.9419               *               *               *               *
150165..................................................          1.3537          0.9320               *               *               *               *
150166..................................................          1.0260          0.9320               *               *               *               *
160001..................................................          1.2035          0.8881         24.5108         25.7255         25.8676         25.3903
160005..................................................          1.2221          0.8709         23.1034         24.7755         24.8586         24.2778
160008..................................................          1.0503          0.8709         22.1402         22.4758         24.1271         22.9093
160013..................................................          1.1826          0.8888         24.0956         24.4099         25.5144         24.6765
160016..................................................          1.5621          0.8881         24.5338         27.1460         26.6516         26.0785
160024..................................................          1.5070          0.9460         27.4158         29.3756         32.4228         29.7117
160028..................................................          1.3546          0.9360         27.8535         30.0576         29.8324         29.2977
160029..................................................          1.5290          0.9337         28.7324         30.6687         32.2010         30.5406
160030..................................................          1.4497          0.9457         28.7786         30.9415         30.4757         30.0901
160032..................................................          1.0815          0.8944         25.4662         26.2935         28.5629         26.7834
160033..................................................          1.6123          0.8709         26.5315         27.2060         27.4787         27.0636
160040..................................................          1.3560          0.9248         25.9032         26.8110         28.2966         27.0153
160045..................................................          1.6650          0.8746         26.6463         27.5289         28.1662         27.4620
160047..................................................          1.3438          0.9360         26.0227         28.1280         29.4261         27.7499
160057..................................................          1.3696          0.9107         25.1272         25.6274         27.7953         26.1996
160058..................................................          1.9928          0.9337         28.4167         28.9924         29.8956         29.1104
160064..................................................          1.5613          0.9248         28.7668         28.4209         33.6067         30.2004
160067..................................................          1.3956          0.9248         24.8137         26.0243         26.7671         25.8721
160069..................................................          1.5119          0.8709         27.4473         27.6157         28.4064         27.8032
160079..................................................          1.4505          0.8746         24.7372         26.1618         28.5014         26.4591
160080..................................................          1.2258          0.8709         25.8252         27.2370         27.8729         26.9717
160082..................................................          1.7394          0.9460         27.4718         28.7831         31.7482         29.3428
160083..................................................          1.6319          0.9460         27.3004         28.3921         29.9472         28.5559
160089..................................................          1.2114          0.9107         23.2149         23.2888         23.9184         23.4747
160101..................................................          1.1157          0.9460         25.0503         25.4740         26.8503         25.8119
160104..................................................          1.6343          0.8709         28.1891         29.8126         27.0516         28.2560
160110..................................................          1.4968          0.9248         26.6633         28.8134         29.9071         28.6042
160112..................................................          1.2363          0.8709         24.7957         25.2886         26.1706         25.4488
160117..................................................          1.3763          0.8709         25.4659         27.3927         24.3309         25.6596
160122..................................................          1.1372          0.8709         23.9177         24.4996         25.3176         24.5888
160124..................................................          1.1221          0.8709         22.5482         24.3063         25.5031         24.1100
160146..................................................          1.4330          0.8745         22.6949         24.8485         25.1816         24.2135
160147..................................................          1.2223          0.8881         28.6303         29.8992         33.6376         30.7344
160153..................................................          1.6977          0.8745         29.9378         30.6173         30.4338         30.3298
160155..................................................          2.0066          0.8709               *               *               *               *
170001..................................................          1.1220          0.8086         23.1260         23.8863         24.5932         23.8766
170006..................................................          1.3222          0.9351         24.2068         27.1033         28.3509         26.6135
170009..................................................          1.0785          0.9453         30.9025         29.6386         32.2817         30.9531
170010..................................................          1.2334          0.8086         23.9707         25.5573         28.1793         25.9458
170012..................................................          1.6303          0.8785         26.1367         27.1195         28.7852         27.3256
170013..................................................          1.7166          0.8785         25.2476         26.7124         28.3035         26.7042
170014..................................................          1.0389          0.9453         23.8135         24.2322         25.8151         24.6246
170016..................................................          1.5893          0.8873         25.8061         26.7536         28.6802         27.0793
170017..................................................          1.1359          0.8980         26.9657         27.2925         29.1445         27.8530
170020..................................................          1.5631          0.8785         23.2757         24.1149         25.0539         24.1602
170023..................................................          1.4632          0.8785         24.0561         23.9812         24.8758         24.3255
170027..................................................          1.4379          0.8086         23.1766         23.4037         24.1118         23.5721
170033..................................................          1.3317          0.8086         21.9709         24.1882         25.0393         23.6609
170039..................................................          0.9397          0.8980         26.9852         26.0952         23.5961         25.4102
170040..................................................          1.9332          0.9453         28.4458         30.2468         30.0807         29.6659
170049..................................................          1.5092          0.9453         25.2070         26.4086         31.8575         27.9185
170058..................................................          1.0992          0.8086         22.9210         26.5949         28.1316         25.7970
170068..................................................          1.2130          0.8885         23.0635         23.8812         23.8492         23.5912
170074..................................................          1.1942          0.8086         23.7829         23.0567         24.8855         23.9145
170075..................................................          0.8436          0.8086         19.7760         19.9351         21.1954         20.2943
170086..................................................          1.5732          0.8873         26.1362         26.3615         28.5234         27.0437
170094..................................................          0.9157          0.8086         21.5295         16.5136         17.1709         18.5438
170103..................................................          1.2784          0.8980         23.8042         24.2003         25.5653         24.5527
170104..................................................          1.4059          0.9453         26.2990         27.6211         29.5069         27.8074
170105..................................................          1.1156          0.8086         21.9606         22.7412         23.4317         22.7174
170109..................................................          1.0350          0.9453         23.1088         23.8515         29.0177         25.4500
170110..................................................          0.8962          0.8086         23.3260         23.9572         24.7910         24.0231
170114..................................................          0.5755               *               *               *               *               *
170120..................................................          1.3720          0.9351         22.0253         22.2805         23.5271         22.6059

[[Page 23744]]

 
170122..................................................          1.6975          0.8980         26.6605         28.7175         29.6314         28.2843
170123..................................................          1.6684          0.8980         27.6653         27.0843         28.7608         27.8479
170133..................................................          1.0196          0.9453         23.1226         25.2301         25.7108         24.7246
170137..................................................          1.3249          0.8086         24.7096         25.3395         26.8014         25.6444
170142..................................................          1.3711          0.8720         23.9527         24.6019         25.5550         24.7027
170145..................................................          1.0867          0.8086         23.2162         23.3967         25.3728         23.9852
170146..................................................          1.5002          0.9453         29.8858         29.0720         31.6994         30.2197
170147..................................................             ***               *         22.4973         24.3268         21.4565         23.0046
170150..................................................          1.1410          0.8252         20.9448         19.6160         22.0251         20.8653
170166..................................................          1.0165          0.8086         21.0762         22.6968         24.1063         22.6638
170175..................................................          1.4832          0.8785         25.6281         26.7229         31.7582         28.0191
170176..................................................          1.5583          0.9453         27.2332         29.0735         30.1114         28.8494
170180..................................................             ***               *         32.5010               *               *         32.5010
170182..................................................          1.4504          0.9453         27.3503         28.9710         30.3781         28.8971
170183..................................................          1.9858          0.8980         25.8340         26.1890         27.7178         26.5683
170185..................................................          1.2572          0.9453         27.8139         28.1780         29.3202         28.5075
170186..................................................          2.5220          0.8980         32.8392         30.2613         30.7638         31.2790
170187..................................................          1.6421          0.8086         22.8493         24.1461         24.6391         23.8933
170188..................................................          1.9852          0.9453         30.6844         32.2573         33.7221         32.2678
170190..................................................          1.0158          0.8720         22.9540         26.2625         27.3023         25.5425
170191..................................................          1.8259          0.8086         22.1197         24.3813         26.0279         24.3247
170192..................................................          1.7639          0.8980         26.2724         27.7421         30.9200         28.4741
170193..................................................          1.3485          0.8785         20.6821         24.8531         24.4126         22.9315
170194..................................................          1.2331          0.9453         29.9014         27.6989         28.1972         28.5250
170195..................................................          2.4249          0.9453         30.1001         29.5947         29.1763         29.5492
170196..................................................          2.4635          0.8980               *         32.1832         29.9641         30.9601
170197..................................................          2.3250          0.8980               *               *               *               *
170198..................................................          1.9320          0.8086               *               *               *               *
180001..................................................          1.3069          0.9590         27.6917         29.7423         29.9655         29.1412
180002..................................................          1.0662          0.8062         25.7862         26.5488         27.3339         26.5496
180004..................................................          1.0759          0.7837         22.0797         20.8805         22.0615         21.6721
180005..................................................          1.1460          0.8767         24.9779         25.6159         27.4304         26.0705
180007..................................................          1.5443          0.8950         25.7042         27.1924         26.9425         26.6126
180009..................................................          1.7525          0.9127         26.4101         27.3228         28.7030         27.5584
180010..................................................          1.8312          0.8950         25.6153         27.7600         28.1667         27.1559
180011..................................................          1.6281          0.8756         25.5463         24.9909         25.0355         25.1733
180012..................................................          1.4715          0.9123         25.6000         26.7279         27.2829         26.5352
180013..................................................          1.5001          0.9276         23.7075         24.8125         26.8088         25.0983
180016..................................................          1.2868          0.9245         24.8408         24.7091         26.9522         25.4644
180017..................................................          1.3104          0.8230         21.8885         21.9715         25.4164         23.1027
180018..................................................          1.3551          0.7837         20.9857         23.3035         23.9155         22.7447
180019..................................................          1.1134          0.7837         24.0283         24.6279         27.6787         25.4951
180020..................................................          1.0616          0.7837         24.6953         25.9975         26.8856         25.8897
180021..................................................          0.9634          0.7837         20.7950         22.0740         22.3752         21.7644
180024..................................................          1.1593          0.9123         31.1159         26.3532         26.9538         28.0398
180025..................................................          1.2308          0.9245         22.6897         28.5935         28.4153         26.7267
180027..................................................          1.2008          0.8302         20.8303         21.7639         23.3873         21.9095
180029..................................................          1.4670          0.8756         25.6479         26.1528         26.3892         26.0660
180035..................................................          1.4807          0.9590         31.0794         32.8461         34.0348         32.7266
180036..................................................          1.3287          0.9127         25.2972         25.6959         30.2621         27.0558
180037..................................................             ***               *         26.3132         27.8506         33.1874         29.1431
180038..................................................          1.5441          0.8764         26.0440         26.9752         28.2413         27.1328
180040..................................................          1.8313          0.9245         27.9979         28.5162         30.2450         28.9050
180043..................................................          1.1741          0.7978         20.9326         20.6439         24.0566         21.9172
180044..................................................          1.5998          0.8767         24.4569         25.8060         25.7978         25.3776
180045..................................................          1.3277          0.9590         27.4732         29.4127         29.9346         28.9840
180046..................................................          1.0026          0.8950         27.1034         27.0962         28.5552         27.5846
180048..................................................          1.3531          0.9123         23.9230         24.3696         24.6786         24.3395
180049..................................................          1.4067          0.8756         22.4769         24.3699         23.5737         23.4731
180050..................................................          1.1306          0.7919         26.3604         25.9557         26.7714         26.3675
180051..................................................          1.2266          0.8302         23.5299         24.3916         25.2356         24.4156
180053..................................................          0.9909          0.7837         21.3044         22.1921         23.0290         22.2290
180056..................................................          1.1314          0.8531         24.3074         24.5326         26.3959         25.0679
180064..................................................          1.2227          0.8151         17.1009         20.1799         21.9508         19.7362
180066..................................................          1.1136          0.9276         22.2713         23.7860         24.9530         23.6732
180067..................................................          1.9454          0.8950         26.0238         27.9852         29.6029         27.9902
180069..................................................          1.0930          0.8767         26.3701         26.6714         27.6777         26.8870

[[Page 23745]]

 
180070..................................................          1.1929          0.8077         20.6741         20.2189         21.3693         20.7657
180078..................................................          1.0594          0.8767         27.6806         28.2762         29.2125         28.3867
180079..................................................          1.1477          0.8096         20.2100         23.6005         24.9898         22.8630
180080..................................................          1.2693          0.7889         21.5818         23.7788         25.2996         23.5872
180087..................................................          1.2269          0.7837         20.8841         22.0302         22.1044         21.6767
180088..................................................          1.7069          0.9245         28.0916         28.6107         30.7936         29.1743
180092..................................................          1.1677          0.8950         23.7909         23.7866         25.2884         24.3103
180093..................................................          1.6170          0.8131         20.5807         21.4392         22.3324         21.4596
180095..................................................          1.0117          0.7837         17.9146         21.5639         21.2154         20.0750
180101..................................................          1.3146          0.8950         27.4506         28.1621         28.8758         28.2013
180102..................................................          1.5042          0.8302         21.0896         25.2343         27.3887         24.3942
180103..................................................          2.0473          0.8950         28.4583         28.1734         29.7626         28.8044
180104..................................................          1.5676          0.8302         25.6157         25.9689         27.1274         26.2415
180105..................................................          0.9511          0.7837         21.6002         23.1917         24.3659         23.0870
180106..................................................          0.8902          0.7837         20.2884         20.7220         21.2265         20.7447
180115..................................................          0.9040          0.7837         20.5539         20.3089         22.7088         21.1833
180116..................................................          1.1839          0.8320         23.5354         25.8927         26.8836         25.4592
180117..................................................          0.9408          0.7837         22.8469         24.7378         24.9567         24.2081
180124..................................................          1.3223          0.9276         24.8292         25.4664         27.1341         25.8362
180127..................................................          1.3584          0.9123         24.6774         26.3947         28.3610         26.4554
180128..................................................          0.9392          0.7837         22.6056         23.8144         23.7770         23.4109
180130..................................................          1.6779          0.9245         27.8900         29.1712         29.6725         28.9399
180132..................................................          1.4346          0.8756         24.5105         25.3789         29.0546         26.3805
180138..................................................          1.1879          0.9245         28.1901         28.6871         29.2584         28.7287
180139..................................................          1.0065          0.7837         23.3569         24.7575         26.2434         24.7763
180141..................................................          1.8666          0.9245         25.3357         27.5912         28.7307         27.2557
180143..................................................          1.6777          0.8950         28.1924         30.8734         28.2122         29.0557
180144..................................................             ***               *         29.5052               *               *         29.5052
180147..................................................             ***               *               *         31.1615               *         31.1615
180148..................................................             ***               *               *         30.1250               *         30.1250
180149..................................................          1.0087          0.7837               *               *         16.4909         16.4909
180150..................................................          1.8775          0.9245               *               *               *               *
190001..................................................          1.0903          0.7682         22.1394         22.1569         22.5328         22.2811
190002..................................................          1.5733          0.8438         23.3368         24.6984         25.9371         24.6300
190003..................................................          1.4214          0.8438         25.8294         26.7844         28.0895         26.9253
190004..................................................          1.5112          0.7870         25.3473         25.0803         24.6536         25.0228
190005..................................................          1.5223          0.9140         22.6029         24.2899         28.3303         24.2844
190006..................................................          1.2838          0.8438         22.7979         24.8836         25.2490         24.3632
190007..................................................          1.1753          0.7682         21.8205         23.1426         24.0527         23.0456
190008..................................................          1.7450          0.7870         24.6074         26.3638         27.2663         26.0087
190009..................................................          1.3606          0.8127         21.1005         24.0696         25.0269         23.3881
190011..................................................          1.0090          0.7961         21.4052         21.6991         21.9165         21.6827
190013..................................................          1.5563          0.7682         21.4573         23.7333         22.8372         22.6699
190014..................................................          1.2264          0.7682         22.7151         22.6405         24.5399         23.2756
190015..................................................          1.3070          0.9140         23.7789         25.1767         26.9572         25.3336
190017..................................................          1.4841          0.8438         24.5390         24.7537         25.5465         24.9732
190019..................................................          1.7201          0.8127         24.0468         25.4624         27.5462         25.7258
190020..................................................          1.2827          0.8142         22.1967         23.4602         24.2346         23.3365
190025..................................................          1.3344          0.7682         23.5007         24.5024         26.5944         24.8092
190026..................................................          1.6101          0.8127         23.7702         24.1556         25.3736         24.4572
190027..................................................          1.6236          0.7682         24.3006         26.7132         31.5026         27.4175
190034..................................................          1.2092          0.7871         20.7334         21.2130         22.9658         21.6044
190036..................................................          1.6604          0.9140         25.4164         25.6551         30.2172         26.9231
190037..................................................             ***               *         19.4071         20.7271         28.0447         21.7538
190039..................................................          1.5115          0.9140         24.4386         25.4003         24.6075         24.8194
190040..................................................          1.4212          0.9140         28.6297         28.0169         28.2426         28.2870
190041..................................................          1.4648          0.8547         28.5376         28.0050         28.7683         28.4375
190044..................................................          1.2898          0.7943         20.9993         21.2604         22.2461         21.5123
190045..................................................          1.5439          0.9140         25.8238         27.1996         27.5854         26.9044
190046..................................................          1.4309          0.9140         23.8552         24.7370               *         24.2936
190050..................................................          1.1484          0.7726         21.0259         20.9142         22.7951         21.5828
190053..................................................          1.2074          0.7783         17.9788         18.5819         20.6282         19.0432
190054..................................................          1.3250          0.7767         23.1471         22.7011         23.5129         23.1218
190060..................................................          1.4709          0.7682         23.7393         22.6291         19.8899         21.9229
190064..................................................          1.6110          0.8142         23.1358         23.7298         26.9941         24.6370
190065..................................................          1.5904          0.8142         22.1880         23.1202         22.9847         22.7749
190078..................................................          1.0906          0.7869         22.2431         22.2346         25.6940         23.4396

[[Page 23746]]

 
190079..................................................          1.1812          0.9140         24.0985         23.8192         25.3327         24.4472
190081..................................................          0.8736          0.7682         20.0121         21.4510         20.4101         20.6028
190086..................................................          1.2760          0.7785         22.0610         22.2895         22.2837         22.2151
190088..................................................          1.1378          0.8547         23.8562         23.1638         24.7445         23.9122
190090..................................................          1.0338          0.7682         23.1241         24.3303         25.8607         24.3672
190098..................................................          1.7595          0.8547         25.6854         25.7449         27.5043         26.3126
190099..................................................          1.0153          0.7871         22.0610         23.2343         25.7481         23.6613
190102..................................................          1.5441          0.8438         27.3126         26.9700         28.3071         27.5010
190106..................................................          1.1415          0.8127         23.5376         26.6227         24.2755         24.7510
190111..................................................          1.6311          0.8547         25.5729         26.5722         27.3180         26.5044
190114..................................................          1.0602          0.7682         17.2678         19.1586         20.3639         18.9135
190115..................................................          1.2209          0.8547         28.2066         26.0797         26.0278         26.7727
190116..................................................          1.1880          0.7767         22.3710         23.4013         24.2156         23.3424
190118..................................................          0.9844          0.8547         22.8809         21.2580         22.6571         22.2425
190122..................................................          1.4015          0.8142         22.0072         22.2371         22.8671         22.4040
190124..................................................             ***               *         26.0032         27.9484         28.6694         27.4838
190125..................................................          1.5711          0.7961         25.5463         24.8256         26.6254         25.6717
190128..................................................          1.0269          0.8142         28.3257         29.6682         31.1762         29.7845
190131..................................................          1.3325          0.8142         27.8465         28.6795         28.5938         28.3736
190133..................................................          0.9162          0.7784         18.2045         22.4311         23.9545         22.0666
190135..................................................          1.6174          0.9140         27.7540         30.5646         35.0524         30.2944
190140..................................................          0.9876          0.7717         18.9652         23.0485         23.6705         21.8176
190144..................................................          1.2672          0.8547         22.9181         23.7875         24.8858         23.8764
190145..................................................          0.9764          0.7772         19.9265         20.8579         21.3982         20.7221
190146..................................................          1.5575          0.9140         27.4824         28.7200         28.5963         28.2726
190151..................................................          0.9239          0.7682         18.7467         18.8391         20.6962         19.4061
190152..................................................          1.1740          0.9140         28.1334         30.8512         34.6485         30.9971
190158..................................................             ***               *         26.4787         30.6450         21.9727         27.7355
190160..................................................          1.5637          0.7961         22.9325         24.7822         25.8632         24.4460
190161..................................................          1.0278          0.7682         22.6187         22.9035         23.8066         23.1213
190162..................................................             ***               *         25.2953               *               *         25.2953
190164..................................................          1.1308          0.8127         25.2560         26.6207         27.7247         26.5855
190167..................................................          1.2763          0.8438         26.4669         25.3283         27.1969         26.3225
190175..................................................          1.2783          0.9140         26.0547         27.4256         30.5928         28.0066
190176..................................................          1.7856          0.9140         25.8826         26.2596               *         26.0715
190177..................................................          1.6464          0.9140         27.7792         28.2751         29.7229         28.5969
190182..................................................             ***               *         27.1682         29.8656         30.7038         29.2917
190183..................................................          1.2357          0.7870         22.6928         22.0119         23.3452         22.7038
190184..................................................          0.9592          0.7785         24.9476         24.1626         22.6137         23.9160
190185..................................................             ***               *         25.6394         28.9759         36.7292         29.7365
190190..................................................          0.9248          0.7843         24.3327         26.7043         27.5056         26.1460
190191..................................................          1.3760          0.8438         24.1923         26.1628         26.9649         25.7635
190196..................................................          0.9701          0.8438         24.0385         25.8472         27.7801         25.9541
190197..................................................             ***               *         25.8071         26.4825         28.7026         26.9781
190199..................................................          1.1052          0.8142         27.3304         32.0194         36.7076         31.6410
190200..................................................             ***               *         28.8173         27.4781               *         28.3200
190201..................................................          1.2572          0.7682         25.1010         24.4563         26.8537         25.4868
190202..................................................          1.5245          0.8142         27.6084         29.6612               *         28.6936
190203..................................................             ***               *         28.1832         29.9753               *         29.0343
190204..................................................          1.4475          0.9140         28.1033         30.5140         32.9125         30.3814
190205..................................................          1.6677          0.8438         26.6832         28.2484         30.1674         28.3935
190206..................................................          2.0426          0.9140         26.7401         29.2371         32.0163         29.3053
190208..................................................          0.8467          0.7682         28.7308         27.9908         24.9395         26.8779
190218..................................................          1.0293          0.8547         26.7262         28.1039         26.5243         27.0954
190236..................................................          1.4591          0.8547         24.7142         26.4614         26.9046         26.0708
190241..................................................          2.2461          0.7870         25.2123         25.7906         26.5307         25.8664
190242..................................................          1.1726          0.8142         24.8461         25.0035         26.9715         25.6625
190245..................................................          1.6582          0.7961         25.5751         26.7642         26.4147         26.2436
190246..................................................          1.8467          0.7843               *         22.7833         31.7133         27.5712
190247..................................................             ***               *         32.7499               *               *         32.7499
190248..................................................             ***               *         23.2220               *               *         23.2220
190249..................................................          1.7284          0.8142         20.0468         25.2523         27.0954         23.4238
190250..................................................          2.1126          0.9140         31.5101         33.3302         32.8347         32.5070
190251..................................................          1.3045          0.8142         21.4464         23.8389         25.1576         23.4538
190252..................................................             ***               *         23.6924               *               *         23.6924
190253..................................................             ***               *         22.8060         23.8037         22.2212         23.0780
190254..................................................             ***               *         32.9290               *               *         32.9290

[[Page 23747]]

 
190255..................................................          0.7692          0.8438         22.2412         16.1593         23.8013         20.1015
190256..................................................          0.8038          0.9140               *         25.9577         25.9352         25.9454
190257..................................................          1.6689          0.7785               *         26.5505         22.7493         24.6724
190258..................................................             ***               *         31.3715         26.1141         25.1970         27.3097
190259..................................................          2.0814          0.8438               *         26.5084         27.5500         27.0088
190260..................................................             ***               *               *         29.3947         33.6205         31.1711
190261..................................................          1.3897          0.7961               *         27.0441         25.4725         26.2680
190262..................................................             ***               *               *         30.3719               *         30.3719
190263..................................................          2.3211          0.8438               *         26.4202         29.7034         28.0032
190264..................................................             ***               *               *         26.5842               *         26.5842
190265..................................................             ***               *               *         22.6231         30.9242         27.1318
190266..................................................          2.3213          0.8142               *               *         24.3790         24.3790
190267..................................................          1.3728          0.9140               *               *         24.2777         24.2777
190268..................................................          1.6840          0.8438               *               *         29.1407         29.1407
190270..................................................          1.8665          0.9140               *               *               *               *
190272..................................................          1.2748          0.8438               *               *         28.4541         28.4541
190273..................................................          1.7599          0.8142               *               *               *               *
190274..................................................          1.6077          0.9140               *               *               *               *
190275..................................................          1.3329          0.9140               *               *               *               *
190276..................................................          0.8985          0.8547               *               *               *               *
190277..................................................          0.8585          0.8069               *               *               *               *
200001..................................................          1.3378          1.0115         25.2542         26.3045         28.1124         26.5658
200002..................................................          1.1591          0.8609         25.7212         27.1151         33.2665         28.3561
200008..................................................          1.3906          0.9927         27.7137         29.1836         29.3519         28.7769
200009..................................................          1.9207          0.9927         30.7510         32.5812         35.0717         32.7319
200018..................................................          1.3207          0.8609         23.5632         22.5027         24.6780         23.5929
200019..................................................          1.2779          0.9927         25.6649         27.7896         28.3393         27.2843
200020..................................................          1.3255          1.0007         32.6436         34.0916         34.5740         33.7902
200021..................................................          1.2204          0.9927         27.1381         29.2054         28.7597         28.4046
200024..................................................          1.6748          0.9644         27.5410         29.7817         30.9932         29.4721
200025..................................................          1.1710          0.9927         26.3124         28.5750         29.3588         28.1289
200031..................................................          1.3018          0.8609         21.2370         22.2151         23.7539         22.4062
200032..................................................          1.1782          0.9075         26.3322         26.8993         27.2259         26.8277
200033..................................................          1.8241          1.0115         29.3108         31.7007         33.6270         31.6171
200034..................................................          1.3255          0.9644         27.0582         27.0103         28.0397         27.3625
200037..................................................          1.1982          0.8609         24.1732         24.9418         26.7798         25.3841
200039..................................................          1.2970          0.9644         25.1179         26.6409         28.8029         26.8816
200040..................................................          1.2039          0.9927         25.9893         27.8053         25.5506         26.3685
200041..................................................          1.2079          0.8609         24.9670         26.6777         27.5049         26.3961
200050..................................................          1.2398          1.0115         27.6825         29.5033         30.1456         29.1592
200052..................................................          1.1153          0.8609         22.5159         24.4204         25.6220         24.1936
200063..................................................          1.1834          0.8609         25.8623         27.9748         28.2184         27.3991
210001..................................................          1.3549          0.9460         28.2858         29.3471         31.2328         29.6476
210002..................................................          1.9987          0.9981         32.3005         33.7388         36.0222         34.1104
210003..................................................          1.6222          1.0670         34.1109         30.7334         28.2547         30.8148
210004..................................................          1.4250          1.1018         33.6056         31.7132         33.9015         33.0686
210005..................................................          1.2610          1.1018         28.9554         29.5835         32.4052         30.3394
210006..................................................          1.0725          0.9981         25.9005         27.3620         27.9844         27.0796
210007..................................................          1.7994          0.9981         31.8767         30.7124         31.4098         31.3077
210008..................................................          1.4105          0.9981         24.3341         28.8850         31.8512         28.2947
210009..................................................          1.6490          0.9981         27.7900         30.2661         31.8249         29.9840
210011..................................................          1.3847          0.9981         30.8575         31.0966         30.7517         30.9025
210012..................................................          1.5973          0.9981         30.3078         31.1778         32.5280         31.3781
210013..................................................          1.1768          0.9981         28.5328         28.9917         32.1151         29.7726
210015..................................................          1.2997          0.9981         29.9261         32.2774         31.6875         31.3239
210016..................................................          1.6120          1.1018         32.3506         33.5493         35.3218         33.6933
210017..................................................          1.2904          0.8795         25.1890         26.8592         26.6187         26.2235
210018..................................................          1.2011          1.1018         29.5533         29.6521         31.5431         30.2539
210019..................................................          1.7205          0.9194         27.3731         28.7844         30.5458         28.9499
210022..................................................          1.4645          1.1018         35.4727         37.3092         36.1806         36.3038
210023..................................................          1.4878          1.0060         32.1812         33.0212         34.1635         33.1583
210024..................................................          1.8236          0.9981         30.6359         32.9434         34.5523         32.7596
210025..................................................          1.2388          0.8795         23.8552         24.8570         23.5138         24.0665
210027..................................................          1.4130          0.8795         24.6343         24.4821         25.2106         24.7916
210028..................................................          1.0692          0.9307         26.3469         26.7462         28.5196         27.2373
210029..................................................          1.2751          0.9981         31.0266         31.8539         32.9078         31.9592
210030..................................................          1.1883          0.8795         26.9763         32.2033         29.1777         29.4507

[[Page 23748]]

 
210032..................................................          1.1828          1.0645         27.0727         27.9359         29.2770         28.1114
210033..................................................          1.1640          0.9981         28.5534         29.2504         28.4332         28.7353
210034..................................................          1.2631          0.9981         30.2908         32.3827         33.0382         31.9423
210035..................................................          1.3018          1.0670         28.6484         27.3901         30.6664         28.8614
210037..................................................          1.2037          0.8795         27.3287         27.8394         28.8691         28.0163
210038..................................................          1.1889          0.9981         29.8121         32.3206         31.1537         31.0730
210039..................................................          1.1193          1.0670         30.4991         32.4139         35.1146         32.6902
210040..................................................          1.2216          0.9981         28.3559         29.2390         31.0827         29.5738
210043..................................................          1.3058          1.0060         26.6524         32.6961         29.2744         29.4113
210044..................................................          1.3653          0.9981         29.7339         30.3349         31.5436         30.5467
210045..................................................          0.9952          0.9194         14.2223         16.3724         19.6097         16.8133
210048..................................................          1.3768          0.9981         27.5043         26.0650         29.2439         27.5592
210049..................................................          1.2275          0.9981         26.0900         27.0161         28.5947         27.3346
210051..................................................          1.2948          1.0670         29.8892         29.5219         30.7936         30.0807
210054..................................................          1.2558          1.0670         27.4328         27.7607         28.6884         27.9549
210055..................................................          1.2394          1.0670         30.6941         31.4905         30.1989         30.7527
210056..................................................          1.3104          0.9981         30.0810         32.3518         32.7755         31.8047
210057..................................................          1.3542          1.1018         31.6787         32.8299         33.7244         32.7501
210058..................................................          1.1208          0.9981         31.0873         31.1988         32.0642         31.4531
210060..................................................          1.2448          1.0670         27.1764         29.9626         32.5116         29.9224
210061..................................................          1.2566          0.8983         23.1645         25.0253         26.6822         25.0230
220001..................................................          1.2273          1.1338         30.6070         31.2316         32.0820         31.3057
220002..................................................          1.3729          1.1338         32.4356         33.6649         35.9738         34.0706
220006..................................................             ***               *         30.7673         33.6438               *         32.1319
220008..................................................          1.2887          1.1338         31.3385         34.7924         35.8651         34.0329
220010..................................................          1.2326          1.1338         30.7804         32.0925         33.7364         32.2148
220011..................................................          1.1369          1.1338         34.7655         36.5640         39.1211         36.8964
220012..................................................          1.4655          1.2672         37.8763         39.7564         41.7040         39.8247
220015..................................................          1.2984          1.0343         29.6315         32.4903         35.2353         32.4365
220016..................................................          1.1282          1.0343         30.4813         32.5863         33.1404         32.0656
220017..................................................          1.3194          1.1994         31.6170         33.3020         34.6550         33.1982
220019..................................................          1.0429          1.1338         24.4009         25.7855         26.3006         25.5037
220020..................................................          1.1312          1.1338         28.5288         30.8458         32.1503         30.5508
220024..................................................          1.2349          1.0343         28.7342         31.9491         32.8073         31.1791
220025..................................................          1.0377          1.1338         25.6478         30.4369         27.6958         27.7639
220028..................................................             ***               *         31.7122         39.3089               *         35.2808
220029..................................................          1.1472          1.1338         30.6935         31.6363         32.6767         31.6963
220030..................................................          1.1059          1.0343         26.8849         28.1347         29.3701         28.1501
220031..................................................          1.5532          1.1994         36.8477         38.9433         39.4182         38.4392
220033..................................................          1.1976          1.1338         31.8249         32.3495         34.6977         33.0203
220035..................................................          1.4173          1.1338         31.4470         34.8739         36.1775         35.0964
220036..................................................          1.5119          1.1994         33.1436         35.9124         37.7268         35.6257
220046..................................................          1.4449          1.0445         30.4460         31.4510         33.8585         31.9500
220049..................................................          1.2309          1.1338         30.4740         32.4652         35.1108         32.7132
220050..................................................          1.0897          1.0343         28.3434         29.5194         30.3160         29.4110
220051..................................................          1.3081          1.0199         30.2552         30.1022         32.8672         31.0914
220052..................................................          1.1432          1.1994         32.4130         32.3532         34.9126         33.2019
220058..................................................          1.0116          1.1338         25.7247         27.8893         30.0325         27.9127
220060..................................................          1.1603          1.1994         32.5477         34.7336         36.8641         34.7665
220062..................................................          0.6341          1.1338         25.0766         25.4224         27.3304         25.9567
220063..................................................          1.2647          1.1338         30.2866         32.9283         32.2417         31.8295
220065..................................................          1.2613          1.0343         27.6009         30.1103         32.3793         30.0468
220066..................................................          1.3284          1.0343         27.8073         29.9736               *         28.8792
220067..................................................          1.2302          1.1994         30.2222         32.4019         33.9807         32.2180
220070..................................................          1.1429          1.1338         33.1299         34.2598         35.6244         34.3611
220071..................................................          1.8365          1.1994         36.5065         37.4087         40.0281         38.0115
220073..................................................          1.1896          1.1338         34.2989         36.0289         37.4224         35.9320
220074\4\...............................................          1.3507          1.1338         30.5607         31.4730         33.2051         31.7041
220B74\4\...............................................             ***               *               *         31.4731         33.2051         32.3862
220075..................................................          1.5438          1.1994         30.9175         32.2957         33.3538         32.1942
220076..................................................             ***               *         27.5148               *               *         27.5148
220077..................................................          1.6655          1.0972         31.7325         34.0168         33.7563         33.1765
220080..................................................          1.1645          1.1338         29.9595         31.1268         33.1617         31.3799
220082..................................................          1.2899          1.1338         30.0611         30.8230         32.2105         31.0609
220083..................................................          1.0693          1.1994         34.5118         34.5969         35.2728         34.8205
220084..................................................          1.2134          1.1338         30.9527         31.6955         34.6254         32.3748
220086..................................................          1.7222          1.1994         34.2388         35.3451         36.2359         35.3173

[[Page 23749]]

 
220088..................................................          1.9446          1.1994         35.8255         34.7637         37.0808         35.9288
220089..................................................             ***               *         32.6305         34.8205               *         33.7125
220090..................................................          1.2394          1.1338         32.9011         34.1963         35.8940         34.3697
220095..................................................          1.1576          1.1338         28.0673         30.8626         31.1619         30.0333
220098..................................................          1.1400          1.1338         30.5869         31.5403         30.6593         30.9378
220100..................................................          1.3072          1.1994         31.9859         34.6599         35.7276         34.1807
220101..................................................          1.2971          1.1338         35.3464         37.7809         36.0984         36.4336
220105..................................................          1.1814          1.1338         33.2625         34.4029         35.8155         34.5228
220108..................................................          1.1999          1.1994         32.6131         33.8854         35.6985         34.0752
220110..................................................          2.0011          1.1994         39.2167         40.7382         43.8401         41.3123
220111..................................................          1.2206          1.1994         33.6167         34.2498         35.6193         34.5167
220116..................................................          1.8714          1.1994         36.4149         38.8799         40.0952         38.4127
220119..................................................          1.1333          1.1994         30.9965         32.0863         33.7174         32.3365
220126..................................................          1.1806          1.1994         31.4882         32.6938         35.6250         33.2716
220133..................................................             ***               *         29.4855         34.9182               *         32.1170
220135..................................................          1.3038          1.2672         36.0203         37.5189         38.7180         37.4435
220153..................................................             ***               *               *         19.8085         17.9600         18.7803
220154..................................................             ***               *               *         28.7898               *         28.7898
220162..................................................          1.5970               *               *               *               *               *
220163..................................................          1.6172          1.1338         34.4874         37.4968         39.4859         37.2285
220171..................................................          1.6935          1.1338         32.7414         35.9948         36.4545         35.0735
220174..................................................          1.1926          1.1338         30.0406         30.9503         32.9113         31.3266
220175..................................................          1.2681               *               *               *         34.1550         34.1550
220176..................................................          1.6474          1.1338               *               *         31.4195         31.4195
230002..................................................          1.3237          1.0113         32.9010         32.7578         33.9675         33.2532
230003..................................................          1.2416          0.9455         27.5824         28.4716         28.9871         28.3360
230004..................................................          1.7110          1.0227         29.3934         31.5136         33.4620         31.5262
230005..................................................          1.2402          0.9337         25.8768         27.7463         29.0625         27.5854
230013..................................................          1.3836          1.0052         24.6511         27.2075         28.6417         26.7586
230015..................................................          1.1593          0.9159         26.2782         27.2541         28.9588         27.5253
230017..................................................          1.6518          1.0910         31.8821         32.5396         36.8018         33.8177
230019..................................................          1.6077          1.0052         32.3401         34.3213         35.1415         33.9317
230020..................................................          1.7476          1.0113         28.5646         29.5324         29.9072         29.3527
230021..................................................          1.5495          1.0365         26.5659         28.6169         29.5397         28.2368
230022..................................................          1.2686          0.9652         25.6683         30.1195         25.7829         27.0325
230024..................................................          1.6538          1.0113         32.1483         32.5892         34.5253         33.1061
230029..................................................          1.6160          1.0052         32.3538         32.3845         33.1460         32.6277
230030..................................................          1.2847          0.8864         23.8082         25.1100         24.9719         24.6466
230031..................................................          1.3571          0.9972         29.7232         30.0120         30.8859         30.2337
230034..................................................          1.3764          0.8864         24.4845         24.4141         29.1079         25.8635
230035..................................................          1.1994          0.9305         24.8822         25.6715         25.7083         25.4572
230036..................................................          1.4140          0.9472         29.3754         29.9642         31.0922         30.1636
230037..................................................          1.3059          1.0113         28.9244         28.5311         28.8529         28.7691
230038..................................................          1.7649          0.9455         28.2012         29.1263         30.1019         29.1994
230040..................................................          1.1794          0.9305         25.5154         26.3190         27.2835         26.3819
230041..................................................          1.5803          0.9472         27.8853         27.9569         30.3060         28.7057
230046..................................................          1.9162          1.0444         31.6235         32.2924         33.5285         32.5197
230047..................................................          1.4494          1.0052         31.1771         31.7075         32.0225         31.6475
230053..................................................          1.6700          1.0113         32.5711         32.1566         33.5420         32.7704
230054..................................................          1.8803          0.9412         25.7591         26.3251         28.1223         26.7475
230055..................................................          1.2587          0.8864         27.4349         28.4787         28.1872         28.0393
230058..................................................          1.1167          0.8864         25.9291         27.3156         27.9625         27.0813
230059..................................................          1.5346          0.9455         27.9091         28.5875         28.3586         28.2947
230060..................................................          1.2934          0.8864         28.2874         27.0288         28.7744         28.0391
230065..................................................             ***               *         32.6255               *               *         32.6255
230066..................................................          1.3058          1.0227         30.6184         30.2104         32.3459         31.0702
230069..................................................          1.1826          1.0810         30.2663         31.3406         31.9653         31.2223
230070..................................................          1.6502          0.9034         25.6778         26.8315         28.0349         26.8663
230071..................................................          0.9448          1.0052         28.3064         29.6728         28.2055         28.7253
230072..................................................          1.3622          0.9455         26.2838         27.4742         28.8006         27.5408
230075..................................................          1.3557          1.0086         28.2540         30.9525         32.1146         30.4322
230077..................................................          1.8799          1.0810         29.8538         30.5567         31.0097         30.4726
230078..................................................          1.1903          0.8864         25.6809         25.7232         27.0050         26.0991
230080..................................................          1.2607          0.9472         24.1573         24.5432         25.6193         24.7905
230081..................................................          1.2326          0.8864         24.7374         26.4337         27.8091         26.3288
230085..................................................          1.2326          1.0910         23.4959         25.4289         27.6459         25.5347
230089..................................................          1.3435          1.0113         31.0522         32.8450         32.2293         31.9436

[[Page 23750]]

 
230092..................................................          1.3964          1.0113         28.6829         29.3442         30.5399         29.5449
230093..................................................          1.2159          0.8922         25.5804         27.4463         27.0555         26.7238
230095..................................................          1.2754          0.9472         22.8681         25.1854         25.9196         24.6699
230096..................................................          1.1779          1.0365         30.6024         31.7399         27.7873         29.8976
230097..................................................          1.6913          0.9305         28.2526         29.8962         31.5152         29.8782
230099..................................................          1.2173          1.0113         29.0221         29.3720         28.7386         29.0351
230100..................................................          1.1914          0.8864         24.1881         25.2118         25.6583         25.0492
230101..................................................          1.1683          0.8864         25.4839         28.4372         28.8595         27.6204
230104\5\...............................................          1.5934          1.0113         32.4634         32.4125         34.0171         32.9570
230B04\5\...............................................             ***               *               *               *         34.0171         34.0171
230105..................................................          1.7842          0.9472         32.4583         30.5515         32.1103         31.7057
230106..................................................          1.2381          0.9455         25.3243         27.8584         30.0195         27.7687
230108..................................................          1.1549          0.8864         20.2539         24.4337         25.7463         23.4436
230110..................................................          1.2539          0.8864         27.0040         25.7196         27.0263         26.5809
230117..................................................          1.8415          1.0910         32.7994         33.0602         33.9148         33.2761
230118..................................................          1.0095          0.8864         23.6110         24.8890         24.8631         24.4400
230119..................................................          1.4381          1.0113         30.7488         31.9696         33.2026         32.0127
230121..................................................          1.2621          0.9652         26.4940         26.8361         27.7495         27.0478
230130..................................................          1.6817          1.0052         30.1608         31.2744         32.5589         31.3612
230132..................................................          1.5413          1.1258         32.3939         35.5304         38.2428         35.3551
230133..................................................          1.4288          0.8864         23.9442         25.0647         25.8516         24.9772
230135..................................................          1.3171          1.0113         25.9583         23.6005         31.5185         26.7530
230141..................................................          1.6173          1.1258         31.6152         33.2553         36.3094         33.7170
230142..................................................          1.2688          1.0113         27.8377         29.7417         29.9882         29.2232
230144..................................................          1.8275          1.0444               *               *               *               *
230146..................................................          1.3735          1.0113         26.8156         27.2621         29.0197         27.7279
230151..................................................          1.3314          1.0052         27.4546         29.8366         28.6704         28.6311
230156..................................................          1.5950          1.0444         32.3755         33.9034         34.7840         33.7042
230165..................................................          1.5974          1.0113         29.6376         31.4242         32.2831         31.1343
230167..................................................          1.6088          0.9899         29.8071         31.0657         32.8063         31.2488
230174..................................................          1.3451          0.9455         30.0563         29.7488         31.2452         30.3405
230176..................................................          1.3115          1.0113         28.1498         28.9798         29.2664         28.8186
230180..................................................          1.1167          0.8864         26.0707         24.9696         24.6000         25.1971
230184..................................................             ***               *         34.6295               *               *         34.6295
230190..................................................             ***               *         30.7875         33.8229         33.6707         32.7904
230193..................................................          1.3561          0.9972         25.1626         26.4728         28.4624         26.7218
230195..................................................          1.4319          1.0052         29.5656         30.9702         32.5528         31.0477
230197..................................................          1.6021          1.1258         32.0063         33.7128         34.8039         33.5209
230204..................................................          1.4349          1.0052         31.5615         32.2882         30.1956         31.3391
230207..................................................          1.2451          1.0052         25.4268         25.1983         26.8215         25.8117
230208..................................................          1.2210          0.9305         23.7523         24.3476         25.2472         24.4569
230212..................................................          1.0426          1.0444         31.9818         32.8567         33.4362         32.7601
230216..................................................          1.4778          0.9972         29.0147         29.2061         28.9567         29.0586
230217..................................................          1.4015          1.0086         30.1136         31.9732         33.0815         31.7828
230222..................................................          1.4250          0.9472         29.9341         30.6482         32.4389         30.9827
230223..................................................          1.3052          1.0052         28.6745         29.8430         31.9496         30.1361
230227..................................................          1.4799          1.0052         30.8218         33.6716         34.2728         32.7518
230230..................................................          1.4804          0.9899         29.8763         31.1712         31.4931         30.8595
230236..................................................          1.5428          0.9455         31.3110         30.8556         31.9088         31.3744
230239..................................................          1.3021          0.8864         21.0814         22.1579         23.5448         22.2557
230241..................................................          1.1943          0.9972         27.6106         28.5516         30.0233         28.7406
230244..................................................          1.4607          1.0113         29.6283         30.0405         32.1407         30.6177
230254..................................................          1.4847          1.0052         29.2653         29.5874         31.2379         30.0646
230257..................................................          0.9794          1.0052         29.6712         30.6372         30.0667         30.1067
230259..................................................          1.2691          1.0444         27.4217         27.5982         27.9557         27.6540
230264..................................................          2.0641          1.0052         22.7768         28.5416         29.2178         26.4132
230269..................................................          1.4701          1.0052         31.3226         31.3800         34.2667         32.3991
230270..................................................          1.3480          1.0113         28.5372         28.8173         29.2388         28.8712
230273..................................................          1.4692          1.0113         31.9862         31.5396         32.5706         32.0372
230275..................................................          0.5428          0.9034         23.8104         25.2133         22.3717         23.7470
230277..................................................          1.4612          1.0052         29.8372         31.4023         32.2518         31.1889
230279..................................................          0.5480          1.0810         27.2816         27.9726         26.8539         27.3521
230283..................................................             ***               *         33.5531               *               *         33.5531
230294..................................................             ***               *         31.6195               *               *         31.6195
230295..................................................             ***               *         27.1298               *               *         27.1298
230296..................................................             ***               *               *         34.2107               *         34.2107
230297..................................................          1.6971          1.0052               *               *               *               *

[[Page 23751]]

 
230298..................................................          0.7864          1.0052               *               *               *               *
230300..................................................          3.3739          1.0052               *               *               *               *
230301..................................................          1.0374          1.0052               *               *               *               *
240001..................................................          1.5531          1.0997         33.1499         34.7673         37.2179         35.0462
240002..................................................          1.8744          1.0519         31.6000         33.1051         34.6345         33.1529
240004..................................................          1.5878          1.0997         32.7010         32.5777         33.5085         32.9298
240006..................................................          1.2147          1.0982         31.0777         33.4777         32.8229         32.4953
240010..................................................          1.9657          1.0982         33.4668         32.7261         35.9102         34.0521
240014..................................................          1.0726          1.0997         29.8905         30.7519         33.4476         31.3959
240017..................................................             ***               *         24.3596               *               *         24.3596
240018..................................................          1.2598          0.9925         28.1432         29.4995         30.5632         29.4372
240019..................................................          1.0353          1.0519         33.7546         32.7052         34.2538         33.5836
240020..................................................          1.1144          1.0997         31.3874         33.2449         34.5686         33.0762
240022..................................................          1.0632          0.9120         26.1920         27.3137         28.5889         27.3645
240030..................................................          1.3950          1.0638         26.5508         27.1312         27.6584         27.1136
240036..................................................          1.6415          1.0997         32.7028         34.2980         37.2177         34.8308
240038..................................................          1.4964          1.0997         31.9891         33.0554         34.7330         33.2508
240040..................................................          1.0575          1.0519         27.5074         28.9009         30.0238         28.8059
240043..................................................          1.2453          0.9120         23.3489         24.0708         25.7420         24.4201
240044..................................................          1.0841          0.9745         25.0988         26.8681         28.5689         26.7906
240047..................................................          1.5230          1.0519         28.6406         29.7835         35.6742         31.1184
240050..................................................          1.0910          1.0997         27.5553         30.9805         33.7946         30.9171
240052..................................................          1.2031          0.9120         28.7206         29.4617         31.0917         29.7873
240053..................................................          1.5039          1.0997         31.4324         33.1148         34.4186         33.0264
240056..................................................          1.3585          1.0997         33.1728         34.0845         35.8580         34.4096
240057..................................................          1.7902          1.0997         30.7703         33.4713         34.8349         33.0717
240059..................................................          1.0937          1.0997         31.0911         32.4803         32.5938         32.0866
240061..................................................          1.8510          1.0982         33.1799         32.0828         34.6008         33.3406
240063..................................................          1.5799          1.0997         33.7895         35.2877         36.9798         35.4057
240064..................................................          1.1730          1.0401         34.3757         27.2407         29.9902         30.4614
240066..................................................          1.5245          1.0997         35.3441         36.0705         39.6582         37.0745
240069..................................................          1.1972          1.0997         29.3718         30.9719         31.1660         30.5144
240071..................................................          1.1037          1.0997         28.6950         31.7754         32.5442         30.9915
240075..................................................          1.1903          1.0638         27.5039         29.1171         30.3218         29.0129
240076..................................................          1.0213          1.0997         30.6936         33.1439         33.7939         32.5944
240078..................................................          1.6519          1.0997         32.5785         34.6118         36.1976         34.5440
240080..................................................          1.9537          1.0997         32.5725         34.8064         36.5363         34.6282
240084..................................................          1.1356          1.0519         26.5975         27.0995         29.0260         27.5332
240088..................................................          1.2998          1.0638         28.0603         29.1387         30.7223         29.3333
240093..................................................          1.4599          1.0997         27.2928         29.1717         30.4718         29.0677
240100..................................................          1.3409          0.9120         30.8391         31.5774         30.9460         31.1194
240101..................................................          1.1984          0.9120         25.6963         26.8849         28.5492         27.1176
240104..................................................          1.2063          1.0997         31.6511         35.0736         35.8816         34.3219
240106..................................................          1.6106          1.0997         30.5927         32.8156         33.9953         32.4894
240115..................................................          1.4822          1.0997         32.0107         33.5288         36.2755         33.9354
240117..................................................          1.1647          0.9647         24.5750         27.6950         29.0889         27.1230
240128..................................................             ***               *         23.3334               *               *         23.3334
240132..................................................          1.2651          1.0997         32.1233         34.6191         36.4224         34.2571
240141..................................................          1.1039          1.0997         31.4468         32.8689         34.2453         32.8961
240166..................................................          1.1593          0.9120         27.6987         26.5328         26.1726         26.6670
240187..................................................          1.2972          1.0997         27.8844         29.1582         30.9633         29.4012
240196..................................................          0.8466          1.0997         31.5965         34.3743         35.0319         33.6757
240206..................................................          0.9236          1.4448               *               *               *               *
240207..................................................          1.2383          1.0997         32.5589         34.6792         36.4537         34.6384
240210..................................................          1.2823          1.0997         32.7123         34.4184         36.5922         34.6233
240211..................................................          1.0511          0.9932         22.5430         17.4044         16.6144         18.6322
240213..................................................          1.4161          1.0997         33.8680         35.7818         37.4575         35.7765
250001..................................................          1.9650          0.8095         23.5222         23.7773         24.3386         23.8768
250002..................................................          0.9549          0.7883         23.4063         25.4201         25.0335         24.6387
250004..................................................          1.7720          0.8909         24.7907         25.8722         24.8072         25.1647
250006..................................................          1.1563          0.8909         24.4282         25.9199         27.0493         25.8303
250007..................................................          1.2323          0.8898         24.8929         27.7665         29.3457         27.3747
250009..................................................          1.2588          0.8361         23.0352         23.4866         24.9100         23.8155
250010..................................................          1.0456          0.7653         21.4322         21.8665         22.7976         22.0351
250012..................................................          0.9464          0.9329         21.5540         23.4837         26.4108         23.6996
250015..................................................          1.1829          0.7653         22.0067         22.2803         22.3674         22.2133
250017..................................................          1.0987          0.7653         22.7660         33.6840         25.7397         26.7933

[[Page 23752]]

 
250018..................................................          0.8867          0.7653         17.1276         17.9025         19.1099         18.0552
250019..................................................          1.5607          0.8898         25.7376         26.2199         27.7207         26.5559
250020..................................................          1.0028          0.7653         22.1851         23.7245         23.1510         23.0478
250023..................................................          0.8728          0.8156         18.0108         18.5067         19.5072         18.7146
250025..................................................          1.1390          0.7653         22.5621         23.1738         23.0544         22.9290
250027..................................................          0.9541          0.7653         24.4937         26.9922         32.5430         27.8433
250031..................................................          1.3451          0.8095         24.8139         25.9189         26.7496         25.8093
250034..................................................          1.5368          0.8909         26.1887         26.7996         27.9267         26.9950
250035..................................................          0.8649          0.7653         20.1622         19.1038         20.5237         19.9107
250036..................................................          1.0485          0.8030         20.3625         19.7951         22.5661         20.8304
250038..................................................          0.9523          0.8095         22.2571         26.9621         30.7941         25.9485
250040..................................................          1.4898          0.8156         24.5962         27.3366         26.2250         26.0460
250042..................................................          1.2547          0.8909         25.6807         26.1190         27.4593         26.4125
250043..................................................          0.9847          0.7653         18.8979         20.8841         21.1254         20.3156
250044..................................................          1.0363          0.7883         24.0508         24.9199         26.1725         25.0759
250048..................................................          1.6491          0.8095         25.2092         24.7659         27.6318         25.8347
250049..................................................          0.8715          0.7653         19.1044         20.4775         24.2222         21.0940
250050..................................................          1.3084          0.7653         20.8084         21.1657         22.4407         21.4799
250051..................................................          0.8661          0.7653         14.3741         13.9532         14.1652         14.1687
250057..................................................          1.1739          0.7653         22.7601         24.3654         22.9665         23.3314
250058..................................................          1.2366          0.7653         19.2502         18.9970         19.6711         19.3080
250059..................................................          0.9358          0.7653         23.8997         26.7491         25.5976         25.3587
250060..................................................          0.8110          0.7653         28.1431         25.4779         27.0347         26.8919
250061..................................................          0.8867          0.7653         17.8267         18.7413         25.1493         20.4689
250067..................................................          1.0949          0.7653         23.1193         25.2189         23.8020         24.0644
250069..................................................          1.4416          0.8280         22.6353         22.4194         23.4494         22.8355
250072..................................................          1.6783          0.8095         25.8399         25.5337         27.5770         26.3178
250077..................................................          0.9717          0.7653         18.3735         19.0416         19.6329         19.0451
250078..................................................          1.5855          0.8156         22.1243         22.8430         23.9580         22.9829
250079..................................................          0.8932          0.7653         45.5166         43.0845         46.0338         44.8458
250081..................................................          1.3682          0.8280         23.9995         25.6808         24.8259         24.8305
250082..................................................          1.4127          0.8150         23.0287         23.5399         25.6206         24.1469
250084..................................................          1.2526          0.7653         19.6492         19.1604         19.5676         19.4638
250085..................................................          1.0182          0.7653         22.5513         24.2915         24.6743         23.8551
250093..................................................          1.1850          0.7653         23.0984         23.9128         26.4337         24.4984
250094..................................................          1.6982          0.8156         24.1422         24.7718         25.4215         24.7893
250095..................................................          1.0314          0.7653         21.7488         23.6140         25.9001         23.7842
250096..................................................          1.2042          0.8095         24.9187         26.3743         27.7270         26.3759
250097..................................................          1.4899          0.8146         21.8139         22.0211         22.7899         22.2472
250099..................................................          1.2725          0.8095         21.1269         21.5656         27.5739         23.2182
250100..................................................          1.5271          0.8280         25.6846         27.0286         27.5468         26.7620
250102..................................................          1.5947          0.8095         24.6652         25.4050         25.5308         25.2035
250104..................................................          1.4396          0.8280         23.4303         24.4311         25.3986         24.4448
250112..................................................          0.9616          0.7653         24.3069         26.3357         27.4138         26.0536
250117..................................................          1.1581          0.8156         22.2450         23.7337         24.5692         23.5009
250120..................................................             ***               *         24.6370         26.6522               *         25.6905
250122..................................................          1.1272          0.7653         27.2795         27.4424         23.4884         26.0511
250123..................................................          1.3504          0.8898         26.6221         27.9058         29.8280         28.1116
250124..................................................          0.8367          0.8095         20.4394         20.5667         21.9411         20.9862
250125..................................................          1.3788          0.8898         27.5158         26.7687         32.7395         28.5834
250126..................................................          1.0192          0.9329         24.4126         25.0019         25.2582         24.9087
250127..................................................          0.8041          1.4448               *               *               *               *
250128..................................................          0.9631          0.8099         17.7624         21.7882         23.5915         21.3639
250134..................................................          0.9291          0.8095         22.2167         21.0211         22.0830         21.7636
250136..................................................          1.0279          0.8095         22.9468         25.2241         27.1454         25.0260
250138..................................................          1.3091          0.8095         24.3018         25.2642         27.3114         25.5721
250141..................................................          1.4795          0.9329         28.5922         30.5112         33.4397         31.0006
250149..................................................          0.8769          0.7653         16.8796         17.2268         17.0956         17.0712
250151..................................................          0.5535          0.7653         18.8846         22.8238               *         19.4286
250152..................................................          0.8224          0.8095         26.9334         26.4559         28.5527         27.2309
250155..................................................             ***               *         22.5728               *               *         22.5728
250156..................................................             ***               *               *         16.8659               *         16.8659
250157..................................................             ***               *               *         29.6398               *         29.6398
250162..................................................          1.0520          0.8912               *               *               *               *
260001..................................................          1.6886          0.9704         27.9230         29.5271         31.1839         29.5270
260004..................................................          0.9098          0.8470         20.3217         21.3629         24.1888         22.1072
260005..................................................          1.5296          0.8986         27.7855         27.9477         31.1215         28.9388

[[Page 23753]]

 
260006..................................................          1.4493          0.8470         30.3440         27.3754         33.7767         30.5981
260009..................................................          1.2153          0.9444         24.2360         25.7546         26.6670         25.5689
260011..................................................          1.5894          0.9038         25.6387         27.5762         31.2590         28.1581
260015..................................................          1.0293          0.8470         24.6139         25.0640         25.0244         24.8950
260017..................................................          1.3008          0.8736         23.5713         25.0461         26.2612         24.9757
260020..................................................          1.7335          0.8986         27.4730         29.3080         30.9576         29.2687
260021..................................................          1.3073          0.8986         29.3646         32.6735         19.4693         25.9620
260022..................................................          1.3246          0.8738         23.3393         24.8713         25.9379         24.7192
260023..................................................          1.3719          0.8986         24.3192         25.4314         25.5884         25.1233
260024..................................................          1.1889          0.8470         19.4952         19.2199         20.7131         19.8199
260025..................................................          1.3981          0.8986         22.2451         24.0358         24.5032         23.6143
260027..................................................          1.6154          0.9444         26.3590         29.3811         31.0217         28.7832
260032..................................................          1.8506          0.8986         25.6763         27.4857         28.7163         27.3241
260034..................................................          1.0142          0.9444         25.0573         27.1685         28.7725         27.0780
260040..................................................          1.7140          0.8470         24.3938         25.9074         27.2449         25.8128
260047..................................................          1.4348          0.8470         25.4978         26.6343         27.2646         26.4797
260048..................................................          1.1808          0.9444         27.6117         28.1515         29.6955         28.5297
260050..................................................          1.1398          1.0267         25.0506         26.2346         27.8050         26.4419
260052..................................................          1.3065          0.8986         26.0052         27.6360         29.6982         27.7827
260057..................................................          1.0872          0.9444         20.9639         21.5925         23.8167         22.1481
260059..................................................          1.2943          0.8547         22.6922         22.3885         24.9630         23.3714
260061..................................................          1.1720          0.8470         22.4766         22.8589         23.6708         22.9805
260062..................................................          1.2709          0.9444         28.1661         28.4975         29.6135         28.7754
260064..................................................          1.3641          0.8470         22.2395         23.3498         21.4934         22.3902
260065..................................................          1.7935          0.8470         27.1014         29.3564         27.9224         28.1492
260068..................................................          1.7301          0.8470         26.0295         27.3475         28.1227         27.1642
260070..................................................          0.9682          0.8470         24.6331         21.9701         25.2991         24.0399
260074..................................................          1.2162          0.8470         25.6218         28.0468         28.6203         27.4572
260077..................................................          1.6229          0.8986         26.7466         27.6624         28.7183         27.7262
260078..................................................          1.2711          0.8470         20.1983         21.1539         23.1780         21.5534
260080..................................................          1.0066          0.8470         17.9107         18.6070         18.6804         18.3878
260081..................................................          1.4925          0.8986         28.1182         29.1890         32.3581         29.9070
260085..................................................          1.5513          0.9444         26.6718         28.0306         29.6492         28.1046
260091..................................................          1.4867          0.8986         28.0537         28.5473         30.1154         28.9182
260094..................................................          1.6133          0.8470         24.1473         23.8654         25.1476         24.3842
260095..................................................          1.3868          0.9444         24.2698         27.6196         29.9069         27.0422
260096..................................................          1.5240          0.9444         29.7312         30.7267         32.9353         31.1666
260097..................................................          1.1896          0.8770         25.0624         25.5634         27.3117         26.0306
260102..................................................          0.9841          0.9444         27.2145         26.7624         30.7667         28.2426
260104..................................................          1.5825          0.8986         28.6247         28.0235         29.6366         28.7794
260105..................................................          1.8539          0.8986         29.8848         29.4766         32.4075         30.5702
260107..................................................             ***               *         25.8177         27.9710         29.7754         27.7676
260108..................................................          1.8291          0.8986         26.6374         27.0758         28.5633         27.4377
260110..................................................          1.6476          0.8470         24.7656         26.6030         28.0368         26.5197
260113..................................................          1.1410          0.8470         21.2072         21.8884         23.0810         22.0233
260115..................................................          1.2609          0.8986         23.1396         24.6389         25.5643         24.4735
260116..................................................          1.0435          0.8470         21.3503         20.7479         22.5593         21.5340
260119..................................................          1.2922          0.8470         27.9769         31.5490         31.4981         30.2546
260137..................................................          1.7457          0.9704         24.3273         27.6592         31.4059         27.8364
260138..................................................          1.8944          0.9444         30.4410         30.6284         31.7554         30.9538
260141..................................................          1.8592          0.8470         24.1555         25.5663         26.6672         25.5210
260142..................................................          1.0838          0.8470         21.5923         21.7609         22.8201         22.0857
260147..................................................          0.9526          0.8470         21.4235         22.1928         22.9670         22.1968
260159..................................................             ***               *         22.6276         23.9515         24.3018         23.5847
260160..................................................          1.0612          0.8470         23.8257         25.5096         26.6702         25.4076
260162..................................................          1.4383          0.8986         27.0236         28.4660         30.5739         28.7100
260163..................................................          1.2130          0.8557         21.6408         21.5566         23.8630         22.3617
260166..................................................          1.2356          0.9444         29.1225         28.5858         29.5234         29.0824
260175..................................................          1.1172          0.9444         25.1817         24.6064         25.7060         25.1720
260176..................................................          1.7557          0.8986         29.3034         31.1056         30.6112         30.3581
260177..................................................          1.2272          0.9444         27.0185         28.7942         29.0786         28.3077
260178..................................................          1.9689          0.8470         25.4782         27.1201         26.9886         26.5981
260179..................................................          1.5286          0.8986         26.6069         28.3234         29.6937         28.2012
260180..................................................          1.5853          0.8986         28.2931         29.3820         30.7313         29.4593
260183..................................................          1.6733          0.8986         27.5577         29.2684         31.4894         29.4549
260186..................................................          1.4640          0.8470         26.9797         28.8610         29.1853         28.3616
260190..................................................          1.2175          0.9444         27.9137         30.5343         30.8981         29.7909

[[Page 23754]]

 
260191..................................................          1.4412          0.8986         24.6973         26.3244         27.8627         26.3553
260193..................................................          1.2305          0.9444         26.8922         28.1060         29.5416         28.1851
260195..................................................          1.2498          0.8470         22.6870         24.0411         25.0275         23.9191
260198..................................................             ***               *         28.0021         27.2555         27.9073         27.7138
260200..................................................          1.2908          0.8986         28.2453         27.4784         30.3290         28.7369
260207..................................................          1.1540          0.8470         22.6109         22.9579         23.6383         23.1705
260209..................................................          1.1532          0.9038         25.0098         25.0749         26.4196         25.5826
260210..................................................          1.3929          0.8986         26.8745         30.5975         36.4040         30.6935
260211..................................................          1.4262          0.9444         40.9821         35.9113         37.1525         38.3586
260213..................................................             ***               *               *         34.8953               *         34.8953
260214..................................................          1.2306          0.9444               *               *         31.0153         31.0153
260216..................................................          1.3065          0.9444               *               *               *               *
260218..................................................          0.8126               *               *               *               *               *
260219..................................................          1.3191          0.8986               *               *               *               *
260220..................................................          2.3259               *               *               *               *               *
270002..................................................          1.1469          0.8640         24.0534         25.2907         28.3363         25.9060
270003..................................................          1.2563          0.8679         28.8700         29.1938         28.0533         28.6560
270004..................................................          1.6239          0.9045         26.1319         26.6779         28.5851         27.1552
270011..................................................          1.0779               *         22.7061         24.4696               *         23.5588
270012..................................................          1.5992          0.8679         25.2914         26.5854         28.0655         26.6761
270014..................................................          1.8067          0.8992         25.8231         27.4811         28.2567         27.1793
270017..................................................          1.3001          0.8909         26.5404         27.4150         29.3524         27.7689
270023..................................................          1.5599          0.8909         25.5682         26.3076         28.1878         26.6584
270032..................................................          1.0422          0.8640         20.3469         20.4330         21.6349         20.8153
270049..................................................          1.7681          0.9045         27.1634         28.6880         29.8869         28.6461
270051..................................................          1.5064          0.8909         26.5621         24.9371         29.3917         26.9486
270057..................................................          1.2964          0.8640         25.5811         27.1838         28.3612         27.1309
270074..................................................          0.8884          1.4448               *               *               *               *
270081..................................................          1.0022               *         19.5612         20.0438               *         19.8033
270086..................................................          1.2443          0.8679         21.0808         20.7976         21.8997         21.2340
270087..................................................          1.3324          0.8640         25.9772         24.8022         24.9177         25.2095
280003..................................................          1.7687          0.9620         30.6124         30.1057         32.3760         30.9970
280009..................................................          1.8349          0.9336         27.0705         29.3634         28.1542         28.1942
280013..................................................          1.7183          0.9400         27.0250         27.9523         30.3102         28.4716
280020..................................................          1.6559          0.9620         27.3284         32.3896         29.4807         29.7217
280023..................................................          1.3206          0.9336         26.7980         29.5132         30.0701         28.7818
280030..................................................          1.9392          0.9400         29.5102         30.6991         31.8740         30.6841
280032..................................................          1.2928          0.9336         24.3995         24.7539         25.6529         24.9364
280040..................................................          1.5775          0.9400         28.7207         29.5276         30.7378         29.6445
280060..................................................          1.6610          0.9400         27.7496         30.3049         30.8594         29.5587
280061..................................................          1.4476          0.9223         26.0208         26.4824         28.9580         27.1706
280065..................................................          1.2542          0.9611         28.0581         28.0132         29.5456         28.5374
280077..................................................          1.3602          0.8841         27.0860         28.2206         29.9204         28.4615
280081..................................................          1.6812          0.9400         28.7464         31.1212         28.9675         29.5979
280105..................................................          1.2560          0.9400         27.8599         29.8488         30.0457         29.2896
280111..................................................          1.1718          0.8761         24.5617         27.4853         28.3536         26.8743
280119..................................................          0.8951          1.4448               *               *               *               *
280123..................................................          0.9698          0.8884         15.4047         22.2185         20.2745         18.6147
280125..................................................          1.5858          0.8761         22.1345         23.2900         24.7453         23.4399
280127..................................................          1.8312          0.9620         29.3684         25.6806         26.5628         26.9797
280128..................................................          2.7488          0.9620         28.5422         28.8734         27.1001         28.1534
280129..................................................          2.0416          0.9400               *         27.8793         27.9490         27.9189
280130..................................................          1.3820          0.9400               *         29.8588         29.9628         29.9161
290001..................................................          1.7753          1.0476         36.3129         35.5113         33.3287         34.9942
290002..................................................          0.8657          0.9837         17.3876         23.9348         22.7349         20.8853
290003..................................................          1.7934          1.1666         30.3373         32.8182         34.6402         32.6118
290005..................................................          1.4648          1.1666         28.3366         31.7107         34.2346         31.0980
290006..................................................          1.0851          1.0476         31.7301         31.9838         33.1563         32.3337
290007..................................................          1.7274          1.1666         38.1938         39.7323         41.2361         39.7802
290008..................................................          1.2072          0.9824         27.3019         31.1116         33.2436         30.5242
290009..................................................          1.6426          1.0476         36.2724         32.3348         34.0900         34.1940
290012..................................................          1.3313          1.1666         32.3966         35.7988         38.5049         35.5355
290019..................................................          1.4604          1.0476         29.3650         30.5964         32.2793         30.8005
290020..................................................          1.0227          0.9824         23.2103         27.6277         27.2889         25.9788
290021..................................................          1.6689          1.1666         32.7894         36.7310         36.8695         35.4886
290022..................................................          1.7132          1.1666         29.9717         33.5330         38.8235         33.9036
290027..................................................          0.8931          0.9824         23.9959         23.9818         29.1114         25.2225

[[Page 23755]]

 
290032..................................................          1.4391          1.0476         31.6711         34.6589         36.9148         34.3264
290039..................................................          1.5440          1.1666         32.1423         34.9622         34.6334         33.9791
290041..................................................          1.4922          1.1666         34.2436         37.6077         38.4409         36.9258
290042..................................................             ***               *               *         22.4859               *         22.4859
290044..................................................             ***               *         37.1662               *               *         37.1662
290045..................................................          1.6567          1.1666         33.1512         34.4584         38.3841         35.4482
290046..................................................          1.4029          1.1666               *         38.7966         38.3084         38.5269
290047..................................................          1.4035          1.1666               *         33.4695         35.6348         34.5601
290049..................................................          1.3302          1.0476               *         26.0725         33.4248         30.0551
290051..................................................          1.8934          1.0027               *               *         32.5253         32.5253
290052..................................................          1.1590          0.9824               *               *               *               *
290053..................................................          1.5711          1.1666               *               *               *               *
300001..................................................          1.4434          1.0807         29.2260         29.8145         31.0102         30.0651
300003..................................................          2.0357          1.0807         34.7900         37.0886         37.7215         36.5476
300005..................................................          1.3788          1.0807         27.8000         27.8431         28.7980         28.1664
300011..................................................          1.3319          1.0807         30.9403         31.8928         33.0771         31.9916
300012..................................................          1.3235          1.0807         30.4972         31.2655         33.0547         31.6597
300014..................................................          1.2318          1.0807         29.7667         29.1847         30.7717         29.9265
300017..................................................          1.2863          1.0807         29.9560         31.6699         33.4139         31.6768
300018..................................................          1.3172          1.0807         29.4270         31.7891         31.5012         30.9778
300019..................................................          1.2444          1.0807         27.5672         28.2287         28.3103         28.0672
300020..................................................          1.1991          1.0807         30.8491         30.9783         32.4635         31.4527
300023..................................................          1.4459          1.0807         31.0040         31.2726         32.3183         31.5692
300029..................................................          1.8204          1.0807         29.8117         31.4429         32.0012         31.1343
300034..................................................          1.8504          1.0807         30.7676         31.6880         33.5519         32.0214
310001..................................................          1.7571          1.2878         41.7460         39.3391         41.4917         40.8275
310002..................................................          1.7914          1.2693         37.9183         37.8652         37.9453         37.9105
310003..................................................          1.1900          1.2878         36.2346         39.0785         40.1509         38.5759
310005..................................................          1.3414          1.1440         32.1319         33.6311         34.7634         33.5607
310006..................................................          1.4339          1.2878         28.4771         28.7321         30.4276         29.2523
310008..................................................          1.3390          1.2878         32.6788         33.3172         34.3243         33.4553
310009..................................................          1.3656          1.2693         33.6940         33.6165         35.4592         34.2954
310010..................................................          1.2858          1.1313         33.9552         33.7009         36.0797         34.6164
310011..................................................          1.2607          1.1599         31.2907         34.3497         37.4820         34.3008
310012..................................................          1.5959          1.2878         38.3590         39.8568         41.9596         40.0664
310013..................................................             ***               *         31.0447         35.6260         32.9465         33.1378
310014..................................................          1.8164          1.1221         30.0793         32.9016         36.5996         33.3018
310015..................................................          1.9106          1.2693         36.8818         39.2928         40.8200         39.0289
310016..................................................          1.3313          1.2878         35.6155         38.2740         41.0326         38.2707
310017..................................................          1.3644          1.2693         32.2434         35.7308         35.9780         34.6067
310018..................................................          1.1472          1.2693         30.3234         32.9704         32.6937         31.9526
310019..................................................          1.5510          1.2878         30.3518         30.6369         31.8909         30.9689
310020..................................................          1.5807          1.2878         33.5516         37.3372         38.4230         37.3143
310021..................................................          1.6495          1.1316         32.1929         31.6562         32.2042         32.0219
310022..................................................          1.3231          1.1221         30.4043         31.1951         32.8059         31.4436
310024..................................................          1.3886          1.1440         33.3415         33.8622         36.6897         34.6507
310025..................................................          1.4248          1.2878         34.3687         32.2630         32.1469         32.9318
310026..................................................          1.3243          1.2878         29.1588         30.1392         30.1294         29.8053
310027..................................................          1.4636          1.1440         29.7793         31.5967         34.6445         31.9780
310028..................................................          1.1907          1.1440         32.2977         33.9911         34.8312         33.7159
310029..................................................          1.7792          1.1221         32.9246         33.6695         35.2057         33.9510
310031..................................................          2.8606          1.1221         37.0668         39.3783         39.5882         38.6577
310032..................................................          1.3218          1.1221         30.7865         33.0258         35.2379         33.0201
310034..................................................          1.4121          1.1221         31.7012         32.7523         36.8586         33.7114
310037..................................................          1.4765          1.2878         38.5415         38.2865         40.4608         39.0092
310038..................................................          1.8931          1.2693         35.9190         36.3344         39.8671         37.3872
310039..................................................          1.2417          1.2693         31.4278         33.2100         32.6403         32.4242
310040..................................................          1.2573          1.2878         33.8535         37.7945         41.2219         37.4721
310041..................................................          1.3358          1.1221         32.8390         33.9799         35.1979         33.9784
310042..................................................             ***               *         34.4986               *               *         34.4986
310044..................................................          1.3493          1.1313         31.9678         33.7614         33.5843         33.0824
310045..................................................          1.6491          1.2878         36.7862         38.4424         39.2064         38.1273
310047..................................................          1.3458          1.1666         34.1520         37.3695         37.7198         36.4657
310048..................................................          1.3736          1.1316         32.9681         33.9506         34.5223         33.8353
310050..................................................          1.2457          1.2693         29.1732         32.3686         37.9191         32.9302
310051..................................................          1.4905          1.1440         35.0121         38.1174         39.7645         37.6891
310052..................................................          1.3237          1.1221         32.5778         33.5849         36.5463         34.2544

[[Page 23756]]

 
310054..................................................          1.4134          1.2693         34.4431         36.9095         38.2409         36.5602
310057..................................................          1.4334          1.1221         31.1268         31.8933         34.2018         32.3544
310058..................................................          1.0541          1.2878         27.1555         30.4080         30.4416         29.4040
310060..................................................          1.2546          1.1221         27.3415         27.8242         27.9121         27.7048
310061..................................................          1.2219          1.1221         31.6648         39.0538         33.5561         34.7375
310063..................................................          1.3448          1.1440         31.9247         33.8519         38.1450         34.4537
310064..................................................          1.5372          1.1666         35.7607         38.6310         39.4132         38.0057
310069..................................................          1.2581          1.1221         31.7642         34.4669         35.1354         33.8309
310070..................................................          1.4555          1.2693         34.3225         36.3279         36.9963         35.8869
310073..................................................          1.7821          1.1221         32.6733         34.2858         36.9226         34.6721
310074..................................................          1.4656          1.2878         40.3494         39.6196         39.0709         39.6558
310075..................................................          1.4250          1.1221         31.5226         32.5338         33.5226         32.5111
310076..................................................          1.6465          1.2693         38.0643         37.5163         38.1641         37.9202
310077..................................................             ***               *         34.6085               *               *         34.6085
310078..................................................             ***               *         30.5761               *               *         30.5761
310081..................................................          1.2620          1.1221         30.1561         31.0699         31.7950         31.0154
310083..................................................          1.3189          1.2693         30.3580         31.9151         28.3385         30.1096
310084..................................................          1.2659          1.1221         33.5941         32.6051         34.9604         33.7173
310086..................................................          1.2615          1.1221         29.5566         29.8794         30.9445         30.1377
310088..................................................          1.1243          1.1666         29.9929         30.3552         31.2420         30.5505
310090..................................................          1.2372          1.1440         32.8191         33.4615         33.9146         33.3953
310091..................................................          1.1327          1.1221         29.3969         31.9762         35.2892         32.2224
310092..................................................          1.4052          1.1313         29.7958         32.7054         32.8408         31.7803
310093..................................................          1.2201          1.2693         29.1288         30.2860         32.3840         30.5687
310096..................................................          1.9372          1.2693         34.1524         35.0707         34.2007         34.4697
310105..................................................          1.1572          1.2878         30.1069         32.5672         32.0252         31.5545
310108..................................................          1.4030          1.2693         33.0172         34.5866         36.2821         34.6390
310110..................................................          1.3096          1.1313         33.2246         33.4809         35.6793         34.1565
310111..................................................          1.2536          1.1221         31.8393         34.8284         36.0727         34.2677
310112..................................................          1.3277          1.1221         31.2372         32.2676         34.5315         32.6218
310113..................................................          1.2425          1.1221         31.0436         33.6771         35.0222         33.3347
310115..................................................          1.3224          1.1221         29.5320         31.9208         32.1173         31.2475
310116..................................................          1.2972          1.2878         29.2748         29.8144         27.5857         28.8828
310118..................................................          1.3587          1.2878         31.1803         31.2296         32.8252         31.7711
310119..................................................          1.8782          1.2693         43.1238         41.5702         41.2971         41.9830
310120..................................................          1.0851          1.1440         29.2535         33.3861         35.1643         32.4707
310122..................................................             ***               *               *         41.9029               *         41.9029
310123..................................................             ***               *               *         37.1022               *         37.1022
310124..................................................             ***               *               *         41.8827               *         41.8827
310125..................................................             ***               *               *         36.2186               *         36.2186
310126..................................................             ***               *               *               *         34.3166         34.3166
320001..................................................          1.6823          0.9499         29.6182         30.0077         31.4174         30.3597
320002..................................................          1.5341          1.0587         32.0477         33.1342         34.1580         33.1619
320003..................................................          1.1298          1.0207         27.6222         31.4473         31.5768         30.3534
320004..................................................          1.3299          0.8858         24.7803         26.2073         28.2392         26.4283
320005..................................................          1.4214          0.9295         24.7543         28.7893         25.2152         26.1577
320006..................................................          1.2584          0.9295         26.9080         28.0964         28.5156         27.8949
320009..................................................          1.5798          0.9499         32.0116         27.8084         31.3279         30.3184
320011..................................................          1.1519          0.9300         25.6693         27.9522         28.9931         27.5536
320013..................................................          1.1126          1.0207         22.8283         30.5865         31.2869         27.7697
320014..................................................          1.0864          0.8858         27.2806         28.7089         30.4781         28.8685
320016..................................................          1.1842          0.8858         25.0835         27.1492         26.6374         26.3150
320017..................................................          1.2575          0.9499         31.6357         33.3496         30.5759         31.7120
320018..................................................          1.5461          0.8882         26.5109         25.9248         28.3438         26.9103
320019..................................................          1.4058          0.9499         27.8067         35.0217         28.6731         30.2204
320021..................................................          1.6185          0.9499         26.9918         28.8504         30.4499         28.7977
320022..................................................          1.1799          0.8858         23.9595         25.3707         27.5132         25.6817
320030..................................................          1.0361          0.8858         21.0378         24.4497         25.5246         23.7752
320033..................................................          1.2183          1.0207         31.7114         30.1471         30.1829         30.6567
320037..................................................          1.2261          0.9499         24.9657         25.2876         27.8969         26.0664
320038..................................................          1.2596          0.8858         21.7022         32.7192         31.6504         29.0042
320057..................................................          0.9342          1.4430               *               *               *               *
320058..................................................          0.7891          1.4430               *               *               *               *
320059..................................................          0.9914          1.4430               *               *               *               *
320060..................................................          1.0159          1.4430               *               *               *               *
320061..................................................          1.0245          1.4430               *               *               *               *
320062..................................................          0.9174          1.4430               *               *               *               *

[[Page 23757]]

 
320063..................................................          1.3932          0.9273         25.0031         26.0104         27.4933         26.1576
320065..................................................          1.3072          0.9273         27.3163         25.7945         26.9113         26.6843
320067..................................................          0.8947          0.8858         24.9865         24.7025         25.4100         25.0450
320069..................................................          1.0782          0.8858         22.4128         23.9863         25.3134         23.9141
320070..................................................          0.9255          1.4430               *               *               *               *
320074..................................................          1.2421          0.9499         31.1333         28.4396         28.8072         29.1304
320079..................................................          1.2567          0.9499         26.1188         27.6877         31.5635         28.5357
320083..................................................          2.4454          0.9499         26.6921         29.5483         32.9443         29.7645
320084..................................................          0.9653          0.8858         17.5788         22.7706         24.2897         21.5109
320085..................................................          1.7562          0.8882         27.9944         27.4100         28.4513         27.9647
320086..................................................          1.4744          0.8858               *               *               *               *
320087..................................................          1.3725          1.0587               *               *               *               *
330002..................................................          1.5701          1.3043         30.9600         32.1956         34.7252         32.6020
330003..................................................          1.3545          0.8833         24.4326         25.2223         26.8348         25.5129
330004..................................................          1.3501          1.0709         28.0594         30.2236         30.3204         29.4839
330005..................................................          1.5906          0.9593         30.3200         31.5030         33.2828         31.7049
330006..................................................          1.2783          1.3043         33.6284         34.2001         36.3279         34.6900
330008..................................................          1.1757          0.9593         23.4429         25.2005         26.2131         24.9414
330009..................................................          1.3652          1.3043         36.2820         38.9166         41.3767         38.8011
330010..................................................          1.0125          0.8375         20.7476         19.7098         20.5800         20.3266
330011..................................................          1.3772          0.8721         25.1308         27.4747         26.8258         26.4851
330013..................................................          1.9475          0.8833         26.4578         26.8382         28.8015         27.3879
330014..................................................          1.3374          1.3043         42.1759         45.7619         46.3155         44.6761
330016..................................................             ***               *         22.0493         23.0769               *         22.5738
330019..................................................          1.3063          1.3043         38.5368         39.7429         44.5627         40.8880
330023..................................................          1.5312          1.2855         35.9428         36.4736         37.5106         36.6960
330024..................................................          1.7996          1.3043         42.7691         43.2342         44.8034         43.6032
330025..................................................          1.0483          0.9593         21.2565         23.2424         24.2691         22.9268
330027..................................................          1.3943          1.2855         42.8000         45.1920         45.9531         44.5412
330028..................................................          1.5319          1.3043         36.6498         36.2901         38.0116         36.9910
330029..................................................          0.5241          0.9593         23.2039         24.0679         22.9321         23.3384
330030..................................................          1.1544          0.8911         24.6175         25.3454         25.5081         25.1586
330033..................................................          1.2323          0.8531         24.5510         24.8022         25.0205         24.7863
330036..................................................          1.2126          1.3043         29.1884         30.3757         30.4633         30.0049
330037..................................................          1.2293          0.8911         22.3689         21.9246         23.4904         22.5870
330041..................................................          1.3098          1.3043         37.4883         36.9934         37.1640         37.2203
330043..................................................          1.4593          1.2729         39.1643         38.8060         40.6059         39.5013
330044..................................................          1.3446          0.8721         26.5669         28.2293         28.2619         27.6916
330045..................................................          1.4086          1.2729         38.1269         40.0326         41.6537         39.9715
330046..................................................          1.3696          1.3043         50.3152         47.4975         52.2364         49.9699
330047..................................................          1.2132          0.8375         24.3932         24.9934         26.1791         25.2159
330049..................................................          1.4907          1.2694         29.8350         34.8585         34.9720         33.3441
330053..................................................          1.0857          0.8911         20.6272         21.8383         20.1297         20.8283
330055..................................................          1.5415          1.3043         41.5934         42.2007         44.2313         42.7264
330056..................................................          1.3947          1.3043         36.0136         38.8910         39.9628         38.2393
330057..................................................          1.6802          0.8833         26.4989         27.7121         30.1910         28.1436
330058..................................................          1.2665          0.8911         22.2524         22.6852         23.6285         22.8634
330059..................................................          1.5527          1.3043         41.7343         44.9162         45.3660         44.0375
330061..................................................          1.1594          1.3043         36.0587         37.8828         37.8620         37.2887
330064..................................................          1.2603          1.3043         38.0437         38.2332         41.5714         39.3164
330065..................................................          1.0618          0.9593         25.3043         24.4004         26.2272         25.3188
330066..................................................          1.2729          0.8833         29.1780         25.8174         27.2069         27.4291
330067..................................................          1.3961          1.2694         27.8900         29.2571         30.7516         29.2920
330072..................................................          1.3012          1.3043         37.8505         39.6996         41.4567         39.5848
330073..................................................          1.1090          0.8911         22.5592         23.4020         25.1380         23.7034
330074..................................................          1.1944          0.8911         22.6629         23.4576         23.1004         23.0807
330075..................................................          1.1190          0.9865         23.1592         24.2552         23.7516         23.7241
330078..................................................          1.4677          0.9593         25.8073         27.2870         27.6659         26.9471
330079..................................................          1.3733          0.8308         24.6054         24.9941         27.9464         25.8287
330080..................................................          1.1760          1.3043         39.1417         38.9405         40.2059         39.4431
330084..................................................          1.0851          0.8308         22.5573         25.6880         27.3430         25.1537
330085..................................................          1.1551          0.9471         25.3285         26.6235         27.1697         26.3813
330086..................................................          1.3189          1.3043         32.7675         35.5269         40.9743         36.5723
330088..................................................          1.0110          1.2729         34.0789         35.3871         35.9962         35.1584
330090..................................................          1.4588          0.9101         25.5351         26.8730         27.7287         26.7363
330091..................................................          1.3843          0.9593         25.9378         27.0040         28.3015         27.0881
330094..................................................          1.2631          0.9901         25.7116         26.9148         28.6203         27.1128

[[Page 23758]]

 
330096..................................................          1.1987          0.8308         22.7189         24.2422         24.7885         23.9177
330100..................................................          1.1185          1.3043         38.3333         39.6244         37.8618         38.6066
330101..................................................          1.8970          1.3043         40.1929         43.7944         45.5381         43.2279
330102..................................................          1.4096          0.9593         25.3879         26.6887         27.2523         26.4449
330103..................................................          1.2008          0.8351         22.8242         24.5585         25.4907         24.2904
330104..................................................          1.3423          1.3043         33.7537         35.1076         36.5857         35.1622
330106..................................................          1.6914          1.2855         43.8210         46.3657         48.2871         46.1844
330107..................................................          1.2407          1.2729         34.9047         35.7384         38.0246         36.2529
330108..................................................          1.1289          0.8347         23.2919         23.9368         25.3011         24.1893
330111..................................................          0.9674          0.9593         20.3473         40.4349         23.2125         25.3142
330115..................................................          1.1888          0.9865         25.2373         23.8235         24.3889         24.4744
330119..................................................          1.7304          1.3043         39.0528         42.2901         41.2326         40.8420
330125..................................................          1.7378          0.8911         27.2920         28.0584         29.4802         28.3192
330126..................................................          1.3038          1.2855         35.2257         36.5689         37.7797         36.5514
330127..................................................          1.3108          1.3043         45.3680         45.2993         45.2542         45.3069
330128..................................................          1.2304          1.3043         39.5197         41.7790         43.3424         41.5728
330132..................................................          1.1001          0.8439         21.0479         21.7648         22.1446         21.6691
330133..................................................          1.3704          1.3043         39.3837         38.5228         39.9011         39.2582
330135..................................................          1.2101          1.1586         27.9132         32.0525         33.2291         31.0896
330136..................................................          1.5320          0.9471         25.8531         26.6680         25.4193         25.9628
330140..................................................          1.7962          0.9865         27.6183         29.3461         31.1320         29.4083
330141..................................................          1.3202          1.2729         39.4701         39.3741         39.1699         39.3348
330144..................................................          0.9865          0.8362         22.9561         23.3874         24.9303         23.7658
330151..................................................          1.2083          0.8362         21.7665         19.7959         21.6335         21.0260
330152..................................................          1.3015          1.3043         37.6721         38.2079         39.5722         38.4999
330153..................................................          1.7175          0.8833         26.4386         28.4446         28.9924         27.9865
330154..................................................          1.6921               *               *               *               *               *
330157..................................................          1.3796          0.9471         26.5686         27.1432         29.7604         27.7881
330158..................................................          1.6713          1.3043         38.2033         41.7010         39.5913         39.8276
330159..................................................          1.3553          0.9865         28.2774         31.7835         33.8472         31.2089
330160..................................................          1.5503          1.3043         36.6208         37.1915         39.1048         37.6457
330162..................................................          1.3383          1.3043         34.9460         37.6226         38.7613         37.1390
330163..................................................          1.1132          0.9593         27.1933         28.3910         28.6229         28.0754
330164..................................................          1.4898          0.8911         27.7217         27.8746         29.8437         28.5199
330166..................................................          1.0613          0.8308         20.4680         20.7121         22.8498         21.3014
330167..................................................          1.6290          1.2855         36.7653         39.1251         39.1824         38.3281
330169..................................................          1.3998          1.3043         45.3774         46.4939         47.5367         46.4021
330171..................................................             ***               *         30.4005         35.1577               *         32.5880
330175..................................................          1.1285          0.8568         23.8509         24.1005         26.7868         24.8937
330177..................................................          0.9936          0.8308         20.6338         22.9834         23.4294         22.3276
330180..................................................          1.1924          0.8833         24.3761         25.4170         26.8643         25.5779
330181..................................................          1.3033          1.2855         41.4104         43.0977         46.2154         43.5483
330182..................................................          2.2878          1.2855         40.9014         41.3033         42.7924         41.6641
330184..................................................          1.3645          1.3043         35.8102         39.0437         39.7213         38.2058
330185..................................................          1.2668          1.2729         36.3155         38.4002         39.6695         38.1531
330188..................................................          1.2402          0.9593         25.1153         27.5988         29.7302         27.4385
330189..................................................          1.2886          0.8833         22.3484         22.4383         25.8116         23.5448
330191..................................................          1.2850          0.8833         25.5656         26.4328         28.2938         26.8175
330193..................................................          1.4383          1.3043         39.9327         39.8910         40.0256         39.9494
330194..................................................          1.7941          1.3043         45.5639         46.8880         49.8845         47.4698
330195..................................................          1.7054          1.3043         39.7802         41.7885         43.3185         41.6774
330196..................................................          1.2884          1.3043         36.7178         38.2525         38.6925         37.9124
330197..................................................          1.1174          0.8308         26.8921         25.9872         26.5516         26.4718
330198..................................................          1.3922          1.2855         33.4930         34.8985         35.8688         34.8129
330199..................................................          1.1949          1.3043         38.6407         40.3948         39.4065         39.4834
330201..................................................          1.8000          1.3043         37.2064         42.6707         46.5096         42.1336
330202..................................................          1.4107          1.3043         37.4150         37.4158         38.7609         37.8756
330203..................................................          1.4153          0.9865         32.1207         34.0499         34.6499         33.6383
330204..................................................          1.4550          1.3043         39.6393         41.9953         39.5313         40.4252
330205..................................................          1.2337          1.1586         31.9510         33.9418         35.3766         33.7848
330208..................................................          1.1951          1.3043         32.1256         33.5287         37.1706         34.2436
330209..................................................             ***               *         30.2038               *               *         30.2038
330211..................................................          1.0836          0.8308         24.4470         25.8752         24.9417         25.1105
330213..................................................          1.0678          0.8308         24.4049         27.4890         28.5365         26.7727
330214..................................................          1.8791          1.3043         41.8719         42.1339         43.2434         42.4360
330215..................................................          1.2792          0.8721         23.7361         23.9583         26.3964         24.6837
330218..................................................          1.0910          0.9865         26.9638         26.9982         28.4109         27.4690

[[Page 23759]]

 
330219..................................................          1.7127          0.9593         29.8889         32.5658         33.2132         31.8655
330221..................................................          1.3708          1.3043         39.2080         40.0514         42.5461         40.6770
330222..................................................          1.2774          0.8833         25.8507         27.7198         28.7835         27.5072
330223..................................................          0.9707          0.8308         23.3669         26.1264         27.1959         25.6000
330224..................................................          1.3100          1.0709         27.9231         29.1738         30.4765         29.2021
330225..................................................          1.2228          1.2855         32.3585         35.7651         32.9013         33.6812
330226..................................................          1.4002          0.8911         24.5646         24.8471         26.3674         25.2746
330229..................................................          1.2244          0.8420         21.9356         23.0577         23.9230         22.9668
330230..................................................          1.0278          1.3043         37.1298         38.6569         39.3870         38.3808
330231..................................................          1.1135          1.3043         40.6697         44.9422         48.9002         44.9236
330232..................................................          1.2072          0.8833         26.3313         27.4639         27.9601         27.2541
330233..................................................          1.5357          1.3043         47.3497         52.7070         40.8517         46.1530
330234..................................................          2.3425          1.3043         48.2306         49.3219         49.8754         49.1340
330235..................................................          1.1520          0.9471         27.7031         29.4346         30.8007         29.3076
330236..................................................          1.5494          1.3043         40.2386         42.8981         42.6166         41.9558
330238..................................................          1.2738          0.8911         21.7435         21.8386         23.3946         22.3482
330239..................................................          1.2402          0.8420         22.3854         23.1885         24.6380         23.4006
330240..................................................          1.4609          1.3043         43.5753         40.5001         41.6117         41.8580
330241..................................................          1.8409          0.9865         30.2304         32.7683         32.9148         32.0133
330242..................................................          1.3112          1.3043         37.4870         36.9015         38.7839         37.7206
330245..................................................          1.7745          0.8721         26.1811         27.4326         28.6678         27.4605
330246..................................................          1.3715          1.2729         37.1611         35.7416         35.9559         36.2356
330247..................................................          1.1834          1.3043         35.4980         39.0219         41.3428         38.4848
330249..................................................          1.3392          0.9865         25.3246         24.6091         26.9847         25.6366
330250..................................................          1.3845          0.9216         27.1606         29.0080         29.6168         28.6244
330259..................................................          1.5072          1.2855         35.1514         36.4788         39.0189         36.8295
330261..................................................          1.2365          1.3043         33.7834         40.2579         38.0192         37.2335
330263..................................................          1.0140          0.8308         23.8738         24.1333         24.2125         24.0872
330264..................................................          1.3203          1.1586         30.4701         31.0557         32.1770         31.4635
330265..................................................          1.2419          0.8911         21.6477         23.9081         22.7426         22.7616
330267..................................................          1.3921          1.3043         32.8541         34.9885         35.3884         34.4218
330268..................................................          0.9313          0.8308         25.3567         23.8793         23.9129         24.3479
330270..................................................          2.0758          1.3043         57.3596         55.2136         52.3126         54.6691
330273..................................................          1.3499          1.3043         37.0157         35.9298         39.7849         37.6016
330276..................................................          1.1594          0.8344         24.3300         26.0935         27.0432         25.8320
330277..................................................          1.2068          0.9101         26.4535         30.9053         30.8138         29.1290
330279..................................................          1.6224          0.9593         27.4539         29.6385         31.2369         29.4467
330285..................................................          1.9771          0.8911         30.1928         31.1235         31.9305         31.0944
330286..................................................          1.3514          1.2729         35.5895         37.6040         38.8533         37.3699
330290..................................................          1.6233          1.3043         39.4690         40.6933         39.8010         39.9779
330304..................................................          1.3053          1.3043         36.2845         37.3537         39.4605         37.8134
330306..................................................          1.4567          1.3043         36.3552         38.7713         39.0391         38.0888
330307..................................................          1.3412          0.9561         29.2529         29.5885         30.8103         29.9028
330314..................................................             ***               *         26.2719         28.1788         22.6868         26.0606
330316..................................................          1.2398          1.3043         34.8567         37.1766         37.9320         36.6690
330331..................................................          1.2869          1.2855         39.8402         41.2694         44.1690         41.7977
330332..................................................          1.3105          1.2855         35.1646         37.0111         38.6906         36.9311
330338..................................................             ***               *         37.7497               *               *         37.7497
330339..................................................          0.7634          0.8833         23.5786         24.3066         25.0041         24.2976
330340..................................................          1.2284          1.2729         37.9000         37.4161         38.4698         37.9265
330350..................................................          1.5260          1.3043         41.1339         44.4617         44.2368         43.3333
330353..................................................          1.2443          1.3043         45.9692         45.0977         46.0175         45.7015
330354..................................................          2.1246               *               *               *               *               *
330357..................................................          1.2886          1.3043         38.2286         40.3850         40.2097         39.5419
330372..................................................          1.2901          1.2855         36.1840         35.1297         37.0288         36.1053
330385..................................................          1.0504          1.3043         48.6175         49.0859         47.3989         48.3826
330386..................................................          1.3408          1.1461         29.9366         33.3216         32.9974         32.1005
330389..................................................          1.7338          1.3043         37.1862         39.6871         37.5883         38.1257
330390..................................................          1.2394          1.3043         36.3842         35.5562         38.7634         36.9285
330393..................................................          1.7385          1.2729         38.0619         39.2186         38.9295         38.7593
330394..................................................          1.6520          0.8721         27.3388         28.4597         28.8056         28.2126
330395..................................................          1.4204          1.3043         36.3921         37.5791         50.1276         40.5815
330396..................................................          1.3480          1.3043         37.4998         39.4904         39.1940         38.7397
330397..................................................          1.4094          1.3043         37.5682         41.4448         41.1659         39.9850
330399..................................................          1.1317          1.3043         34.7394         36.7626         39.8000         37.1071
330401..................................................          1.3519          1.2729         37.8559         40.4485         41.7804         40.0688
330403..................................................          0.9101          0.8911         25.5163         25.2937         28.7267         26.3688

[[Page 23760]]

 
330404..................................................          0.9366          1.3043               *               *         36.1044         36.1044
330405..................................................          0.9452          1.3043               *               *         35.2698         35.2698
330406..................................................          0.9450          0.8833               *               *         28.2727         28.2727
330407..................................................          0.9449          0.8833               *               *               *               *
340001..................................................          1.4870          0.9570         28.3988         29.5709         29.9082         29.3235
340002..................................................          1.7858          0.9192         28.4860         29.6622         30.7384         29.6332
340003..................................................          1.2344          0.8632         24.1602         26.0888         26.6393         25.6927
340004..................................................          1.4318          0.9096         26.6404         27.5283         27.9184         27.3734
340008..................................................          1.2672          0.9567         26.7443         27.7206         29.0639         27.8645
340010..................................................          1.3315          0.9557         27.2105         28.7544         29.5207         28.5197
340011..................................................          1.1738          0.8632         19.7441         22.0047         22.5138         21.4242
340012..................................................          1.2246          0.8632         23.2288         24.7576         24.9253         24.3215
340013..................................................          1.2360          0.9307         23.9492         26.3607         26.9137         25.7232
340014..................................................          1.6086          0.8984         27.4888         27.8384         29.5330         28.3119
340015..................................................          1.3956          0.9570         28.0585         28.3928         30.0958         28.8519
340016..................................................          1.3330          0.8632         25.6454         27.2365         27.9629         26.9654
340017..................................................          1.2759          0.9192         25.7780         27.5672         28.4845         27.2551
340020..................................................          1.1889          0.8788         26.4465         27.5473         28.3440         27.4399
340021..................................................          1.3379          0.9570         29.4864         29.3835         31.3610         30.1011
340023..................................................          1.3629          0.9307         26.4225         26.2716         27.6909         26.8311
340024..................................................          1.1349          0.8809         23.6638         26.4001         26.8984         25.6597
340025..................................................          1.2988          0.9192         23.5881         24.0101         25.2827         24.3044
340027..................................................          1.2181          0.9174         25.5973         26.3840         26.6506         26.2232
340028..................................................          1.5011          0.9923         28.0323         30.7591         31.9846         30.2233
340030..................................................          1.9766          0.9693         29.6630         30.4591         31.1985         30.4842
340032..................................................          1.4553          0.9570         26.5958         28.7636         29.2058         28.2291
340035..................................................          1.0979          0.8632         23.9669         24.6262         26.0827         24.8874
340036..................................................          1.3100          0.9685         27.2691         27.3860         29.0626         27.9422
340037..................................................          1.1218          0.8794         25.6262         29.0618         30.5346         28.5630
340038..................................................          1.2380          0.8885         22.4829         24.2111         26.2582         24.3742
340039..................................................          1.2806          0.9570         27.4457         27.8228         29.5042         28.2768
340040..................................................          1.9081          0.9346         27.6626         28.7434         30.1256         28.8796
340041..................................................          1.3315          0.8946         24.3595         26.8314         27.1270         26.1141
340042..................................................          1.2353          0.8632         25.0110         25.6349         27.0573         25.9214
340047..................................................          1.8051          0.8984         27.4022         28.4968         28.7600         28.2338
340049..................................................          1.7851          0.9693         30.6791         29.6826         31.5524         30.6567
340050..................................................          1.2008          0.9567         26.0365         27.5274         29.2266         27.6025
340051..................................................          1.1886          0.8794         23.9612         24.4561         25.4961         24.6507
340053..................................................          1.4900          0.9570         27.8577         28.9355         30.8320         29.2316
340055..................................................          1.2129          0.8946         26.0647         26.5752         29.0098         27.1555
340060..................................................          1.0621          0.9141         22.9097         25.1791         26.8366         24.9813
340061..................................................          1.7496          0.9693         27.0089         29.8574         31.2885         29.4140
340064..................................................          1.1205          0.8632         23.4233         23.9701         25.0796         24.1848
340068..................................................          1.2915          0.8632         22.6814         23.6757         24.7388         23.6999
340069..................................................          1.8414          0.9693         29.3439         31.4951         32.2147         31.0749
340070..................................................          1.2531          0.8984         25.3226         26.6546         27.7660         26.6186
340071..................................................          1.0621          0.9557         26.3921         27.9748         29.7321         28.0710
340072..................................................          1.1433               *         25.2493         24.1350               *         24.6895
340073..................................................          1.6527          0.9693         30.9849         31.6803         33.2859         32.0279
340075..................................................          1.2349          0.8946         25.1551         25.1438         26.8298         25.7432
340084..................................................          1.1236          0.9570         21.1363         23.1300         25.6868         23.2795
340085..................................................          1.1506          0.8882         26.5164         27.9572         29.1072         27.8491
340087..................................................          1.2341          0.8632         22.4287         25.4730         23.8343         23.9111
340090..................................................          1.3071          0.9685         26.4031         26.7428         28.3594         27.2234
340091..................................................          1.6022          0.9096         27.1285         28.8044         30.4345         28.8160
340096..................................................          1.2333          0.8882         24.9036         26.5438         26.5795         26.0408
340097..................................................          1.2431          0.8632         26.2228         29.8005         27.9788         27.9546
340098..................................................          1.4670          0.9570         28.2493         29.7180         31.3896         29.8226
340099..................................................          1.2912          0.8632         21.8564         23.9702         26.0062         24.0248
340104..................................................          0.7848          0.8794         16.1204         17.0165         19.9477         17.8305
340106..................................................          1.1406          0.8632         26.0892         26.1340         24.5134         25.5139
340107..................................................          1.1991          0.9068         24.1762         26.5626         27.3548         26.0750
340109..................................................          1.2448          0.8868         25.4464         26.6383         26.6462         26.2343
340113..................................................          1.9457          0.9570         28.5587         30.3841         32.3765         30.4662
340114..................................................          1.5304          0.9693         28.3222         28.1311         30.1188         28.8788
340115..................................................          1.6260          0.9693         26.7592         27.2781         28.0955         27.3861
340116..................................................          1.7476          0.8946         27.5881         29.3698         29.9425         28.9452

[[Page 23761]]

 
340119..................................................          1.2861          0.9570         25.6226         29.4470         27.2924         27.4283
340120..................................................          1.0708          0.8632         25.9134         25.5399         26.1449         25.8647
340121..................................................          1.0930          0.9087         23.1343         23.8854         25.1565         24.0798
340123..................................................          1.2779          0.9141         26.0637         28.5669         28.7125         27.7861
340124..................................................             ***               *         22.2988         23.5480         25.7275         23.7126
340126..................................................          1.3283          0.9557         26.9866         28.2247         30.6880         28.6662
340127..................................................          1.1942          0.9693         26.4746         28.2161         28.8647         27.8604
340129..................................................          1.3110          0.9570         25.7976         26.7606         31.7833         27.9613
340130..................................................          1.3497          0.9570         26.1717         28.1594         29.5278         27.9862
340131..................................................          1.4690          0.9174         27.4750         28.8542         29.6545         28.6874
340132..................................................          1.2127          0.8632         23.5856         24.6162         25.3247         24.5295
340133..................................................          1.0197          0.8940         23.4678         24.8579         26.8831         25.1020
340137..................................................             ***               *         22.1741         28.9672         27.0855         25.1884
340138..................................................          0.9092          0.9693               *               *               *               *
340141..................................................          1.6729          0.9087         29.3878         29.3171         29.3351         29.3465
340142..................................................          1.2123          0.8632         26.6886         27.7555         28.2393         27.5936
340143..................................................          1.5447          0.8946         28.0082         27.9777         29.3839         28.4856
340144..................................................          1.2183          0.9570         26.1865         27.0150         27.6523         26.9370
340145..................................................          1.2148          0.9570         25.8459         26.7482         28.0628         26.9029
340147..................................................          1.3027          0.9557         26.9162         28.2626         29.6936         28.3096
340148..................................................          1.5007          0.8984         25.3660         25.8325         27.9119         26.4048
340151..................................................          1.2153          0.8684         22.7736         23.2158         24.5768         23.5273
340153..................................................          1.9232          0.9570         27.6509         28.5979         29.8260         28.7235
340155..................................................          1.4750          0.9693         30.3443         30.9501         31.7547         31.0367
340156..................................................          0.8722          1.4446               *               *               *               *
340158..................................................          1.1294          0.9087         27.7816         27.6526         29.4088         28.3011
340159..................................................          1.2146          0.9693         24.2588         25.3108         28.1688         25.9712
340160..................................................          1.3520          0.8632         21.7923         23.4631         24.2003         23.1718
340166..................................................          1.3505          0.9570         27.1132         28.5395         29.9101         28.5234
340168..................................................          0.4196          0.9087               *               *               *               *
340171..................................................          1.1184          0.9570         27.8539         27.4701         31.1928         28.9088
340173..................................................          1.3301          0.9693         28.3502         30.2815         30.9813         29.9351
340177..................................................             ***               *         26.7155               *               *         26.7155
340179..................................................             ***               *         34.1895               *               *         34.1895
340182..................................................             ***               *         27.8071               *               *         27.8071
340183..................................................          1.1992          0.9570               *               *         30.1224         30.1224
350002..................................................          1.8113          0.7336         22.4307         23.5869         23.6039         23.2267
350003..................................................          1.2133          0.7336         23.9639         24.9975         24.5802         24.5236
350006..................................................          1.5637          0.7336         21.2726         22.4626         23.4334         22.3834
350009..................................................          1.0718          0.8212         23.8681         24.5737         23.9783         24.1447
350010..................................................          1.0699               *         20.1290         20.4198               *         20.2749
350011..................................................          1.9136          0.8212         23.8400         24.1135         26.0184         24.6622
350014..................................................          0.9542               *         19.1684         17.5837               *         18.3437
350015..................................................          1.5991          0.7336         20.9046         21.3342         22.9107         21.7900
350017..................................................          1.2273          0.7336         22.4359         21.6187         24.0965         22.7331
350019..................................................          1.6984          0.7709         23.2018         24.9615         24.9880         24.4055
350030..................................................          0.9524          0.7336         20.2722         22.5976         23.1013         22.0048
350063..................................................          0.9136          1.4365               *               *               *               *
350064..................................................          0.7388          1.4365               *               *               *               *
350070..................................................          1.7656          0.8212         25.2365         26.2454         26.2850         25.9334
360001..................................................          1.4815          0.9581         25.8669         28.8623         30.1018         28.2801
360002..................................................          1.2851          0.8723         24.5155         25.4859         25.2198         25.0794
360003..................................................          1.7681          0.9581         28.9672         30.7812         31.8948         30.5710
360006..................................................          1.8125          0.9869         30.1363         30.9806         31.8259         31.0038
360008..................................................          1.3172          0.8759         26.2632         27.5683         28.0182         27.2862
360009..................................................          1.5509          0.9299         25.0007         27.0618         28.2407         26.7836
360010..................................................          1.2398          0.8784         23.7825         24.7352         25.5935         24.7214
360011..................................................          1.2808          0.9657         27.6036         31.5587         29.9864         29.6800
360012..................................................          1.3492          0.9869         30.1416         31.0526         31.9806         31.0579
360013..................................................          1.0853          0.9299         27.0893         29.8412         30.2383         29.0666
360014..................................................          1.1225          0.9657         27.1017         27.0743         28.1800         27.4862
360016..................................................          1.4873          0.9581         27.8031         29.6298         30.2164         29.2161
360017..................................................          1.6193          0.9869         29.8525         31.7081         33.2491         31.6157
360019..................................................          1.3267          0.9266         26.9178         27.2997         28.3226         27.5252
360020..................................................          1.5825          0.9266         23.6400         25.6328         27.6681         25.6284
360025..................................................          1.4547          0.9267         27.4533         27.1546         28.4754         27.6992
360026..................................................          1.3750          0.9321         25.5379         25.2945         27.5409         26.1280

[[Page 23762]]

 
360027..................................................          1.5168          0.9266         27.4454         28.2923         29.6304         28.4671
360029..................................................          1.1810          0.9267         24.3216         26.4208         27.8825         26.2449
360032..................................................          1.2265          0.8582         25.0034         25.9916         27.2621         26.0956
360035..................................................          1.6390          0.9869         30.0172         31.3181         31.2432         30.8528
360036..................................................          1.1944          0.9266         27.8343         29.3514         29.9390         29.0664
360037..................................................          1.5004          0.9266         29.0046         30.0446         30.6535         29.8835
360038..................................................          1.5826          0.9581         25.4274         31.0611         31.3759         29.1457
360039..................................................          1.4590          0.9657         23.9783         24.7873         25.8206         24.8982
360040..................................................          1.2069          0.8969         24.8569         25.5337         26.7437         25.7182
360041..................................................          1.4496          0.9266         26.1522         26.6755         28.4427         27.1150
360044..................................................          1.1770          0.8709         21.5619         24.3840         24.7681         23.5345
360046..................................................          1.2150          0.9581         25.4673         26.2417         28.2956         26.6958
360048..................................................          1.8237          0.9267         29.3415         29.4378         30.0370         29.6170
360049..................................................             ***               *         26.2222               *               *         26.2222
360051..................................................          1.6897          0.9321         26.8501         28.1167         29.4411         28.1381
360052..................................................          1.5471          0.9321         26.2066         26.8806         28.4711         27.2049
360054..................................................          1.3413          0.8759         22.9359         24.8248         23.6593         23.7903
360055..................................................          1.4007          0.8931         27.3941         30.0143         31.4776         29.5863
360056..................................................          1.5488          0.9581         26.5318         30.3677         31.1802         29.4451
360058..................................................          1.1206          0.8582         23.8119         24.5003         25.9278         24.7681
360059..................................................          1.4695          0.9266         29.3624         30.6173         30.6279         30.2152
360062..................................................          1.5597          0.9869         31.7422         32.8893         32.8990         32.5514
360064..................................................          1.5123          0.8931         25.2336         27.7795         28.6078         27.1789
360065..................................................          1.2709          0.9266         28.0405         29.7155         31.5056         29.7621
360066..................................................          1.4332          0.9299         27.1436         29.7605         30.9636         29.2899
360068..................................................          1.8584          0.9267         26.2065         26.6933         28.6320         27.1929
360070..................................................          1.6693          0.8845         27.2389         27.8891         28.8717         27.9936
360071..................................................          1.1466          0.8617         23.4619         26.4081         25.7940         25.2133
360072..................................................          1.5262          0.9869         25.9589         27.2286         28.3666         27.2276
360074..................................................          1.2813          0.9267         25.8959         27.5328         27.9970         27.1581
360075..................................................          1.2013          0.9266         26.8925         26.1657         28.3916         27.1857
360076..................................................          1.5143          0.9581         28.1013         29.0148         29.2102         28.7968
360077..................................................          1.5018          0.9266         28.4449         28.0133         28.3010         28.2547
360078..................................................          1.2814          0.9266         25.7885         27.4689         27.3636         26.8573
360079..................................................          1.7270          0.9321         27.2437         30.1230         31.3114         29.5585
360080..................................................          1.1032          0.8582         21.4526         22.7020         21.8797         22.0297
360081..................................................          1.3032          0.9267         29.8366         29.5312         31.4274         30.2589
360082..................................................          1.3735          0.9266         29.2561         28.7925         30.5823         29.5279
360084..................................................          1.6319          0.8845         27.3917         28.5402         29.2435         28.4167
360085..................................................          2.0543          0.9869         31.5800         32.8502         33.1267         32.5905
360086..................................................          1.6514          0.9321         25.4218         27.3124         28.3559         27.0242
360087..................................................          1.4326          0.9266         29.6579         28.4185         28.6324         28.8850
360089..................................................          1.1327          0.8582         25.3465         25.5608         28.0769         26.2935
360090..................................................          1.4661          0.9267         29.0199         30.7530         29.2643         29.6802
360091..................................................          1.3415          0.9266         25.8657         27.6809         28.1671         27.2522
360092..................................................          1.2566          0.9869         25.4954         25.4055         28.0797         26.3112
360095..................................................          1.4803          0.9267         26.4635         29.3787         30.1514         28.6022
360096..................................................          1.1353          0.8582         25.9275         26.8653         27.9493         26.9250
360098..................................................          1.4304          0.9266         25.5973         26.6382         26.5824         26.3001
360100..................................................          1.3412          0.8845         25.4523         23.6167         25.8131         24.9650
360101..................................................          1.4779          0.9266         27.6030         29.7817         30.6609         29.3460
360107..................................................          1.1819          0.9267         24.6095         26.0534         26.8168         25.8586
360109..................................................          1.0429          0.8582         26.3131         30.1382         30.4624         28.9111
360112..................................................          1.8522          0.9267         30.5715         31.1356         32.4383         31.4039
360113..................................................          1.2805          0.9581         26.6556         30.2871         30.3893         29.0672
360115..................................................          1.3320          0.9266         25.9841         26.1821         26.8438         26.3395
360116..................................................          1.2122          0.9581         25.1717         26.4968         26.8619         26.2113
360118..................................................          1.4755          0.9295         27.3884         28.5643         29.9812         28.5726
360121..................................................          1.2872          0.9267         27.4442         28.3835         31.6755         29.0943
360123..................................................          1.4063          0.9266         27.1920         28.0334         28.5418         27.9298
360125..................................................          1.2052          0.8582         24.1388         25.9067         27.1761         25.6993
360130..................................................          1.5015          0.9266         25.6570         26.3986         28.1792         26.7600
360131..................................................          1.3679          0.8845         25.3719         26.6635         27.3408         26.4479
360132..................................................          1.3742          0.9581         27.7724         29.4070         29.8386         28.9945
360133..................................................          1.5965          0.9321         29.8684         31.7521         33.1791         31.6376
360134..................................................          1.7642          0.9581         27.7339         28.5141         29.9175         28.7663
360137..................................................          1.7064          0.9266         26.1250         27.6894         30.3093         28.0256

[[Page 23763]]

 
360141..................................................          1.6073          0.8931         29.7937         31.1778         31.9380         30.9580
360143..................................................          1.3047          0.9266         28.3057         26.9394         28.0681         27.7625
360144..................................................          1.3394          0.9266         28.2473         28.9177         29.6531         28.9566
360145..................................................          1.6504          0.9266         27.1908         28.1835         29.3247         28.2623
360147..................................................          1.2554          0.8582         25.5854         27.5548         29.2356         27.4482
360148..................................................          1.1785          0.8582         26.0837         26.3399         25.7446         26.0498
360150..................................................          1.3213          0.9266         25.1217         28.2561         27.8825         27.0949
360151..................................................          1.4719          0.8845         25.3780         26.5636         26.9664         26.3114
360152..................................................          1.5125          0.9869         29.9425         31.5377         33.3560         31.6190
360153..................................................          0.9954          0.8582         19.8499         20.2147         21.8404         20.6626
360155..................................................          1.4645          0.9266         26.9127         28.9521         28.8915         28.2820
360156..................................................          1.1512          0.8701         24.3281         25.0833         26.2253         25.2574
360159..................................................          1.3312          0.9657         29.1529         28.6174         29.0171         28.9284
360161..................................................          1.3364          0.8931         25.4433         27.0875         27.7406         26.7559
360163..................................................          1.8747          0.9581         28.9742         30.0724         31.2057         30.0774
360170..................................................          1.1878          0.9869         28.5474         29.5954         30.0025         29.4160
360172..................................................          1.3762          0.9266         27.5669         28.8283         30.2315         28.8817
360174..................................................          1.2862          0.9321         26.8586         28.3143         28.3749         27.8656
360175..................................................          1.2487          0.9657         28.1531         28.3054         29.7479         28.7375
360179..................................................          1.5492          0.9581         30.0311         29.8299         31.3518         30.4088
360180..................................................          2.3387          0.9266         29.6633         31.4342         32.0205         31.0895
360185..................................................          1.2624          0.8582         25.6800         26.1080         26.4201         26.0786
360187..................................................          1.4967          0.9321         24.9353         25.7600         27.3727         26.0387
360189..................................................          1.1420          0.9869         26.3756         27.5097         28.2736         27.4040
360192..................................................          1.3279          0.9266         26.4616         27.5991         29.1980         27.8031
360195..................................................          1.0799          0.9266         25.0922         27.6155         27.2619         26.6349
360197..................................................          1.1347          0.9657         28.7580         28.9207         28.5250         28.7314
360203..................................................          1.1898          0.8582         24.4433         25.3692         27.7551         25.8598
360210..................................................          1.2170          0.9869         28.2976         29.6476         31.8161         29.9477
360211..................................................          1.6076          0.8582         25.7053         26.5459         27.2721         26.4875
360212..................................................          1.3076          0.9266         25.6080         26.6976         28.5868         26.9659
360218..................................................          1.2246          0.9869         29.8662         30.0101         31.0690         30.3264
360230..................................................          1.5275          0.9266         28.8018         30.0661         30.5975         29.8409
360234..................................................          1.4185          0.9581         25.9360         31.0656         30.7904         29.2950
360236..................................................          1.3057          0.9581         25.6728         29.5321         29.9348         28.6891
360239..................................................          1.3536          0.9321         27.2939         30.7728         31.7919         29.9651
360241..................................................             ***               *         23.0662         25.7290         25.8138         24.8236
360242..................................................          1.9535               *               *               *               *               *
360245..................................................          0.6344          0.9266         20.6504         20.3426         20.4587         20.4760
360247..................................................          0.4196          0.9869         19.3677               *               *         19.3677
360253..................................................          2.2617          0.9581         33.2371         34.3347         34.6849         34.0994
360259..................................................          1.2301          0.9267         25.9878         27.2902         28.0868         27.1587
360261..................................................          1.5079          0.9118         22.3614         25.6332         26.6241         24.8458
360262..................................................          1.2975          0.9267         28.6995         30.1559         31.5616         30.2316
360263..................................................          1.9432          0.9299         25.1652         25.4864         28.1657         26.3875
360264..................................................             ***               *         36.0754               *               *         36.0754
360265..................................................             ***               *         36.6265               *               *         36.6265
360266..................................................          2.1538          0.9869               *         31.7565         29.8358         30.6488
360267..................................................             ***               *               *         34.0936               *         34.0936
360268..................................................             ***               *               *         34.0526               *         34.0526
360269..................................................          1.7035          0.9581               *         24.8552         25.5163         25.2427
360270..................................................          1.1268          0.8582               *               *         28.8661         28.8661
360271..................................................             ***               *               *               *         28.4331         28.4331
360272..................................................             ***               *               *               *         38.0986         38.0986
360273..................................................             ***               *               *               *         37.6617         37.6617
360274..................................................          1.5016          0.9321               *               *               *               *
360276..................................................          1.1341          0.8931               *               *               *               *
370001..................................................          1.6484          0.8652         26.0194         26.8884         28.4890         27.1483
370002..................................................          1.1271          0.8016         22.0476         23.6886         26.2488         23.9833
370004..................................................          1.1127          0.9349         26.7434         26.8521         28.2786         27.2955
370006..................................................          1.2372          0.8784         22.4802         23.9935         25.2294         23.8425
370007..................................................          1.0227          0.8016         19.4036         20.3706         21.1255         20.2911
370008..................................................          1.4408          0.8686         25.3352         26.6563         27.9923         26.6850
370011..................................................          1.0018          0.8686         21.9649         22.3391         23.1755         22.5131
370013..................................................          1.5415          0.8686         26.5364         27.2667         28.3486         27.4244
370014..................................................          1.0690          0.9291         25.9393         26.4488         28.8951         27.1129
370015..................................................          1.0296          0.8652         24.7547         25.5815         27.8050         26.1032

[[Page 23764]]

 
370016..................................................          1.5756          0.8686         26.7938         29.8284         30.4646         28.9272
370018..................................................          1.5016          0.8652         25.3573         24.6868         31.2325         27.0624
370019..................................................          1.1994          0.8016         22.0221         25.2814         26.7609         24.7201
370020..................................................          1.4065          0.8016         20.8723         22.7566         27.7807         23.6027
370022..................................................          1.1935          0.8016         24.6099         22.2289         26.4826         24.3184
370023..................................................          1.2804          0.8106         23.5170         24.0376         24.9575         24.1637
370025..................................................          1.3471          0.8652         23.9873         24.5547         24.8323         24.4542
370026..................................................          1.4489          0.8686         25.8428         25.5172         26.0190         25.7953
370028..................................................          1.9475          0.8686         27.8621         28.5619         29.9829         28.8114
370029..................................................          1.1365          0.8016         26.8508         28.5309         30.0133         28.4170
370030..................................................          1.0209          0.8652         24.1483         25.8212         26.0822         25.3421
370032..................................................          1.4768          0.8686         24.8626         26.2642         28.0726         26.3353
370034..................................................          1.2643          0.8016         19.5099         20.4106         23.2177         21.1222
370036..................................................          1.0929          0.8016         19.2318         19.8162         21.1549         20.1518
370037..................................................          1.6173          0.8686         24.9553         25.2350         26.8975         25.7110
370039..................................................          1.0375          0.8652         23.0254         23.5745         25.3412         23.9675
370040..................................................          0.9726          0.8016         22.8356         26.7395         19.7632         23.1713
370041..................................................          0.8769          0.8652         22.6731         22.9834         29.5069         24.8467
370047..................................................          1.4262          0.8686         24.1991         24.4766         27.8930         25.5715
370048..................................................          1.0294          0.8016         21.4543         22.0627         23.4845         22.3179
370049..................................................          1.3024          0.8686         23.8844         22.8755         24.2087         23.6440
370051..................................................          1.0519          0.8016         19.8329         19.3222         21.8711         20.3135
370054..................................................          1.2382          0.8016         22.4652         25.2142         23.4638         23.6682
370056..................................................          1.8723          0.8630         24.3986         25.5453         27.6169         25.8232
370057..................................................          1.0258          0.8652         19.8683         22.1337         23.1808         21.6643
370060..................................................          1.0456          0.8652         19.9025         23.3858         25.5560         22.9757
370065..................................................          1.0154          0.8112         21.2343         23.5815         24.0050         22.9087
370072..................................................          0.8329          0.8274         11.7942         13.0963         22.8589         14.5180
370078..................................................          1.5381          0.8652         27.8611         26.6972         30.4817         28.2974
370080..................................................          0.9489          0.8016         19.9595         22.4113         23.7218         22.0520
370083..................................................          0.9450          0.8067         19.2568         20.9878         21.9159         20.6845
370084..................................................          1.0056          0.8016         19.6230         20.7326         17.4201         19.1737
370089..................................................          1.4095          0.8016         20.6153         22.1523         22.0592         21.6429
370091..................................................          1.6019          0.8652         24.1438         25.8697         28.0464         26.0375
370093..................................................          1.6611          0.8686         26.0459         27.5356         26.7255         26.7691
370094..................................................          1.3751          0.8686         24.5555         26.5265         28.3484         26.4229
370097..................................................          1.2821          0.8630         26.3168         26.8138         28.0905         27.0817
370099..................................................          1.0542          0.8016         24.9971         26.7206         30.5425         27.4897
370100..................................................          0.9080          0.8116         17.9732         19.4002         20.6297         19.4038
370103..................................................          1.0407          0.8016         18.8933         19.4273         22.2665         20.0894
370105..................................................          2.0282          0.8686         26.7973         26.6399         30.5423         27.9853
370106..................................................          1.4171          0.8686         27.8979         28.5957         29.6782         28.7253
370112..................................................          0.9279          0.8016         16.0592         16.7888         19.0125         17.3058
370113..................................................          1.1274          0.8950         26.9720         26.4608         30.0045         27.8038
370114..................................................          1.5752          0.8652         23.0006         25.9841         27.3069         25.4424
370138..................................................          1.0937          0.8016         20.2528         22.1675         23.6337         21.8806
370139..................................................          0.9151          0.8016         19.4287         20.5156         21.0751         20.3636
370148..................................................          1.5372          0.8686         27.0904         28.1933         29.3428         28.2968
370149..................................................          1.3311          0.8686         23.3493         23.3423         23.0749         23.2542
370153..................................................          1.1065          0.8016         23.2778         24.1667         25.9232         24.4635
370156..................................................          1.0044          0.8137         25.2562         23.0104         22.7138         23.5680
370158..................................................          0.9394          0.8686         20.7641         21.5228         22.0059         21.4295
370166..................................................          0.8545          0.8652         25.1107         24.7251         26.3414         25.3950
370169..................................................          0.9454          0.8179         16.8252         16.6752         24.5386         19.7622
370170..................................................          0.9052          1.4446               *               *               *               *
370171..................................................          0.9693          1.4446               *               *               *               *
370172..................................................          0.8569          1.4704               *               *               *               *
370173..................................................          0.9838          1.4446               *               *               *               *
370174..................................................          0.9087          1.4446               *               *               *               *
370176..................................................          1.3084          0.8652         24.7655         24.9650         26.6672         25.4759
370178..................................................          0.9114          0.8016         16.0179         16.0747         15.5266         15.8654
370180..................................................          1.1405          1.4446               *               *               *               *
370183..................................................          0.9683          0.8652         24.7103         23.8419         30.3849         26.4222
370190..................................................          1.5039          0.8652         29.1568         34.6942         32.5630         32.3673
370192..................................................          1.9589          0.8686         27.6367         19.0638         19.1330         21.1807
370196..................................................             ***               *         22.3498         20.8296         24.6968         22.8178
370199..................................................          0.9156          0.8686         23.3989         23.7412         23.9357         23.7085

[[Page 23765]]

 
370200..................................................          1.0572          0.8016         20.5175         21.7153         19.7049         20.6651
370201..................................................          1.7010          0.8686         23.8090         24.2364         25.5862         24.5320
370202..................................................          1.4934          0.8652         26.1132         25.7966         25.8246         25.9084
370203..................................................          1.9356          0.8686         22.8869         25.7770         30.3614         26.3098
370206..................................................          1.7577          0.8686         26.0353         27.5752         30.8129         28.1710
370210..................................................          2.1582          0.8652         23.3786         27.2111         25.7890         25.4309
370211..................................................          1.1931          0.8686         27.8737         28.6537         30.9637         29.3408
370212..................................................          1.8217          0.8686         19.1720         20.3495         20.0910         19.8981
370214..................................................          0.8902          0.8137         20.6217         21.0732         20.1491         20.5858
370215..................................................          2.3013          0.8686         31.5652         32.4087         32.0922         32.0514
370216..................................................          2.0050          0.8652         27.2429         25.8260         29.6639         27.5894
370217..................................................             ***               *         26.8677               *               *         26.8677
370218..................................................          1.9640          0.8652               *         30.3445         23.7493         26.4612
370219..................................................             ***               *               *               *         41.4373         41.4373
370220..................................................          2.3081          0.8686               *               *         21.3140         21.3140
370222..................................................          1.8753          0.8686               *               *         26.9158         26.9158
370223..................................................          0.8701          0.8686               *               *         24.0138         24.0138
370226..................................................          1.4674          0.8016               *               *               *               *
370227..................................................          0.9326          0.8652               *               *               *               *
370228..................................................          1.2387          0.8652               *               *               *               *
380001..................................................          1.2850          1.1204         29.5842         32.0770         33.8473         31.8553
380002..................................................          1.2143          1.0298         30.3385         31.5246         32.6801         31.5496
380004..................................................          1.6454          1.1204         32.6901         34.5432         36.1178         34.4710
380005..................................................          1.4198          1.0298         30.9087         33.2849         33.5739         32.5875
380007..................................................          1.9643          1.1204         33.9601         35.1697         36.4198         35.2082
380009..................................................          2.0934          1.1204         32.4016         34.5635         36.5661         34.5647
380010..................................................             ***               *         34.4208               *               *         34.4208
380014..................................................          1.8838          1.1076         33.6078         33.1928         35.7074         34.1739
380017..................................................          1.7891          1.1204         34.2605         35.3734         37.0024         35.5661
380018..................................................          1.8551          1.0298         30.9923         31.8181         32.4859         31.7959
380020..................................................          1.4577          1.1157         29.6053         34.6183         35.7367         32.9979
380021..................................................          1.4597          1.1204         29.2164         32.6142         33.0611         31.5746
380022..................................................          1.3523          1.0572         30.1742         29.6224         30.9162         30.2422
380025..................................................          1.1973          1.1204         35.5084         36.4910         38.1479         36.7332
380027..................................................          1.3782          1.1157         26.4982         28.0247         31.4378         28.6431
380029..................................................          1.2617          1.0725         28.7994         29.4461         33.3348         30.6606
380033..................................................          1.7377          1.1157         33.4828         34.0094         36.0221         34.5420
380037..................................................          1.3322          1.1204         32.4033         32.7922         34.0301         33.1177
380038..................................................          1.2761          1.1204         34.5971         35.1105         35.0334         34.9145
380039..................................................             ***               *         38.0989               *               *         38.0989
380040..................................................          1.4621          1.0298         31.2286         32.9081         34.4710         32.9570
380047..................................................          1.8056          1.1043         31.0584         32.8188         35.8144         33.3095
380050..................................................          1.4231          1.0298         27.1814         29.7329         31.3064         29.4427
380051..................................................          1.7594          1.1204         30.8891         32.8545         34.6659         32.8426
380052..................................................          1.2624          1.0298         25.6085         28.6119         27.7647         27.2628
380056..................................................          1.1073          1.0725         27.7253         29.1686         31.0190         29.2586
380060..................................................          1.4994          1.1204         32.0101         33.8863         35.1087         33.6769
380061..................................................          1.6390          1.1204         32.3699         34.5230         35.7630         34.2152
380071..................................................          1.3775          1.1204         31.7761         31.0901         31.6798         31.5133
380075..................................................          1.3482          1.0298         33.8962         31.6884         34.0174         33.2050
380081..................................................             ***               *         26.8149               *               *         26.8149
380082..................................................          1.2966          1.1204         35.6708         35.7821         37.7239         36.4069
380089..................................................          1.3399          1.1204         34.6015         35.4850         36.9989         35.7198
380090..................................................          1.3418          1.1157         33.0990         35.5535         41.4499         36.7267
380091..................................................          1.4734          1.1204         39.9703         40.5066         38.4947         39.6719
380100..................................................             ***               *               *               *         45.3849         45.3849
390001..................................................          1.5668          0.8342         23.6075         24.3251         25.4178         24.4575
390002..................................................          1.3393          0.8579         24.7867         25.0860         25.9811         25.2995
390003..................................................          1.2164          0.8342         23.3672         24.5099         26.2863         24.7251
390004..................................................          1.6088          0.9185         24.4068         25.2424         26.5037         25.3610
390006..................................................          1.9527          0.9185         26.8581         28.6926         30.9901         28.9685
390008..................................................          1.1400          0.8402         22.8042         22.6297         22.9409         22.7921
390009..................................................          1.8038          0.8708         26.7462         26.7234         28.7325         27.4264
390010..................................................          1.1889          0.8579         24.5785         24.8196         26.0951         25.1622
390011..................................................             ***               *         21.4856         20.2291               *         20.8697
390012..................................................          1.1856          1.0992         30.7542         32.4856         34.1980         32.4294
390013..................................................          1.3619          0.9185         25.0037         26.2323         28.3024         26.5751

[[Page 23766]]

 
390016..................................................          1.2430          0.8559         23.2095         24.3488         26.1785         24.5413
390019..................................................          1.1210          0.9675         24.0538         25.7515         25.3173         24.9933
390022..................................................             ***               *         30.3565         29.6308               *         29.9808
390023..................................................          1.2632          1.0992         35.4452         34.7787         36.2584         35.4918
390024..................................................             ***               *         33.5186         38.8750         37.4780         36.5096
390025..................................................          0.4329          1.0992         19.1362         20.3878               *         19.7743
390026..................................................          1.3079          1.0992         31.8512         31.8309         36.0580         33.1365
390027..................................................          1.6538          1.0992         35.5692         39.2158         40.9084         38.5953
390028..................................................          1.5828          0.8579         27.1869         27.1451         29.6197         27.9531
390030..................................................          1.1870          0.8626         23.6063         24.6343         26.5661         24.9940
390031..................................................          1.2126          0.9204         26.2654         27.2033         26.1246         26.5387
390032..................................................          1.2693          0.8579         23.9466         24.5243         25.3739         24.6172
390035..................................................          1.1907          1.0992         28.4564         29.5417         27.2114         28.3541
390036..................................................          1.4853          0.8579         21.6358         24.4917         26.1934         24.0498
390037..................................................          1.4598          0.8579         25.4290         25.2296         27.0768         25.9180
390039..................................................          1.2528          0.8342         22.0208         23.2300         22.1517         22.4609
390041..................................................          1.3077          0.8579         22.9814         24.2257         25.1175         24.1286
390042..................................................          1.3624          0.8579         28.3633         28.0996         29.6193         28.7201
390043..................................................          1.1959          0.8342         23.2378         24.2087         24.3584         23.9394
390044..................................................          1.5562          1.0788         28.7758         29.4057         29.9946         29.4217
390045..................................................          1.4816          0.8342         23.9343         24.6495         25.8784         24.8306
390046..................................................          1.6617          0.9799         29.6574         30.5115         32.5260         30.9440
390048..................................................          1.1221          0.9185         28.5342         28.3152         28.4555         28.4340
390049..................................................          1.5809          0.9675         29.6121         30.7431         30.4709         30.2929
390050..................................................          2.0142          0.8579         27.2599         27.3481         29.6697         28.1208
390052..................................................          1.1476          0.8389         24.9510         25.1462         26.3688         25.5002
390054..................................................             ***               *         24.4435         27.4805         27.5682         26.3435
390056..................................................          1.1124          0.8378         23.5077         23.5821         24.7026         23.9359
390057..................................................          1.3322          1.0992         29.7982         30.9198         31.0260         30.6011
390058..................................................          1.3063          0.9185         26.9546         27.7296         29.6597         28.1041
390061..................................................          1.5170          0.9799         29.1318         30.0597         30.9185         29.9889
390062..................................................          1.1231          0.8342         21.2999         21.0713         22.8844         21.7734
390063..................................................          1.8374          0.8708         26.4998         26.8381         28.3963         27.2925
390065..................................................          1.3159          1.1006         27.6249         29.5654         31.8827         29.7493
390066..................................................          1.3881          0.9185         25.9645         25.4407         29.0022         26.8307
390067..................................................          1.7872          0.9185         29.7234         30.6128         32.2862         30.8943
390068..................................................          1.3404          0.9799         26.7358         29.0962         29.6963         28.5413
390070..................................................          1.3523          1.0992         33.3185         34.4935         34.5477         34.1258
390071..................................................          1.0062          0.8342         24.6462         24.8467         26.3816         25.3085
390072..................................................          1.0663          0.8342         25.3029         26.2568         28.8131         26.7355
390073..................................................          1.6919          0.8342         25.7822         26.4083         27.0855         26.4996
390074..................................................             ***               *         23.6500         25.4098               *         24.5222
390076..................................................          1.3189          1.0992         31.8500         32.7671         33.9877         32.8740
390079..................................................          1.8491          0.8560         22.5607         24.4452         26.0178         24.3375
390080..................................................          1.3943          1.0992         28.7063         29.2645         31.6193         29.8842
390081..................................................          1.2389          1.0992         31.7569         33.6247         36.4760         33.9941
390084..................................................          1.1285          0.8342         23.2039         24.3372         24.3181         23.9420
390086..................................................          1.5931          0.8342         23.5141         25.0992         24.7444         24.4724
390090..................................................          1.9186          0.8579         27.3528         27.0122         30.1231         28.1610
390091..................................................          1.1759          0.8559         21.7010         23.3562         23.2108         22.7618
390093..................................................          1.1913          0.8559         22.6082         22.6023         23.8837         23.0312
390095..................................................          1.1678          0.8342         22.6150         24.6290         25.3848         24.2111
390096..................................................          1.6015          1.0788         28.8258         28.6055         30.3896         29.2646
390097..................................................          1.2500          1.0992         26.1741         27.9858         28.1266         27.3784
390100..................................................          1.6431          0.9799         30.0132         30.0234         32.5896         30.9302
390101..................................................          1.2844          0.9666         23.1497         24.8377         27.3460         25.1596
390102..................................................          1.4773          0.8579         24.8369         24.4589         25.5321         24.9493
390103..................................................             ***               *         20.5741         20.4446               *         20.5090
390104..................................................          1.1021          0.8342         19.2326         19.6630         20.4543         19.7621
390107..................................................          1.5861          0.8579         24.1159         24.6565         25.6775         24.8676
390108..................................................          1.1988          1.0992         27.8171         28.5928         34.3038         30.1995
390110..................................................          1.5950          0.8579         27.7311         25.3407         25.7142         26.1477
390111..................................................          2.1581          1.0992         34.2990         34.8756         38.6429         35.9670
390112..................................................          1.3266          0.8342         20.2380         21.5439         18.4179         19.9664
390113..................................................          1.3312          0.8559         23.3686         24.2593         24.8661         24.1707
390114..................................................          1.6377          0.8579         26.9620         27.9184         28.5319         27.8260
390115..................................................          1.4264          1.0992         29.6905         30.8063         32.5023         31.0518

[[Page 23767]]

 
390116..................................................          1.2605          1.0992         32.2513         33.2562         33.9272         33.1578
390117..................................................          1.1784          0.8344         20.7821         21.5038         22.2319         21.5356
390118..................................................          1.1738          0.8342         20.5614         21.8917         23.6529         22.0851
390119..................................................          1.2800          0.8342         23.0928         24.3245         25.3896         24.2630
390121..................................................             ***               *         25.4826               *               *         25.4826
390122..................................................          1.1069          0.8395         23.1866         23.3220         24.6425         23.7140
390123..................................................          1.1993          1.0992         32.4528         34.0062         35.1219         33.8960
390125..................................................          1.2499          0.8364         22.4033         22.8816         24.0182         23.1230
390127..................................................          1.3561          1.0992         31.9091         33.6557         33.1200         32.8957
390128..................................................          1.2331          0.8579         24.1628         24.1390         25.1844         24.5037
390130..................................................          1.1985          0.8342         23.0592         23.2504         30.3208         25.3350
390131..................................................          1.3570          0.8579         23.0577         23.5783         27.7127         24.8832
390132..................................................          1.4504          1.0992         29.6396         31.1168         30.0723         30.2692
390133..................................................          1.7609          0.9675         31.1083         32.9812         33.0697         32.4255
390136..................................................             ***               *         23.9813               *               *         23.9813
390137..................................................          1.4546          0.8342         24.2878         26.1457         26.9140         25.8031
390138..................................................          1.1966          0.9185         25.3410         27.4231         27.7549         26.8681
390139..................................................          1.3522          1.0992         34.1447         34.0836         36.4969         34.9221
390142..................................................          1.5286          1.0992         33.8224         34.5773         33.3491         33.9107
390145..................................................          1.5880          0.8579         24.6672         25.6980         26.9194         25.7780
390146..................................................          1.1823          0.8364         22.6752         25.1805         23.9869         23.9695
390147..................................................          1.3781          0.8579         26.8522         28.6606         29.0974         28.1881
390150..................................................          1.1119          0.8579         22.8228         22.7668         22.6473         22.7481
390151..................................................          1.3436          1.1006         29.9254         31.4067         31.8952         31.1171
390153..................................................          1.3705          1.0992         32.8234         33.2427         36.0259         34.1045
390154..................................................          1.2171          0.8342         22.8391         23.3559         23.9776         23.4008
390156..................................................          1.3593          1.0992         32.2688         32.8999         33.7034         32.9631
390157..................................................          1.3257          0.8579         21.5923         22.1112         23.0975         22.2734
390160..................................................          1.3326          0.8579         24.0208         22.9696         25.2027         24.0528
390162..................................................          1.5041          1.1449         35.5057         34.5809         35.1818         35.0918
390163..................................................          1.2454          0.8559         23.2055         22.8341         24.8747         23.6452
390164..................................................          2.1300          0.8579         26.3087         27.1950         29.7760         27.7684
390166..................................................             ***               *         20.9272         23.3255         28.2160         23.9468
390168..................................................          1.4758          0.8579         26.1365         26.9816         27.3654         26.8304
390169..................................................          1.4118          0.8342         26.5514         26.2643         26.6049         26.4723
390173..................................................          1.2178          0.8342         23.9927         25.6455         27.6024         25.7719
390174..................................................          1.6824          1.0992         34.2069         34.8999         34.9029         34.6825
390176..................................................          1.1316          0.8579         23.9779         24.1247         12.3126         18.1769
390178..................................................          1.3247          0.8930         22.6006         23.1452         23.9151         23.2190
390179..................................................          1.4264          1.0992         28.0688         30.1219         31.5474         29.9836
390180..................................................          1.3926          1.0992         34.9832         35.5291         38.2969         36.3036
390181..................................................             ***               *         25.9871         26.6021         27.8820         26.8191
390183..................................................          1.1452          0.8342         27.0122         27.8358         28.2196         27.6769
390184..................................................          1.0915          0.8579         22.7451         23.9736         23.9958         23.5369
390185..................................................          1.2586          0.9675         25.4256         27.1119         25.5306         25.9878
390189..................................................          1.1436          0.8342         22.6796         23.6215         23.4893         23.2864
390192..................................................          1.0388          0.8342         20.5459         23.6171         23.7948         22.6673
390194..................................................          1.2037          0.9675         27.5890         26.3152         23.7351         25.7636
390195..................................................          1.6565          1.0992         34.2980         34.5594         37.2471         35.3797
390196..................................................          1.6460               *               *               *               *               *
390197..................................................          1.4171          0.9675         26.8270         27.2455         28.1394         27.4100
390198..................................................          1.1294          0.8708         20.5979         20.4350         21.0850         20.7061
390199..................................................          1.1366          0.8342         22.3224         23.0046         24.5461         23.3008
390201..................................................          1.3518          0.9512         27.0054         27.3542         28.5649         27.6588
390203..................................................          1.5297          1.0992         29.4930         29.1370         30.7209         29.8038
390204..................................................          1.2911          1.0992         29.5251         30.7346         32.0218         30.7952
390211..................................................          1.2835          0.8930         25.1689         26.5052         27.7862         26.4993
390217..................................................          1.2278          0.8579         23.5879         24.1886         26.2690         24.6769
390219..................................................          1.3577          0.8579         25.4886         26.1196         26.3253         25.9698
390220..................................................          1.0888          1.0992         28.9128         30.7435         32.0869         30.6085
390222..................................................          1.2691          1.0992         30.9464         31.7361         32.3724         31.7085
390223..................................................          1.9836          1.0992         30.2523         34.3280         37.4105         33.8814
390225..................................................          1.1877          0.9799         27.5803         27.2555         26.3628         26.9591
390226..................................................          1.7135          1.0992         32.6658         32.6508         35.4653         33.6044
390228..................................................          1.3609          0.8579         23.9845         24.2242         25.5103         24.5893
390231..................................................          1.4014          1.0992         30.9339         32.8353         35.2285         33.0470
390233..................................................          1.3823          0.9666         25.6904         27.2597         28.3647         27.1364

[[Page 23768]]

 
390236..................................................          0.9818          0.8345         22.1144         23.1290         24.5566         23.2393
390237..................................................          1.5868          0.8342         27.4944         28.4337         29.0645         28.3719
390246..................................................          1.1777               *         25.1956         26.0179               *         25.6189
390256..................................................          1.9774          0.9185         28.0617         28.8970         28.5871         28.5302
390258..................................................          1.4533          1.0992         30.4142         31.7164         32.0531         31.4303
390263..................................................          1.5092          0.9675         28.5864         29.9850         31.7255         30.1997
390265..................................................          1.5374          0.8579         24.0675         25.0166         27.7776         25.6284
390266..................................................          1.1912          0.8930         20.8789         22.2228         23.0128         22.0423
390267..................................................          1.2760          0.8579         24.2428         24.8309         25.7553         24.9521
390268..................................................          1.4064          0.8810         25.6643         26.7342         28.4188         27.0040
390270..................................................          1.6183          0.8342         24.9510         26.5010         27.0286         26.2567
390272..................................................          0.6051          1.0992               *               *         32.9893         32.9893
390278..................................................          0.6005          1.0992         26.6664         28.6323         28.8290         28.0560
390285..................................................          1.4914          1.0992         36.7163         37.6669         38.4678         37.6177
390286..................................................          1.2124          1.0992         29.5281         31.3393         31.7320         30.8704
390287..................................................             ***               *         39.3176         42.2401               *         40.3959
390288..................................................             ***               *         30.9701               *               *         30.9701
390289..................................................             ***               *         30.7583               *               *         30.7583
390290..................................................          1.8004          1.0992         38.3776         41.1426         47.7624         42.2989
390302..................................................          0.8675          1.0992               *               *               *               *
390303..................................................             ***               *         27.5580               *               *         27.5580
390304..................................................          1.2958          1.0992         30.4832         32.1633         33.4111         32.1082
390305..................................................             ***               *               *         29.3217               *         29.3217
390306..................................................             ***               *               *         40.3789               *         40.3789
390307..................................................          2.0387          0.8930               *         24.5393         22.9455         23.6860
390308..................................................             ***               *               *         36.1737               *         36.1737
390309..................................................             ***               *               *         37.8924               *         37.8924
390310..................................................             ***               *               *         44.3991               *         44.3991
390311..................................................             ***               *               *               *         49.8990         49.8990
390312..................................................          1.2883          1.0992               *               *         51.3342         51.3342
390313..................................................          1.1642          0.9204               *               *               *               *
390314..................................................          1.9344          0.9675               *               *               *               *
390315..................................................          1.6395          0.8579               *               *               *               *
390316..................................................          1.6856          0.9518               *               *               *               *
390318..................................................          0.8280          0.9675               *               *               *               *
400001..................................................          1.3295          0.4404         13.9386         14.9151         15.4246         14.7738
400002..................................................          1.9377          0.4122         15.3833         12.9440         12.9793         13.6878
400003..................................................          1.3791          0.4122         13.9258         15.7906         14.6853         14.8161
400004..................................................          1.2115          0.4404         12.0923         12.5928         13.5193         12.7362
400005..................................................          1.2533          0.4404         10.3505         11.1152         11.7582         11.0789
400006..................................................          1.1625          0.4404          8.1841          8.1381               *          8.1610
400007..................................................          1.1605          0.4404         11.8203         12.0743         10.4935         11.4512
400009..................................................          0.9834          0.3137          9.3834          9.5114         10.1204          9.6757
400010..................................................          0.9051          0.3311          9.8132         10.7993         10.4202         10.3256
400011..................................................          1.1055          0.4404          9.6641          8.5503          9.4065          9.2136
400012..................................................          1.4864          0.4404         12.3362         10.1156               *         11.0797
400013..................................................          1.3650          0.4404         11.1414         11.4222         12.3068         11.6476
400014..................................................          1.3749          0.3896         10.5286          9.9395         12.3295         10.8952
400015..................................................          1.4718          0.4404         13.7043         22.2017         21.9216         18.9475
400016..................................................          1.4676          0.4404         16.6472         16.1931         17.9101         16.9079
400017..................................................          0.8958          0.4404         10.3123          9.9185         10.0587         10.0981
400018..................................................          1.1103          0.4404         11.9184         12.3942         13.1567         12.5002
400019..................................................          1.5158          0.4404         12.8380         14.7133         15.2358         14.0763
400021..................................................          1.3614          0.4648         14.4549         13.9217         14.9779         14.4495
400022..................................................          1.4439          0.4122         14.9089         15.3625         15.2119         15.1640
400024..................................................          0.8933          0.3896         10.8439         12.6226         13.7214         12.2509
400026..................................................          1.1373          0.3137          9.9262          7.1179          8.9063          8.4875
400028..................................................          1.1913          0.4122         11.3260         10.6711          9.6940         10.5465
400032..................................................          1.1451          0.4404         10.3736         10.7141         10.7841         10.6281
400044..................................................          1.4861          0.4122         14.6420         11.3551         12.1404         12.5283
400048..................................................          1.3035          0.3137          9.6416          9.6860         10.5172          9.9689
400061..................................................          2.2573          0.4404         18.1303         18.0093         17.4499         17.8500
400079..................................................          1.2280          0.3311          9.5296         10.4599         10.6123         10.2200
400087..................................................          1.3360          0.4404         11.0377         11.4162         12.0032         11.4590
400098..................................................          1.3491          0.4404         13.8034         13.7878         12.8752         13.4675
400102..................................................          1.1900          0.4404         10.5879         12.1761         12.1258         11.5565
400103..................................................          1.9297          0.3896         10.6971         11.7488         11.3309         11.2618

[[Page 23769]]

 
400104..................................................          1.2190          0.4404         11.4322         12.8404         12.6932         12.3296
400105..................................................          1.2578          0.4404         15.6626         16.9029         17.0458         16.5427
400106..................................................          1.1085          0.4404         13.4097         12.9272         14.8543         13.7089
400109..................................................          1.4302          0.4404         14.4386         14.8208         14.5707         14.6114
400110..................................................          1.2156          0.3358         11.1812          9.9278         10.8210         10.6067
400111..................................................          1.2130          0.3311         14.1718         10.2141         10.7888         11.5139
400112..................................................          1.2446          0.4404         10.1512         13.5177         11.2302         11.5795
400113..................................................          1.1764          0.4122         10.5305         10.9503         11.5947         11.0441
400114..................................................          1.1726          0.4404         10.1379         10.8913         11.6870         10.9257
400115..................................................          1.0815          0.4404         12.0713          9.6200         10.6805         10.8173
400117..................................................          1.1347          0.4404          9.5929         11.6258         12.1537         11.0019
400118..................................................          1.2649          0.4404         12.8692         12.7861         12.6196         12.7539
400120..................................................          1.3351          0.4404         13.4069         14.0817         14.5200         14.0199
400121..................................................          1.1129          0.4404          9.7427          9.1826          9.9712          9.6244
400122..................................................          1.8905          0.4404          8.9478          9.5814         10.0960          9.5553
400123..................................................          1.2353          0.3896         12.8317         12.5609         13.8597         13.0762
400124..................................................          2.6860          0.4404         17.2139         17.9140         19.1698         18.1028
400125..................................................          1.2073          0.4067         11.9787         13.5394         13.1075         12.8846
400126..................................................          1.2894          0.4648         14.1062         16.5726               *         15.3043
400127..................................................          2.0911          0.4404         17.8303         20.7775               *         19.5304
400128..................................................          1.0184          0.4404               *         12.3520               *         12.3520
410001..................................................          1.3144          1.1338         29.0877         30.0315         30.5848         29.9101
410004..................................................          1.3107          1.1338         29.4953         31.3023         35.2360         31.9950
410005..................................................          1.2724          1.1338         28.1141         31.4387         34.5807         31.2615
410006..................................................          1.3911          1.0669         30.1855         32.8456         33.5403         32.1894
410007..................................................          1.6113          1.1338         33.2896         32.0730         34.2549         33.1928
410008..................................................          1.3225          1.0669         30.9505         32.5889         33.5128         32.3511
410009..................................................          1.2374          1.0669         31.7300         32.8422         34.3405         32.9948
410010..................................................          1.1305          1.1338         32.0704         32.7379         34.8380         33.2523
410011..................................................          1.4882          1.1338         33.8781         30.1941         36.7639         33.5131
410012..................................................          1.5728          1.1338         33.6072         37.0299         35.5818         35.4055
410013..................................................          1.2045          1.1587         35.8075         41.0010         40.1823         38.9884
420002..................................................          1.5630          0.9561         29.5592         30.5111         31.2220         30.4468
420004..................................................          1.9671          0.9231         28.1455         28.9250         30.2325         29.1286
420005..................................................          1.1610          0.8609         25.0420         24.6968         26.5027         25.3750
420006..................................................             ***               *         26.3293         27.7764         29.1383         27.7486
420007..................................................          1.6315          0.9294         26.8165         29.0901         28.9533         28.2944
420009..................................................          1.4114          0.9294         27.0147         29.9378         28.6625         28.5279
420010..................................................          1.1406          0.8609         25.1452         25.5710         26.5503         25.7612
420011..................................................          1.1778          0.9605         22.1787         25.5130         25.9543         24.5702
420015..................................................          1.3156          0.9605         24.1685         26.3499         27.4912         26.0287
420016..................................................          0.9672          0.8609         21.6266         22.5681         23.4313         22.5462
420018..................................................          1.8307          0.8984         25.6687         27.5563         29.0897         27.4853
420019..................................................          1.0990          0.8767         22.5489         25.4954         25.8113         24.4094
420020..................................................          1.3500          0.9231         28.4344         27.5000         29.2372         28.3934
420023..................................................          1.7169          0.9605         27.4589         28.9321         30.4471         28.9941
420026..................................................          1.8642          0.8984         27.8986         28.0647         29.5039         28.4725
420027..................................................          1.5767          0.9294         26.4472         28.5621         31.3772         28.7401
420030..................................................          1.3204          0.9231         27.8435         28.4433         30.3403         28.8720
420033..................................................          1.1839          0.9605         30.4162         31.1608         32.4244         31.3429
420036..................................................          1.2480          0.9557         23.8742         24.6505         26.3463         24.9665
420037..................................................          1.3390          0.9605         29.8321         30.9556         32.7083         31.1311
420038..................................................          1.2831          0.9605         24.6642         26.6435         27.1507         26.1466
420039..................................................          1.0529          0.9017         28.2220         26.5582         26.3100         26.9774
420043..................................................          1.1111          0.8766         24.0971         25.7951         25.8352         25.2415
420048..................................................          1.2885          0.8984         25.9610         26.9625         27.4313         26.8137
420049..................................................          1.2591          0.8683         26.0953         25.7060         28.0020         26.6253
420051..................................................          1.7106          0.8609         25.9056         26.4710         27.4172         26.6012
420053..................................................          1.2316          0.8644         23.2246         24.4793         25.5724         24.4361
420054..................................................          1.1106          0.8612         25.6779         25.6444         26.7888         26.0196
420055..................................................          1.0931          0.8609         24.0965         25.1738         25.3132         24.8604
420056..................................................          1.3487          0.8609         27.7250         28.4512         29.7763         28.7570
420057..................................................          1.2036          0.8609         24.9313         26.2489         25.6602         25.6193
420062..................................................          1.1026          0.9557         26.7467         25.9569         27.2249         26.6400
420064..................................................          1.2630          0.8683         24.3540         24.6507         25.0602         24.6890
420065..................................................          1.4161          0.9231         25.5483         26.8118         28.1872         26.8671
420066..................................................          0.9980          0.8609         25.1062         25.0932               *         25.0997

[[Page 23770]]

 
420067..................................................          1.3639          0.8827         25.8561         26.5658         27.7148         26.7379
420068..................................................          1.3759          0.9231         25.6857         27.7315         28.0296         27.1430
420069..................................................          1.2054          0.8609         22.3445         23.7494         24.4638         23.5595
420070..................................................          1.3136          0.8984         24.7899         27.5988         27.6406         26.7218
420071..................................................          1.4339          0.9294         25.2862         27.6371         28.1087         27.0462
420072..................................................          1.1634          0.8609         17.8019         21.6587         20.7707         19.9748
420073..................................................          1.3829          0.8984         25.5204         26.1120         28.2651         26.7147
420078..................................................          1.8607          0.9605         29.5135         30.9001         32.0165         30.8100
420079..................................................          1.5040          0.9231         27.5439         28.6374         30.5954         28.9420
420080..................................................          1.4321          0.8827         28.6060         31.5670         32.8693         30.8888
420082..................................................          1.5113          0.9597         31.2671         33.9874         34.8836         33.3515
420083..................................................          1.4528          0.9294         26.4932         28.9007         29.6565         28.4194
420085..................................................          1.5909          0.9074         27.8386         29.1127         29.9059         28.9688
420086..................................................          1.4584          0.8984         28.0485         27.9523         29.6321         28.5671
420087..................................................          1.8044          0.9231         25.4697         26.8409         28.4609         26.9052
420089..................................................          1.3777          0.9231         28.1855         29.5862         31.7347         29.8346
420091..................................................          1.4537          0.8609         26.0592         27.2520         27.9042         27.0840
420093..................................................             ***               *         28.0765         33.0474               *         30.2237
420098..................................................          1.2041          0.8609         30.7532         27.1939         27.6701         28.2065
420099..................................................             ***               *               *         30.3089               *         30.3089
420100..................................................             ***               *               *               *         29.2958         29.2958
420101..................................................          1.2049          0.8609               *               *         33.1975         33.1975
420102..................................................          1.4677          0.9605               *               *               *               *
430005..................................................          1.3356          0.8428         22.4111         23.8694         25.4368         23.9203
430008..................................................          1.1161          0.8963         24.4277         26.0873         27.2262         25.9003
430012..................................................          1.3044          0.9262         24.0326         25.2030         27.0179         25.4023
430013..................................................          1.2029          0.9262         25.9828         27.0427         28.4945         27.1837
430014..................................................          1.4127          0.8428         26.8752         27.9288         28.9278         27.9157
430015..................................................          1.1983          0.8428         23.6296         26.5787         28.0396         26.1008
430016..................................................          1.5975          0.9379         28.9376         32.8765         31.1313         30.9581
430027..................................................          1.7417          0.9379         26.6044         27.5759         29.2595         27.8481
430048..................................................          1.2671          0.8557         24.1969         25.1715         25.6411         25.0133
430060..................................................          0.9444          0.8428         13.2618               *               *         13.2618
430064..................................................          0.9859          0.8428         18.3125         16.4916         17.7325         17.4427
430077..................................................          1.7222          0.9618         25.8572         27.2116         31.1926         28.0482
430081..................................................          0.9388          1.4448               *               *               *               *
430082..................................................          0.8463          1.4448               *               *               *               *
430083..................................................          0.8496          1.4448               *               *               *               *
430084..................................................          0.9068          1.4448               *               *               *               *
430085..................................................          0.8878          1.4448               *               *               *               *
430089..................................................          1.8588          0.8783         22.3335         23.2467         24.9033         23.5426
430090..................................................          1.6017          0.9379         26.4862         29.0197         32.7369         29.5038
430091..................................................          2.2308          0.9502         25.1105         24.7274         26.7238         25.5162
430092..................................................          1.8871          0.8428         21.6478         21.9197         23.2508         22.2946
430093..................................................          1.3555          0.9502         27.5326         26.0232         24.7398         26.0952
430094..................................................          1.7381          0.8557         22.9091         23.2894         23.6605         23.3062
430095..................................................          2.4765          0.9379         31.3409         32.2326         32.5850         32.0536
430096..................................................          1.9114          0.8428         21.6713         24.6041         24.9608         23.8070
440001..................................................          1.1662          0.7999         21.2398         21.5755         25.4844         22.7818
440002..................................................          1.7208          0.8886         25.7434         26.3802         26.9121         26.3584
440003..................................................          1.3386          0.9445         28.4862         28.3557         26.0107         27.4326
440006..................................................          1.4409          0.9445         29.7146         31.5533         31.7373         31.0128
440007..................................................          0.9815          0.8176         19.9754         18.8273         22.7570         20.4815
440008..................................................          0.9673          0.8339         23.2126         27.3732         26.8850         25.9985
440009..................................................          1.1674          0.7957         23.9279         23.8148         24.4410         24.0653
440010..................................................          0.9494          0.7957         19.3669         19.6231         20.2498         19.7446
440011..................................................          1.3656          0.7957         23.6154         23.6698         24.8292         24.0419
440012..................................................          1.5047          0.7964         24.0169         23.7871         24.9243         24.2664
440015..................................................          1.8290          0.7957         25.0430         26.0601         27.1580         26.0995
440016..................................................          1.0436          0.8101         23.0350         24.5812         25.2515         24.2770
440017..................................................          1.7685          0.7964         25.0588         24.6707         26.1800         25.3213
440018..................................................          1.1100          0.7999         23.2107         25.0780         24.5898         24.3284
440019..................................................          1.6911          0.7957         25.3592         25.2230         26.2435         25.5920
440020..................................................          1.0903          0.8614         24.0995         24.7785         27.5620         25.4792
440024..................................................          1.1324          0.8717         23.9745         24.7705         26.2519         25.0623
440025..................................................          1.1246          0.8611         22.5407         22.6571         24.0274         23.0928
440026..................................................             ***               *         28.0349         26.8153         28.4597         27.7725

[[Page 23771]]

 
440029..................................................          1.4650          0.9445         30.1204         31.2310         31.4630         30.9557
440030..................................................          1.2893          0.8013         23.7670         22.2607         22.3131         22.8053
440031..................................................          1.1356          0.7976         20.8964         22.6790         22.0708         21.8517
440032..................................................          1.1644          0.7957         19.7150         21.0380         23.8016         21.5383
440033..................................................          1.0637          0.7984         21.1087         22.7991         23.9790         22.5856
440034..................................................          1.6302          0.7957         24.6994         25.5061         25.9124         25.3762
440035..................................................          1.3910          0.9252         25.9613         26.2451         27.9203         26.6992
440039..................................................          2.1051          0.9445         29.8611         30.1790         30.1901         30.0895
440040..................................................          0.9210          0.7957         20.8637         20.8817         21.1282         20.9641
440046..................................................          1.3069          0.9445         27.9539         29.7377         30.7314         29.5270
440047..................................................          0.9617          0.8295         21.7892         22.8323         25.2156         23.3140
440048..................................................          1.8071          0.9305         29.4789         29.3187         30.6710         29.8250
440049..................................................          1.6747          0.9305         26.4772         28.8742         29.8603         28.4462
440050..................................................          1.2834          0.7964         24.4616         24.9694         26.3815         25.3086
440051..................................................          0.9337          0.8039         23.9253         23.4866         23.6554         23.6741
440052..................................................          1.0032          0.7957         22.8016         22.6128         24.4075         23.2437
440053..................................................          1.2712          0.9445         27.1197         27.8180         30.3887         28.4325
440054..................................................          1.0962          0.7957         23.5137         23.7931         21.9638         23.0467
440056..................................................          1.2127          0.7957         22.7820         23.2313         24.0623         23.3523
440057..................................................          1.1032          0.7978         16.6346         17.2176         19.3540         17.6957
440058..................................................          1.2003          0.7957         24.3522         26.0706         29.1174         26.6028
440059..................................................          1.4855          0.9252         28.3565         27.9467         29.4514         28.5989
440060..................................................          1.1325          0.8339         24.1024         25.0795         26.5869         25.2908
440061..................................................          1.1295          0.7957         23.9678         23.7360         25.4125         24.3711
440063..................................................          1.6197          0.7999         24.2566         23.9644         26.0741         24.7976
440064..................................................          0.9999          0.8857         23.7176         26.1246         26.7947         25.5515
440065..................................................          1.2421          0.9445         24.6169         25.8536         25.6096         25.3745
440067..................................................          1.1905          0.7957         24.4772         24.6553         26.0852         25.0966
440068..................................................          1.1835          0.8717         24.8146         26.1071         27.9066         26.2722
440070..................................................          1.0014          0.8066         20.0938         21.9166         23.2223         21.7288
440072..................................................          1.0393          0.8886         23.9563         25.7089         26.1643         25.2966
440073..................................................          1.4453          0.9252         26.3570         27.6154         27.5114         27.1567
440081..................................................          1.1673          0.8009         20.7125         20.7688         21.9671         21.1573
440082..................................................          1.9913          0.9445         30.6115         32.2479         32.8913         31.8790
440083..................................................          0.9577          0.7957         25.6099         23.6356         25.7074         24.9682
440084..................................................          1.1762          0.7982         18.6043         18.8699         19.8938         19.1297
440091..................................................          1.7581          0.8857         26.5687         28.1989         28.9678         27.9314
440102..................................................          1.0796          0.7957         20.7363         21.6762         22.1103         21.5215
440104..................................................          1.7788          0.8857         26.5741         27.9756         28.0888         27.5200
440105..................................................          0.9119          0.7999         22.9372         22.7962         23.7139         23.1599
440109..................................................          1.0139          0.8027         20.8924         21.4629         22.5885         21.7090
440110..................................................          1.1221          0.7957         20.9179         22.5929         23.6262         22.5559
440111..................................................          1.2820          0.9445         29.0975         28.8453         29.7446         29.2213
440115..................................................          0.9684          0.8295         23.1409         23.7107         24.9776         23.9354
440120..................................................          1.4947          0.7957         25.7161         24.7572         26.0604         25.5176
440125..................................................          1.6557          0.7957         22.8097         23.6328         24.0920         23.4915
440130..................................................          1.1217          0.7957         23.9955         25.1262         26.3188         25.1413
440131..................................................          1.1784          0.9305         25.6666         26.9649         28.3153         26.9308
440132..................................................          1.2291          0.7957         23.9410         24.0708         29.3371         25.7508
440133..................................................          1.7069          0.9445         29.2829         29.6093         32.5699         30.4215
440135..................................................          0.6898          0.7957         28.1925         27.7037         27.2084         27.7046
440137..................................................          1.0639          0.8695         22.2538         22.9547         24.6130         23.2371
440141..................................................          0.9917          0.7957         24.2406         24.9917         24.8736         24.6802
440144..................................................          1.2549          0.9252         23.9241         25.2293         26.3207         25.2055
440147..................................................             ***               *         33.1756         34.8199         36.6955         34.8975
440148..................................................          1.1236          0.9252         23.9810         22.6188         28.0703         24.8107
440150..................................................          1.4307          0.9445         28.1012         29.4381         30.5491         29.3876
440151..................................................          1.1663          0.9252         27.1729         28.2203         28.6580         27.9977
440152..................................................          2.0008          0.9305         27.1877         28.4612         29.0563         28.2859
440153..................................................          1.0509          0.7964         23.6473         24.9388         23.3772         23.9591
440156..................................................          1.6421          0.8857         27.7309         28.5645         30.5139         28.9635
440159..................................................          1.4818          0.9305         26.9098         25.8289         27.2779         26.6811
440161..................................................          1.9267          0.9445         28.7074         29.9894         31.0647         29.9300
440162..................................................             ***               *         27.6837         24.8705         24.6410         25.6902
440166..................................................             ***               *         35.3064               *               *         35.3064
440168..................................................          1.0456          0.9305         28.1215         29.4028         31.3312         29.7029
440173..................................................          1.4350          0.7957         23.1167         24.0621         23.1355         23.4173

[[Page 23772]]

 
440174..................................................          0.8828          0.8269         25.4829         26.2087         27.4573         26.4456
440175..................................................          1.0111          0.7957         24.4848         24.7869         26.7698         25.3295
440176..................................................          1.3339          0.7964         22.9631         23.7695         24.9405         23.9373
440180..................................................          1.3459          0.7984         24.9841         22.3070         24.3370         23.7701
440181..................................................          0.9020          0.8322         24.8857         25.9450         26.4759         25.8145
440182..................................................          0.9536          0.8101         24.3302         25.0111         24.9897         24.8044
440183..................................................          1.6228          0.9305         29.1982         30.6599         30.9900         30.2946
440184..................................................          1.1292          0.7999         24.5786         23.3970         26.9069         24.9779
440185..................................................          1.1883          0.8717         25.3817         26.7473         26.3958         26.1839
440186..................................................          0.9919          0.9445         27.3733         28.9124         28.2842         28.1940
440187..................................................          1.0974          0.7957         24.0723         25.8238         27.4029         25.7687
440189..................................................          1.4158          0.8452         28.2621         28.8974         30.5766         29.1873
440192..................................................          1.0765          0.9252         27.3917         29.6272         30.6519         29.2789
440193..................................................          1.3104          0.9445         24.3622         25.2124         25.9713         25.1845
440194..................................................          1.2925          0.9445         29.4706         30.8593         32.3002         30.9187
440197..................................................          1.3992          0.9445         29.4275         30.1184         31.4294         30.3064
440200..................................................          0.9829          0.9445         21.1860         23.8654         23.8295         22.9591
440203..................................................             ***               *         23.7451         17.9041               *         20.6007
440217..................................................          1.3768          0.9305         28.8641         29.8888         31.6636         30.1328
440218..................................................          2.0116          0.9445         23.7257         18.7275         36.9244         25.9465
440222..................................................          1.0088          0.9305         28.4664         29.0062         30.5130         29.3485
440225..................................................          0.8097          0.7957         24.8328         27.8860         26.9656         26.4719
440226..................................................          1.5694          0.7957         26.5831         27.1348         28.3176         27.3318
440227..................................................          1.2974          0.9445               *         30.7785         31.9097         31.3743
440228..................................................          1.5738          0.9305               *         28.3687         29.5349         29.0087
450002..................................................          1.4448          0.8867         28.0936         28.8521         29.7157         28.8515
450005..................................................          1.2408          0.8595         24.4933         24.5405         27.3460         25.4548
450007..................................................          1.3344          0.8949         23.0026         23.9490         24.4625         23.8045
450008..................................................          1.3803          0.8855         24.4701         24.5965         24.4362         24.5017
450010..................................................          1.5960          0.9175         25.5503         25.5582         30.1022         27.0858
450011..................................................          1.6560          0.9193         26.7418         28.5329         29.9285         28.4349
450015..................................................          1.5911          0.9852         29.9193         29.4919         30.3151         29.9209
450018..................................................          1.5354          0.9925         30.2383         30.7852         31.3118         30.7838
450021..................................................          1.8903          0.9852         29.5658         31.3107         31.7338         30.8752
450023..................................................          1.4138          0.8153         25.4450         25.5346         25.1670         25.3821
450024..................................................          1.5693          0.8867         26.9113         28.2047         27.3787         27.5109
450028..................................................          1.5788          0.9226         29.1438         29.5792         29.5668         29.4314
450029..................................................          1.6143          0.8816         25.0602         26.9361         28.6442         26.7635
450031..................................................          1.4439          0.9852         29.0824         30.3542         29.2123         29.5392
450032..................................................          1.2547          0.8407         21.5084         25.5785         26.3146         24.2723
450033..................................................          1.5969          0.9226         29.2468         27.8680         29.7653         28.9230
450034..................................................          1.5308          0.8595         26.5313         27.6929         29.6291         28.1119
450035..................................................          1.5326          0.9925         28.0668         28.8049         30.3345         29.0806
450037..................................................          1.5845          0.8666         26.6207         28.3403         28.2594         27.7345
450039..................................................          1.5955          0.9852         26.7503         28.2081         29.8132         28.2727
450040..................................................          1.7553          0.8712         25.4734         26.8412         28.5453         26.9585
450042..................................................          1.7455          0.8703         26.6382         26.5429         27.6115         26.9555
450044..................................................          1.6959          0.9852         31.0381         29.4293         32.9897         31.1698
450046..................................................          1.5774          0.8494         24.8947         25.5903         27.2425         25.9770
450047..................................................          0.8561          0.9226         21.8824         23.8457         24.9663         23.5090
450051..................................................          1.9250          0.9852         28.8829         29.9038         30.3953         29.7565
450052..................................................          0.9850          0.8153         22.6448         23.0007         24.3959         23.3480
450054..................................................          1.7911          0.8855         27.5399         26.5599         30.2202         28.0403
450055..................................................          1.0449          0.8153         22.9245         23.6382         24.1423         23.5765
450056..................................................          1.6824          0.9521         28.3092         31.4971         32.0873         30.6432
450058..................................................          1.5743          0.8949         26.6926         26.9918         27.7297         27.1586
450059..................................................          1.2980          0.9024         26.8325         27.3856         28.5629         27.5865
450064..................................................          1.5113          0.9852         26.8355         28.2786         29.0474         28.0416
450068..................................................          2.0486          0.9925         29.5876         30.5001         32.0346         30.7379
450072..................................................          1.2155          0.9925         25.8619         27.1081         28.0902         27.0430
450073..................................................          0.8877          0.8153         26.9446         26.1567         22.2326         25.0645
450076..................................................          1.6904               *               *               *               *               *
450078..................................................          0.8999          0.8153         21.4716         20.0758         20.7809         20.7567
450079..................................................          1.6789          0.9852         30.2420         30.5968         36.8906         32.4452
450080..................................................          1.2493          0.8666         27.9191         26.2439         26.8091         27.0298
450082..................................................          1.1597          0.8153         23.9025         24.2018         25.5648         24.5569
450083..................................................          1.7529          0.8901         27.4955         32.6462         30.2031         29.9862

[[Page 23773]]

 
450085..................................................          1.0822          0.8153         24.3637         25.6440         26.3606         25.4425
450087..................................................          1.3998          0.9852         30.0095         31.2668         32.6536         31.3363
450090..................................................          1.2615          0.8803         21.3837         21.8839         22.7815         22.0412
450092..................................................          1.2126          0.8153         24.9917         26.2781         28.2267         26.4935
450096..................................................             ***               *         26.5103         28.1902               *         27.3122
450097..................................................          1.4580          0.9925         29.0142         29.8734         31.9758         30.2412
450099..................................................          1.3019          0.8883         31.3495         31.7829         29.8469         30.9845
450101..................................................          1.6171          0.8703         25.4409         26.7457         28.4201         26.8726
450102..................................................          1.7083          0.8901         25.6318         26.4161         27.3343         26.4779
450104..................................................          1.1855          0.8949         24.6169         28.8063         27.7838         26.9841
450107..................................................          1.5806          0.8867         27.6064         27.8177         29.0310         28.1649
450108..................................................          1.1922          0.8949         21.6557         19.3245         22.4281         21.1092
450119..................................................          1.3181          0.9118         27.8027         31.1026         34.4129         30.7679
450121..................................................             ***               *         29.1296         27.7472               *         28.4439
450123..................................................          1.3318          0.8595         24.9674         26.2469         24.0420         24.9404
450124..................................................          1.7511          0.9521         28.2571         30.9140         31.9772         30.4250
450126..................................................          1.3989          0.9925         29.3768         30.5540         32.0348         30.6758
450128..................................................          1.2318          0.9118         25.1122         26.3296         28.3156         26.5694
450130..................................................          1.1977          0.8949         24.3295         24.3842         26.9201         25.2414
450131..................................................             ***               *         25.9494               *               *         25.9494
450132..................................................          1.6322          0.9425         30.1620         31.9981         31.1340         31.0941
450133..................................................          1.5320          0.9283         28.4647         30.0648         30.9597         29.8077
450135..................................................          1.6395          0.9852         27.8983         30.1385         30.7885         29.6276
450137..................................................          1.6679          0.9852         31.4950         31.9644         35.7749         33.2271
450143..................................................          1.0277          0.9521         23.4592         23.6834         24.4333         23.8654
450144..................................................          1.0083          0.8712         26.2881         29.2987         31.1551         28.7443
450147..................................................          1.4564          0.8153         24.3562         24.7221         26.3019         25.1662
450148..................................................          1.2241          0.9852         27.0894         29.6777         30.0530         28.8673
450151..................................................             ***               *         23.9558         26.2011         22.8759         24.2772
450152..................................................          1.2565          0.8855         23.3428         23.1056         24.3424         23.6074
450154..................................................          1.3302          0.8153         21.7237         22.9357         24.2578         22.9598
450155..................................................          1.1251          0.8153         21.7604         24.8052         24.8768         23.6641
450162..................................................          1.3269          0.8712         33.3285         32.9317         33.7803         33.3236
450163..................................................          1.0627          0.8207         24.1267         24.7857         27.0963         25.3188
450165..................................................          1.1447          0.8949         28.6490         29.1839         30.2222         29.3460
450176..................................................          1.4003          0.9118         23.1284         24.4338         25.8569         24.4742
450177..................................................          1.0905          0.8153         23.7624         24.4064         26.0891         24.7683
450178..................................................          0.9986          0.9283         27.8405         27.1184         28.5998         27.8381
450184..................................................          1.5684          0.9925         28.5399         29.5940         30.9705         29.6894
450187..................................................          1.2150          0.9925         28.3243         27.7374         29.2737         28.4472
450188..................................................          0.9254          0.8153         23.0595         23.2280         24.6816         23.6817
450191..................................................          1.1258          0.9521         26.5863         28.3937         31.1321         28.6333
450192..................................................          1.1180          0.8424         24.1186         26.4722         26.9874         25.8921
450193..................................................          2.0321          0.9925         34.4545         36.4793         37.1873         36.0649
450194..................................................          1.2632          0.8366         22.9605         24.3531         30.4368         25.7167
450196..................................................          1.4595          0.9852         24.0161         23.4577         25.4820         24.2962
450200..................................................          1.6042          0.8195         23.5012         25.6413         27.9825         25.4502
450201..................................................          0.9730          0.8153         23.2510         23.2800         22.5445         22.9956
450203..................................................          1.2116          0.9684         26.5237         27.8795         28.0968         27.5107
450209..................................................          1.8278          0.8997         27.5668         30.6146         31.9858         29.9981
450210..................................................          1.0215          0.8304         21.8722         22.5736         22.9049         22.4486
450211..................................................          1.3455          0.8666         28.4581         28.3770         28.8471         28.5692
450213..................................................          1.7959          0.8949         25.9169         26.8566         28.0289         26.9446
450214..................................................          1.2281          0.9925         27.4357         27.9913         28.2247         27.8829
450219..................................................          0.9660          0.8153         21.9207         23.9636         24.7267         23.5184
450221..................................................          1.1119          0.8153         19.3793         21.3721         20.7113         20.5035
450222..................................................          1.6824          0.9925         30.0314         30.3801         31.9231         30.7843
450224..................................................          1.3283          0.8901         26.8302         28.4382         28.7921         28.0121
450229..................................................          1.6525          0.8408         24.4450         25.1370         26.8016         25.3958
450231..................................................          1.6726          0.8997         27.1674         26.9783         27.0533         27.0671
450234..................................................          1.0198          0.8153         20.6889         20.4659         21.6802         21.1358
450235..................................................          1.0077          0.8153         23.5212         21.8967         23.8005         23.0639
450236..................................................          1.1319          0.8542         23.5426         22.9622         24.5926         23.6934
450237..................................................          1.6540          0.8949         25.7939         30.5885         31.2172         28.9557
450239..................................................          0.9770          0.8855         21.2586         19.1359         18.4232         19.4675
450241..................................................          1.0252          0.8153         20.8732         21.3641         28.4948         23.5112
450243..................................................          1.0024          0.8153         15.4510         17.2966         19.0176         17.2995

[[Page 23774]]

 
450253..................................................          0.9321          0.9925         24.2435         24.1056         22.9919         23.7733
450270..................................................          1.2113          0.8424         15.2190         19.8180         12.9994         15.5383
450271..................................................          1.2778          0.9684         22.7035         24.1269         23.9525         23.6286
450272..................................................          1.2096          0.9521         26.2576         27.0521         29.0903         27.4843
450280..................................................          1.4612          0.9852         29.9730         31.6575         34.9324         32.1866
450283..................................................          1.0893          0.9852         22.7938         24.1754         28.2079         24.8171
450289..................................................          1.4524          0.9925         32.2645         32.6533         32.6122         32.5225
450292..................................................          1.2808          0.9852         26.3242         26.8110         29.0226         27.3779
450293..................................................          0.8910          0.8153         23.6413         24.0827         24.1552         23.9551
450296..................................................          1.0439          0.9925         30.4324         31.5596         33.4528         31.7845
450299..................................................          1.5997          0.9193         27.5797         28.4171         29.4576         28.5044
450306..................................................          0.9802          0.8408         21.4558         22.9486         22.6822         22.3403
450315..................................................          2.4335          0.9852         37.1721               *         31.4204         33.9617
450324..................................................          1.5212          0.9852         25.1633         26.6093         27.9889         26.5490
450330..................................................          1.2552          0.9925         26.0771         27.1100         27.7403         26.9930
450340..................................................          1.4092          0.8600         25.0344         25.6791         30.5228         26.9242
450346..................................................          1.4343          0.8595         23.6072         23.8720         24.8416         24.1224
450347..................................................          1.2208          0.9925         28.7667         30.7825         28.5780         29.3911
450348..................................................          1.0018          0.8153         21.6787         21.0484         22.6822         21.8120
450351..................................................          1.2791          0.9684         26.5388         29.2560         29.9580         28.5841
450352..................................................          1.1062          0.9852         26.2281         27.2983         27.6466         27.0615
450353..................................................             ***               *         27.0248         27.9576               *         27.5079
450358..................................................          1.9716          0.9925         31.4926         32.5922         33.9078         32.6875
450369..................................................          0.9268          0.8153         19.9148         22.8525         24.1950         22.2632
450370..................................................          1.2579          0.8388         25.5834         26.3235         29.0806         27.0009
450372..................................................          1.4550          0.9852         30.8886         29.5022         30.9328         30.4453
450373..................................................          0.9144          0.8153         24.8286         27.0726         27.4243         26.4835
450378..................................................          1.3092          0.9925         30.3883         32.2278         33.0566         31.9025
450379..................................................          1.4002          0.9852         33.7521         35.3807         35.0613         34.7094
450388..................................................          1.7004          0.8949         27.4328         27.8155         29.5360         28.2774
450389..................................................          1.1714          0.9852         25.6732         26.9638         26.8481         26.4861
450393..................................................          0.7662          0.9852         21.9347               *         39.0250         28.4483
450395..................................................          1.0730          0.9925         27.5189         26.7743         28.4265         27.6022
450399..................................................          0.8925          0.8153         20.3528         22.1731         20.6300         21.0332
450400..................................................          1.0684          0.8153         23.6358         26.2871         29.5008         26.1110
450403..................................................          1.3192          0.9852         29.0359         29.8643         31.7040         30.2580
450411..................................................          1.0061          0.8153         20.9372         21.5746         21.7875         21.4276
450418..................................................             ***               *         28.4362               *               *         28.4362
450419..................................................          1.3124          0.9852         31.9966         34.2427         34.9949         33.8163
450422..................................................          1.2786          0.9852         34.4331         31.3454         32.4640         32.6976
450424..................................................          1.3562          0.9925         28.2463         30.7228         29.8269         29.5962
450431..................................................          1.6067          0.9521         26.3263         27.3926         28.5263         27.4173
450438..................................................          1.1486          0.8388         27.8659         26.5223         27.7728         27.3852
450446..................................................          0.7131          0.9925         17.0691         17.2871         15.4631         16.6064
450447..................................................          1.3552          0.9852         25.4200         26.5238         28.3710         26.7880
450451..................................................          1.0753          0.8689         24.6201         26.5477         25.8824         25.6945
450460..................................................          0.9426          0.8206         22.4227         24.9870         25.2172         24.1531
450462..................................................          1.7253          0.9852         29.6069         30.1466         30.6488         30.1364
450465..................................................          1.1257          0.9925         26.2759         27.0835         28.1840         27.2041
450469..................................................          1.4624          0.9852         26.3262         26.3445         31.1333         27.8724
450475..................................................          1.1940          0.8666         23.0942         24.5176         24.7023         24.0834
450484..................................................          1.4990          0.8666         26.7242         28.3913         27.7774         27.6347
450488..................................................          1.1180          0.8666         22.3981         23.7985         24.9095         23.7092
450489..................................................          0.9839          0.8153         23.4806         25.2680         26.9542         25.1940
450497..................................................          0.9966          0.8528         22.0918         23.1860         23.0703         22.7799
450498..................................................          0.9829          0.8153         18.6563         20.2475         20.6876         19.8494
450508..................................................          1.4530          0.8666         28.4471         27.2850         29.1501         28.3018
450514..................................................             ***               *         26.3704         27.3043         26.4002         26.6921
450518..................................................          1.4419          0.8595         28.1755         29.1322         27.5863         28.1826
450530..................................................          1.2667          0.9925         29.1349         29.9720         30.7727         29.9520
450537..................................................          1.5128          0.9852         27.7757         28.7448         30.9146         29.1361
450539..................................................          1.2202          0.8220         23.1829         24.2151         25.0188         24.1139
450547..................................................          0.9744          0.9852         23.7820         34.3349         25.4122         27.1653
450558..................................................          1.7678          0.8408         26.9407         28.0655         28.7729         27.9448
450563..................................................          1.5299          0.9852         30.8332         32.0507         32.6847         31.9164
450565..................................................          1.3270          0.9684         26.7942         28.1741         27.4760         27.4805
450571..................................................          1.6222          0.8600         25.2108         27.4605         26.5303         26.3740

[[Page 23775]]

 
450573..................................................          1.0770          0.8279         22.0797         22.1492         24.6744         22.9817
450578..................................................          0.9673          0.8153         22.5167         25.0498         25.2476         24.2617
450580..................................................          1.0515          0.8153         22.3886         23.9004         25.9872         23.9915
450584..................................................          1.0829          0.8153         20.5257         22.5204         23.6045         22.1623
450586..................................................          1.0201          0.8153         18.9107         20.6699         18.3294         19.3042
450587..................................................          1.2259          0.8153         23.1202         25.0174         25.9358         24.6518
450591..................................................          1.1895          0.9925         25.7031         27.1744         27.9847         26.9265
450596..................................................          1.1854          0.9684         27.4011         29.8462         31.6577         29.6788
450597..................................................          0.9963          0.8153         24.7853         24.2586         24.8439         24.6216
450604..................................................          1.3397          0.8153         24.4743         25.9133         29.1526         26.5819
450605..................................................          0.9810          0.8494         20.9276         23.9332         14.8030         19.8571
450610..................................................          1.5974          0.9925         27.7317         28.3713         30.5957         28.8793
450615..................................................          0.9986          0.8185         21.8442         24.1902         22.6324         22.8680
450617..................................................          1.5826          0.9925         28.0225         28.8323         30.2898         29.0536
450620..................................................          0.9635          0.8153         18.6183         20.3723         21.2530         20.0799
450630..................................................          1.5054          0.9925         29.1462         29.8431         31.7991         30.2292
450634..................................................          1.6203          0.9852         28.7312         30.3274         31.7983         30.2933
450638..................................................          1.5993          0.9925         30.6572         32.4911         33.3208         32.0988
450639..................................................          1.4598          0.9852         30.4019         32.6255         34.3727         32.4471
450641..................................................          0.9799          0.8528         19.4389         20.2483         21.7288         20.4546
450643..................................................          1.3367          0.8816         22.7355         24.4999         27.2517         24.7934
450644..................................................          1.5467          0.9925         29.7918         30.7815         31.6848         30.7914
450646..................................................          1.4527          0.8867         25.6313         26.8060         27.4611         26.6291
450647..................................................          1.8764          0.9852         30.6924         32.4236         34.0988         32.4013
450651..................................................          1.5358          0.9852         30.4484         31.9261         33.6467         32.0226
450653..................................................          1.1592          0.8153         25.2144         26.1756         26.5346         25.9882
450654..................................................          0.9049          0.8153         21.5002         22.5447         25.0736         23.0141
450656..................................................          1.4220          0.8666         25.5050         28.1493         29.7276         27.7366
450658..................................................          0.9793          0.8153         22.2293         24.7856         22.7086         23.2037
450659..................................................          1.4021          0.9925         31.5024         34.2380         34.2632         33.2709
450661..................................................          1.4614          0.9425         30.2610         30.0751         29.2361         29.8375
450662..................................................          1.6460          0.9226         29.0535         29.0532         30.9608         29.6825
450668..................................................          1.5414          0.8867         28.8635         30.6114         30.2059         29.8659
450669..................................................          1.2189          0.9852         27.9796         30.2374         32.1221         30.1382
450670..................................................          1.4361          0.9925         25.9638         26.4266         26.2942         26.2315
450672..................................................          1.8349          0.9852         30.1191         31.8420         33.0834         31.7654
450674..................................................          0.9478          0.9925         28.7101         29.8971         31.9284         30.1847
450675..................................................          1.4578          0.9852         28.9005         30.9562         32.6351         30.8652
450677..................................................          1.3166          0.9852         25.9555         27.2760         27.1594         26.8126
450678..................................................          1.4170          0.9852         31.1563         33.3386         33.5496         32.6557
450683..................................................          1.2015          0.9852         27.4925         21.1737         24.8430         24.2908
450684..................................................          1.2814          0.9925         29.3025         30.2139         31.2746         30.2639
450686..................................................          1.6149          0.8712         24.2331         25.8530         26.4851         25.5754
450688..................................................          1.2727          0.9852         26.8599         26.9897         29.4376         27.7076
450690..................................................          1.3408          0.8901         26.5528         26.1743         30.0569         27.4939
450694..................................................          1.1759          0.8153         23.9961         24.0031         27.0859         24.8819
450697..................................................          1.4748          0.8949         24.8667         26.4132         28.2983         26.4744
450698..................................................          0.9175          0.8280         20.0955         21.5742         23.3052         21.6138
450702..................................................          1.6153          0.8666         26.8384         26.3696         27.1300         26.7835
450709..................................................          1.4034          0.9925         26.8146         27.1077         31.3218         28.4257
450711..................................................          1.4823          0.9118         26.7472         27.5622         28.1016         27.5198
450713..................................................          1.5563          0.9521         28.8285         29.4980         30.4912         29.6225
450715..................................................          1.3146          0.9852         17.3991         17.0235               *         17.2098
450716..................................................          1.4070          0.9925         32.3960         33.7096         33.9898         33.3800
450718..................................................          1.4669          0.9521         27.3215         28.1560         29.7584         28.4466
450723..................................................          1.4494          0.9852         28.5103         30.1704         31.0456         29.9614
450730..................................................          1.3722          0.9852         31.3324         32.7293         32.8896         32.3004
450742..................................................          1.1754          0.9852         27.2023         30.0583         30.4185         29.2913
450743..................................................          1.4478          0.9852         28.3362         28.4736         29.5077         28.8191
450746..................................................          0.8780          0.8153         20.6343         22.7873         23.3483         22.2429
450747..................................................          1.1965          0.8901         23.8314         25.8175         28.3918         25.8472
450749..................................................          0.9371          0.8153         20.0487         22.1562         23.9271         21.9555
450751..................................................             ***               *         18.7456         21.4223               *         20.1469
450754..................................................          0.9429          0.8153         22.1819         24.7797         22.8559         23.2191
450755..................................................          0.9660          0.8429         19.8988         22.2006         24.7427         22.1319
450758..................................................             ***               *         28.7342         28.2803         28.3285         28.4884
450760..................................................          1.0061          0.8867         24.7489         25.1637         23.7138         24.5602

[[Page 23776]]

 
450766..................................................          2.0334          0.9852         30.8004         30.2341         31.2061         30.7524
450770..................................................          1.1706          0.9521         24.1647         24.3244         23.6084         24.0129
450771..................................................          1.7003          0.9852         30.7105         32.0500         32.4987         31.7652
450774..................................................          1.7600          0.9925         27.2080         25.7436         27.5052         26.8202
450775..................................................          1.3943          0.9925         28.1428         29.8230         31.6636         29.9048
450779..................................................          1.2842          0.9852         29.9674         31.8403         32.0748         31.3351
450780..................................................          2.5251          0.8949         26.7611         27.0084         28.5545         27.4508
450788..................................................          1.5291          0.8494         26.2840         28.3759         29.7646         28.1299
450795..................................................          1.1739          0.9925         25.2007         32.9803         43.8548         34.0292
450796..................................................          1.8173          0.8997         36.4073         37.6274         39.4710         37.9807
450797..................................................          1.2450          0.9925         24.8950         24.8598         26.0293         25.2371
450801..................................................          1.4989          0.8195         24.6328         23.6072         25.6368         24.6370
450803..................................................          1.2105          0.9925         28.9235         29.0106         28.7024         28.8861
450804..................................................          2.0345          0.9925         27.8775         29.1282         31.1869         29.4370
450808..................................................          1.8935          0.9521         21.9793         23.0312         29.6456         24.9240
450809..................................................          1.6551          0.9521         26.4223         27.3080         29.4671         27.7555
450811..................................................          1.7218          0.9118         27.2584         31.2208         31.7219         29.8931
450813..................................................          1.1338          0.8949         20.1710         22.9289         26.5793         23.2366
450820..................................................          1.4186          0.9925         31.4666         33.9030         34.7415         33.5465
450822..................................................          1.3260          0.9852         32.2968         32.2145         34.4032         32.9996
450824..................................................          2.6758          0.9521         31.2375         33.3653         31.8377         32.1641
450825..................................................          1.4768          0.9118         20.6457         25.1521         25.7993         23.7848
450827..................................................          1.4405          0.9175         23.7554         24.1984         24.3655         24.1145
450828..................................................          1.3774          0.8153         24.4740         24.8236         26.9546         25.5737
450829..................................................             ***               *         20.6016         19.5842               *         20.0933
450830..................................................          1.0119          0.9283         28.5902         27.8005         28.4004         28.2670
450831..................................................          0.9180          0.9925         23.3880         23.9467         24.4124         23.8672
450832..................................................          1.3167          0.9925         26.5229         27.3290         28.1375         27.3874
450833..................................................          1.1878          0.9852         27.0133         27.9649         29.0241         28.0113
450834..................................................          1.6180          0.9193         20.9607         27.4844         26.7240         24.5166
450838..................................................          1.0772          0.8279         19.5754         18.9620         19.2941         19.2971
450839..................................................          0.9688          0.8153         25.8222         27.2199         27.5319         26.8415
450840..................................................          1.2996          0.9852         30.1743         32.2538         32.4135         31.6992
450841..................................................          1.9116          0.9226         20.9410         20.9424         24.4366         22.2249
450844..................................................          1.3797          0.9925         30.7887         33.7978         33.0727         32.7243
450845..................................................          1.8834          0.8867         29.4933         29.9265         28.5011         29.2842
450847..................................................          1.2564          0.9925         28.5548         29.7356         30.7409         29.7031
450848..................................................          1.2904          0.9925         29.5355         30.5546         31.1455         30.4213
450850..................................................          1.5769          0.9562         21.9266         31.9606         27.2645         26.5516
450851..................................................          2.3662          0.9852         32.6950         35.1102         32.8357         33.5034
450853..................................................          1.7353          0.9852         36.1169         37.1043         38.3572         37.3449
450854..................................................             ***               *         27.1868               *               *         27.1868
450855..................................................          1.6258          0.9226         30.8855         32.6916         30.7321         31.4205
450856..................................................          2.0970          0.8949         39.0865         37.7362         35.4977         37.3569
450857..................................................             ***               *         30.4632               *               *         30.4632
450860..................................................          1.8529          0.9925         24.0171         29.1075         33.3360         29.3070
450861..................................................             ***               *         34.9290               *               *         34.9290
450862..................................................          1.5594          0.9925         31.2224         31.8095         33.7932         32.2128
450863..................................................             ***               *         24.8825               *               *         24.8825
450864..................................................          2.1890          0.8901         23.3765         24.5049         25.3514         24.5415
450865..................................................          1.1032          0.9521         29.1763         29.9559         31.9179         30.4451
450866..................................................             ***               *         15.2959               *               *         15.2959
450867..................................................          1.1589          0.9521         28.2289         29.5879         31.4926         29.7806
450868..................................................          1.7418          0.9425         27.9579         25.3486         27.7398         27.0759
450869..................................................          2.1455          0.9118         22.6253         26.1616         28.7406         27.5500
450870..................................................             ***               *         37.4364               *               *         37.4364
450871..................................................          1.8768          0.9521               *         28.9150         32.3967         30.6337
450872..................................................          1.3756          0.9852               *         27.2833         31.7321         29.8421
450873..................................................             ***               *               *         14.8821               *         14.8821
450874..................................................          1.6738          0.9852               *         34.6083         35.6817         35.2071
450875..................................................          1.7360          0.8997               *         23.2763         23.2949         23.2862
450876..................................................          1.9264          0.8712               *         28.4343         30.3498         29.4575
450877..................................................          1.4979          0.8867               *         26.1867         29.2330         27.6968
450878..................................................          2.5641          0.8949               *         31.6750         33.6233         32.6691
450879..................................................          1.3352          0.8816               *         35.5672         36.4836         36.0727
450880..................................................          1.5477          0.9852               *         35.9572         32.6680         34.0899
450881..................................................             ***               *               *         24.5464               *         24.5464

[[Page 23777]]

 
450882..................................................             ***               *               *         26.6910               *         26.6910
450883..................................................          2.4793          0.9852               *         35.2646         37.1500         36.2387
450884..................................................          1.0281          0.8715               *         27.8213         23.5791         25.5501
450885..................................................          1.4517          0.9852               *         34.1148         36.0926         35.1477
450886..................................................          1.5017          0.9852               *               *         30.1552         30.1552
450887..................................................             ***               *               *               *         25.5574         25.5574
450888..................................................          1.7096          0.9708               *               *         28.5970         28.5970
450889..................................................          1.5530          0.9852               *               *         35.6125         35.6125
450890..................................................          1.8266          0.9852               *               *         32.1973         32.1973
450891..................................................          1.4143          0.9852               *               *         39.0842         39.0842
450892..................................................             ***               *               *               *         39.5303         39.5303
450893..................................................          1.3909          0.9852               *               *         36.2633         36.2633
450894..................................................          1.7932          0.9852               *               *         25.9422         25.9422
450895..................................................             ***               *               *         18.4142               *         18.4142
460001..................................................          1.8307          0.9075         28.7150         30.0040               *         29.3648
460003..................................................          1.5382          0.9271         31.4135         32.3427         29.6430         31.1480
460004..................................................          1.7729          0.9271         28.2040         29.6342         29.8751         29.2534
460005..................................................          1.5237          0.9271         25.0239         26.0731         29.4163         26.8371
460006..................................................          1.4480          0.9271         27.1392         28.3678         28.9633         28.1485
460007..................................................          1.3341          0.9228         27.1308         28.0035         29.1171         28.1204
460008..................................................          1.3382          0.9271         29.5907         31.5485         27.6886         29.5829
460009..................................................          1.9760          0.9271         27.2885         28.3836         29.4687         28.4457
460010..................................................          2.0995          0.9271         29.0063         30.4606         30.9793         30.1575
460011..................................................          1.3236          0.8395         24.4402         24.9677         26.5474         25.3370
460013..................................................          1.3909          0.9075         27.7381         29.2731         29.7232         28.9118
460014..................................................          1.1488          0.9271         28.2647         29.5963         30.6427         29.4780
460015..................................................          1.3542          0.8827         27.2506         29.1318         28.7993         28.4031
460017..................................................          1.5067          0.8778         24.3030         26.1589         28.7101         26.4243
460018..................................................          0.8937          0.8395         22.0517         22.8028         22.0916         22.3156
460019..................................................          1.1962          0.8395         24.3756         23.2202         25.1607         24.2508
460020..................................................          0.9177               *         18.5159               *               *         18.5159
460021..................................................          1.7949          1.1388         28.0291         29.5761         29.7373         29.2069
460023..................................................          1.2032          0.9075         26.9512         28.5884         28.9445         28.1975
460026..................................................          1.0634          0.9052         26.9295         27.9487         29.2757         28.0634
460030..................................................          1.1657          0.8395         23.5942         24.4218         26.8971         24.9667
460033..................................................          0.8711          0.8395         25.3422         26.6606         27.9090         26.6490
460035..................................................          0.9610          0.8395         20.6322         21.9115         23.8672         22.1202
460039..................................................          1.0970          0.8827         29.5651         30.4912         30.0656         30.0667
460041..................................................          1.3694          0.9271         26.4640         26.3807         26.7342         26.5286
460042..................................................          1.4973          0.9271         24.9454         26.8389         36.2868         28.7517
460043..................................................          0.9867          0.9075         28.2008         28.6668         29.5636         28.8137
460044..................................................          1.3270          0.9271         27.4928         28.7023         29.5056         28.5642
460047..................................................          1.6851          0.9271         28.2336         29.9990         30.9988         29.7618
460049..................................................          1.9801          0.9271         26.6702         28.4884         28.6251         27.9963
460051..................................................          1.4090          0.9271         27.0160         27.8841         28.1118         27.6918
460052..................................................          1.6516          0.9075         26.1629         27.1995         28.7433         27.4110
460054..................................................          1.6931          0.8827         24.9926         25.7870         26.3926         25.7328
460055..................................................          1.4742          0.9075               *               *               *               *
470001..................................................          1.2668          0.9297         28.3017         29.7540         32.2867         30.1248
470003..................................................          1.8776          0.9275         28.1137         30.1973         30.0513         29.4645
470005..................................................          1.3533          0.9275         30.7872         33.1981         33.9946         32.7064
470011..................................................          1.1581          0.9275         28.1330         29.6269         30.8723         29.5547
470012..................................................          1.2088          0.9275         26.0225         27.0751         29.8242         27.6835
470024..................................................          1.1462          0.9275         27.0394         26.6351         27.3091         26.9932
490001..................................................          1.0923          0.8061         23.2174         24.0368         24.6876         23.9910
490002..................................................          1.0162          0.8061         20.8609         21.7092         24.0666         22.0939
490004..................................................          1.2931          0.9449         27.1676         27.5890         28.8643         27.8908
490005..................................................          1.5720          1.0669         29.8215         30.5349         31.4889         30.6457
490007..................................................          2.0360          0.8869         27.6572         29.3098         30.7391         29.2722
490009..................................................          1.9926          0.9728         30.4722         28.4642         31.4238         30.0808
490011..................................................          1.5707          0.8869         26.4766         27.4764         28.8762         27.6271
490012..................................................          1.0101          0.8061         21.0605         22.9922         21.8319         21.9360
490013..................................................          1.3744          0.9694         24.7521         25.5560         27.3086         25.8824
490017..................................................          1.5021          0.8869         25.8216         27.5902         29.6761         27.7176
490018..................................................          1.3622          0.9449         26.2510         27.2644         27.8664         27.1379
490019..................................................          1.1503          1.0669         25.9885         25.8264         29.8874         27.1451
490020..................................................          1.2876          0.9203         27.3142         29.3468         30.5993         29.0707

[[Page 23778]]

 
490021..................................................          1.4622          0.8646         25.7938         27.0641         28.1233         26.9966
490022..................................................          1.4112          1.0669         32.2676         30.1203         31.7964         31.3740
490023..................................................          1.3297          1.0669         30.3416         30.9920         32.6291         31.3336
490024..................................................          1.6994          0.8889         26.1125         27.9689         29.0379         27.6964
490027..................................................          1.1143          0.8061         24.0288         23.0017         24.3832         23.7446
490032..................................................          1.9515          0.9203         25.2654         28.5897         28.0097         27.3514
490033..................................................          1.0967          1.0669         31.2922         31.8282         30.9894         31.3730
490037..................................................          1.2781          0.8061         24.7711         25.2859         26.2942         25.4675
490038..................................................          1.2238          0.8061         21.8509         22.6504         24.0844         22.8205
490040..................................................          1.5127          1.1017         32.6564         34.1841         35.6796         34.1603
490041..................................................          1.5635          0.8869         26.0897         27.1613         29.1224         27.4587
490042..................................................          1.3157          0.8750         24.4650         25.7333         26.6055         25.6256
490043..................................................          1.3375          1.1017         33.7096         35.8872         36.5934         35.4348
490044..................................................          1.4493          0.8869         23.3527         23.3793         24.1751         23.6463
490045..................................................          1.3427          1.0669         32.0937         30.3772         32.8751         31.7663
490046..................................................          1.5416          0.8869         26.6517         27.9604         29.3861         28.0339
490048..................................................          1.4333          0.8646         26.2828         27.0620         28.0302         27.1308
490050..................................................          1.5231          1.0669         31.3885         32.2993         31.1346         31.5946
490052..................................................          1.6678          0.8869         23.5973         25.0046         25.1956         24.5749
490053..................................................          1.1871          0.8061         23.3315         23.8004         24.6193         23.9160
490057..................................................          1.6362          0.8869         26.6898         27.4918         29.0678         27.7786
490059..................................................          1.6585          0.9203         27.3611         30.8669         32.1008         30.0791
490060..................................................          1.0194          0.8061         23.6113         24.3192         25.7752         24.5807
490063..................................................          1.8759          1.1017         31.3619         31.6069         34.1154         32.3880
490066..................................................          1.3873          0.8869         27.8250         29.5917         31.4281         29.7032
490067..................................................          1.2870          0.9203         24.9021         25.9497         26.7787         25.8584
490069..................................................          1.5365          0.9203         27.3181         29.1527         30.1463         28.8658
490071..................................................          1.4069          0.9203         29.7186         31.7061         33.7101         31.7115
490073..................................................             ***               *         33.1829         34.5774         46.4178         36.1085
490075..................................................          1.3188          0.8483         25.2022         25.7323         27.3411         26.0795
490077..................................................          1.4181          0.9728         26.6806         28.1506         31.0002         28.6185
490079..................................................          1.2674          0.8985         25.3103         25.2340         24.2052         24.9039
490084..................................................          1.1427          0.8248         24.9007         25.7657         26.3132         25.6727
490088..................................................          1.0983          0.8646         24.1471         25.0619         26.0270         25.0928
490089..................................................          1.1018          0.8889         24.9438         25.9902         27.4562         26.1612
490090..................................................          1.0545          0.8061         25.1157         25.5418         27.0746         25.9182
490092..................................................          1.0775          0.8061         23.3439         25.7405         27.5268         25.4745
490093..................................................          1.5429          0.8869         25.6531         26.7886         28.7103         27.0735
490094..................................................          0.9727          0.9203         28.2165         28.9155         29.7975         28.9991
490097..................................................          1.0690          0.9203         26.5322         27.1470         27.4607         27.0696
490098..................................................          1.2889          0.8061         23.2782         25.1625         26.7140         25.0883
490101..................................................          1.4144          1.1017         31.2377         32.3695         32.9490         32.2107
490104..................................................          0.7712          0.9203               *         17.0548         19.0055         18.0437
490105..................................................          0.8355          0.8061         25.5329         26.3827               *         25.9379
490106..................................................          0.7733          0.8061         23.8334         25.7352         26.2318         25.2383
490107..................................................          1.4215          1.1017         32.2672         33.5430         35.0239         33.6804
490108..................................................          1.0546          0.8646         22.9076         23.3204         25.1884         23.8173
490109..................................................          0.9060          0.8869         22.7854         24.2296         21.6710         22.7835
490110..................................................          1.3576          0.8307         24.2887         24.9861         26.3071         25.2068
490111..................................................          1.1082          0.8061         22.1476         22.7336         26.4282         23.6179
490112..................................................          1.7315          0.9203         27.1932         29.0816         31.2526         29.1894
490113..................................................          1.2911          1.0669         31.8177         32.4547         34.7813         33.0718
490114..................................................          1.1439          0.8061         22.5255         22.1387         23.0526         22.5829
490115..................................................          1.2011          0.8061         22.4058         23.5718         23.2109         23.0488
490116..................................................          1.1712          0.8061         24.2258         24.3853         25.0343         24.5470
490117..................................................          1.1002          0.8061         19.6398         18.1138         20.3031         19.3436
490118..................................................          1.6337          0.9203         27.6749         29.0569         31.2383         29.3451
490119..................................................          1.3013          0.8869         26.5756         27.8866         29.5203         28.0191
490120..................................................          1.4551          0.8869         25.8795         25.9610         27.1973         26.3518
490122..................................................          1.5919          1.1017         32.0743         33.3719         35.2212         33.5744
490123..................................................          1.1435          0.8061         24.3490         24.2254         24.5997         24.3927
490126..................................................          1.1732          0.8061         23.6690         24.0908         25.3282         24.3545
490127..................................................          1.1178          0.8061         21.3735         23.5161         23.1390         22.6004
490130..................................................          1.2203          0.8869         23.9982         25.3352         25.9771         25.1170
490134..................................................          0.8323          0.8061               *         33.2405         31.1474         32.1153
490135..................................................          0.7518          0.8889               *         25.9998         27.2771         26.6418
490136..................................................          1.4451          0.9203               *               *         31.2889         31.2889

[[Page 23779]]

 
490138..................................................          1.9348          0.8646               *               *               *               *
500001..................................................          1.6024          1.1562         31.1605         33.0901         37.5297         33.7723
500002..................................................          1.3750          1.0164         27.6400         29.1448         30.1855         29.0190
500003..................................................          1.3968          1.1377         30.6939         32.1262         32.7960         31.8089
500005..................................................          1.8014          1.1562         33.5117         35.0997         36.0900         34.9342
500007..................................................          1.3520          1.1377         29.2869         30.5263         31.0289         30.3229
500008..................................................          1.9737          1.1562         32.6052         33.5666         34.7787         33.6731
500011..................................................          1.3817          1.1562         31.4514         32.6223         38.3960         33.9417
500012..................................................          1.7799          1.0164         30.0509         33.8101         33.1661         32.2294
500014..................................................          1.6593          1.1562         36.1380         36.5833         37.2677         36.6858
500015..................................................          1.4000          1.1562         34.5877         37.5724         40.8644         37.5957
500016..................................................          1.6703          1.1377         31.4905         32.9177         34.2801         32.9164
500019..................................................          1.2524          1.0295         30.5594         31.6242         33.8866         32.0653
500021..................................................          1.3071          1.1377         30.7927         32.4702         33.5572         32.3511
500024..................................................          1.7453          1.1462         32.6171         36.1647         37.4510         35.4266
500025..................................................          1.9117          1.1562         37.7952         40.6369         44.7077         41.0323
500026..................................................          1.4550          1.1562         32.8369         34.5881         35.5055         34.3334
500027..................................................          1.4942          1.1562         34.6164         39.2906         42.4941         38.7477
500030..................................................          1.6959          1.1395         32.4426         34.9174         36.7964         34.7347
500031..................................................          1.2671          1.1297         32.8833         33.2391         34.1649         33.4481
500033..................................................          1.2468          1.0164         30.6292         31.8891         32.6732         31.7837
500036..................................................          1.3290          1.0164         28.7096         30.5938         31.9136         30.4918
500037..................................................          1.0577          1.0164         28.1056         31.2654         29.1752         29.5198
500039..................................................          1.5629          1.1377         32.2245         33.5606         34.5710         33.5071
500041..................................................          1.4344          1.1186         30.3627         34.2017         36.9240         33.8434
500044..................................................          1.8913          1.0514         29.0214         31.0936         32.0719         30.6373
500049..................................................          1.3698          1.0164         27.7170         29.8189         30.8120         29.5153
500050..................................................          1.5082          1.1186         32.6751         33.7713         35.7229         34.0820
500051..................................................          1.7917          1.1562         32.5764         34.7610         36.4745         34.6036
500052..................................................          1.4632          1.1562               *               *               *               *
500053..................................................          1.2557          1.0164         28.2901         30.2811         28.5649         29.0318
500054..................................................          1.9737          1.0514         31.6595         32.5105         34.8088         32.9758
500058..................................................          1.6843          1.0164         30.7487         30.7034         32.6820         31.4274
500060..................................................          1.3541          1.1562         37.4869         38.7682         40.3002         38.8996
500064..................................................          1.8909          1.1562         31.6112         32.3581         34.7906         32.9459
500072..................................................          1.2605          1.0576         31.2000         32.5269         33.1128         32.3268
500077..................................................          1.4765          1.0514         31.6153         33.2223         34.3082         33.0354
500079..................................................          1.3733          1.1377         31.3280         32.5809         34.2468         32.6847
500084..................................................          1.2608          1.1562         30.2411         32.7883         33.3057         32.1164
500088..................................................          1.4739          1.1562         35.3770         36.7953         38.5166         36.8898
500108..................................................          1.6172          1.1377         31.8483         34.3872         35.8890         34.0321
500119..................................................          1.3809          1.0514         29.7028         31.2233         31.7102         30.8549
500124..................................................          1.4071          1.1562         32.3505         34.4790         36.3296         34.3958
500129..................................................          1.5755          1.1377         32.1102         34.4447         37.3169         34.6824
500134..................................................          0.5967          1.1562         27.2428         28.1374         28.9744         28.2246
500139..................................................          1.4903          1.1462         33.9739         34.6412         37.5682         35.2949
500141..................................................          1.2645          1.1562         31.3308         33.7532         34.2350         33.1511
500143..................................................          0.5889          1.1462         23.6766         25.3099         26.3882         25.1082
500148..................................................          1.2204          1.0164         26.4206         37.7830         24.6331         30.3555
500150..................................................          1.2775          1.1186               *               *         34.7828         34.7828
510001..................................................          1.9319          0.8569         25.2973         25.8693         26.7901         26.0184
510002..................................................          1.2681          0.8732         23.8921         23.7270         24.8834         24.1721
510006..................................................          1.3528          0.8631         24.9627         24.8777         26.6403         25.4772
510007..................................................          1.6750          0.9107         24.7264         27.1149         28.5769         26.8115
510008..................................................          1.3363          0.9253         26.3554         27.5241         27.4687         27.1395
510012..................................................          0.9584          0.7759         18.8984         20.8455         22.9026         20.8292
510013..................................................          1.1635          0.7635         22.7882         22.8779         22.9605         22.8737
510018..................................................          1.0730          0.8398         22.4597         23.1043         23.7726         23.1223
510022..................................................          1.8098          0.8398         26.9511         26.8328         27.6095         27.1376
510023..................................................          1.2565          0.8011         20.6435         21.0940         23.1446         21.6346
510024..................................................          1.7530          0.8569         25.5634         26.6621         31.1308         27.8371
510026..................................................          0.9848          0.7635         17.9908         19.2025         17.8264         18.3206
510029..................................................          1.2995          0.8398         22.7104         24.0872         25.3908         24.0179
510030..................................................          1.1499          0.7635         24.3936         24.2007         25.5580         24.7270
510031..................................................          1.4626          0.8398         23.2624         24.0237         26.7854         24.6110
510033..................................................          1.5988          0.8028         22.6189         24.0796         24.2824         23.6905
510038..................................................          1.0704          0.7635         20.6565         20.9180         21.7526         21.1101

[[Page 23780]]

 
510039..................................................          1.3740          0.7635         19.8751         20.4719         21.3807         20.5901
510046..................................................          1.3781          0.7795         22.1712         22.2935         24.7175         23.0443
510047..................................................          1.2053          0.8569         27.1214         27.6859         28.8777         27.9077
510048..................................................          1.1872          0.7635         18.8576         22.7930         23.6384         21.5406
510050..................................................          1.5377          0.8569         21.0772         21.9009         23.5780         22.1906
510053..................................................          1.0938          0.7635         22.3318         21.5338         22.6278         22.1640
510055..................................................          1.5578          0.9107         28.4615         29.4111         30.7366         29.5844
510058..................................................          1.3382          0.8028         23.9015         25.3248         24.8750         24.7020
510059..................................................             ***               *         22.1435         20.8847         21.9025         21.6378
510062..................................................          1.2241          0.8398         26.2296         26.7066         27.7962         26.9089
510067..................................................          1.0951          0.7635         25.0437         25.2130         25.2231         25.1585
510070..................................................          1.2034          0.8398         23.5639         23.9742         25.4968         24.3383
510071..................................................          1.2818          0.7795         23.4508         23.2954         23.4542         23.4003
510072..................................................          1.0733          0.7635         20.5146         19.4370         20.2379         20.0443
510077..................................................          1.0382          0.8748         24.5010         25.9515         27.1603         25.8349
510082..................................................          1.1006          0.7635         19.9081         20.3279         21.1654         20.4929
510085..................................................          1.2021          0.8398         26.3877         26.2617         26.8122         26.4911
510086..................................................          1.0879          0.7635         19.8735         19.2606         20.1963         19.7687
510090..................................................             ***               *               *               *         39.0764         39.0764
520002..................................................          1.3026          0.9823         27.7705         29.0501         31.9053         29.6240
520004..................................................          1.4018          0.9796         27.6530         28.9857         30.9192         29.2469
520008..................................................          1.5695          1.0182         30.7553         33.8057         33.6749         32.7716
520009..................................................          1.6546          0.9511         27.4044         28.8591         29.6272         28.6360
520011..................................................          1.2826          0.9511         26.6268         28.0224         29.5006         28.0213
520013..................................................          1.4977          1.0976         29.0018         30.1834         32.1701         30.5206
520017..................................................          1.1201          0.9599         28.4699         29.3278         31.0517         29.6386
520019..................................................          1.3503          0.9511         28.6971         29.8640         30.2175         29.6442
520021..................................................          1.3207          1.0315         28.4182         29.1129         29.7788         29.1139
520027..................................................          1.4430          1.0182         31.4284         32.4137         33.5809         32.5077
520028..................................................          1.3966          1.1014         26.7260         28.0813         29.4683         28.3047
520030..................................................          1.6874          0.9823         29.4678         30.5724         31.6785         30.5738
520033..................................................          1.2248          0.9511         28.0662         29.0236         30.2616         29.1742
520034..................................................          1.2622          0.9511         26.1094         26.8886         28.1800         27.0611
520035..................................................          1.3586          0.9587         27.3276         28.1048         29.4053         28.2938
520037..................................................          1.7405          0.9823         30.1799         32.2144         31.6795         31.3757
520038..................................................          1.2048          1.0182         29.3134         29.6339         30.5249         29.8341
520040..................................................             ***               *         29.1262         31.2038         35.9633         32.0420
520041..................................................          1.0813          1.1232         23.5495         25.3764         26.1572         25.0721
520044..................................................          1.3626          0.9587         27.3685         28.2382         28.6601         28.1191
520045..................................................          1.5915          0.9511         27.3336         29.2556         30.0840         28.8905
520048..................................................          1.5102          0.9511         26.8080         29.1870         30.1468         28.5889
520049..................................................          2.0434          0.9511         26.9851         28.0936         29.4223         28.1983
520051..................................................          1.5346          1.0182         31.9949         31.5974         32.4111         32.0738
520057..................................................          1.1885          0.9704         27.7528         29.1158         31.3292         29.4114
520059..................................................          1.3571          1.0026         29.5801         30.4491         31.1783         30.4093
520060..................................................             ***               *         24.8638               *               *         24.8638
520062..................................................          1.3331          1.0182         28.8510         32.8584         32.6992         31.5738
520063..................................................          1.1678          1.0182         29.0993         30.3391         31.5185         30.3770
520064..................................................          1.5219          1.0182         30.3225         31.5723         33.1248         31.5779
520066..................................................          1.4182          0.9824         29.2088         31.0644         31.6673         30.6304
520070..................................................          1.6950          0.9599         27.6771         28.2059         30.0451         28.7359
520071..................................................          1.2135          1.0026         30.0262         30.6930         31.5435         30.8053
520075..................................................          1.6946          0.9511         29.2920         30.1582         32.2755         30.5484
520076..................................................          1.2239          1.1014         27.3335         27.4423         26.8932         27.2252
520078..................................................          1.4666          1.0182         29.9837         31.6606         32.0179         31.1768
520083..................................................          1.7215          1.1232         30.8826         32.7728         34.7200         32.8276
520087..................................................          1.7126          0.9796         28.5810         30.5659         31.9747         30.3890
520088..................................................          1.3463          0.9523         30.7450         30.6657         30.7462         30.7187
520089..................................................          1.5744          1.1232         33.8793         33.4098         34.9331         34.0808
520091..................................................          1.2752          0.9511         25.4593         27.3442         28.7166         27.1741
520095..................................................          1.2282          0.9704         30.4216         32.0381         33.2399         31.9187
520096..................................................          1.3683          1.0026         27.8896         29.5985         28.5204         28.6435
520097..................................................          1.3252          0.9511         29.1479         29.9998         31.0204         30.0765
520098..................................................          2.0129          1.1232         32.5785         36.5776         38.0962         35.8078
520100..................................................          1.3329          0.9824         29.3243         29.9458         31.7748         30.3552
520102..................................................          1.1961          1.0026         29.1680         30.7990         31.5735         30.5379
520103..................................................          1.5575          1.0182         30.3165         32.6269         34.5620         32.5629

[[Page 23781]]

 
520107..................................................          1.3439          0.9523         28.9878         29.4178         30.0343         29.4887
520109..................................................          1.0451          0.9511         24.7228         25.0697         25.9723         25.2667
520113..................................................          1.2659          0.9511         31.4708         33.3475         33.3023         32.7086
520116..................................................          1.2564          1.0026         27.9688         30.2156         31.6687         29.9794
520132..................................................             ***               *         25.0006         27.3431               *         26.0481
520136..................................................          1.6351          1.0182         30.6522         32.1479         32.3480         31.6992
520138..................................................          1.8898          1.0182         30.8016         31.6581         32.5653         31.6762
520139..................................................          1.3351          1.0182         28.8870         30.4903         31.7060         30.3322
520140..................................................             ***               *         31.0043         31.1315               *         31.0699
520152..................................................             ***               *         29.7308               *               *         29.7308
520160..................................................          1.7768          0.9511         27.9548         29.5582         30.3037         29.2715
520170..................................................          1.4785          1.0182         30.4309         31.4710         31.7586         31.2272
520173..................................................          1.0888               *         29.2429         31.0599               *         30.1478
520177..................................................          1.5992          1.0182         31.4555         32.5714         33.1218         32.4064
520189..................................................          1.1684          1.0315         28.0014         29.0295         29.2212         28.7600
520193..................................................          1.7185          0.9511         27.8113         29.2007         29.4715         28.8651
520194..................................................          1.5801          1.0182         30.1668         31.4379         30.9993         30.8959
520195..................................................          0.6565          1.0182         36.3116         36.2900         41.6044         37.9667
520196..................................................          1.7736          0.9599         36.9266         31.1175         31.6125         32.7571
520197..................................................             ***               *               *         30.1917               *         30.1917
520198..................................................          1.3572          0.9511               *         28.5975         29.9781         29.2918
520199..................................................          2.0438          1.0182               *         36.5699         37.0103         36.7943
520202..................................................          1.6509          0.9823               *               *               *               *
520203..................................................          2.9989          1.1232               *               *               *               *
530002..................................................          1.1984          0.9223         28.3063         29.2069         29.2407         28.9305
530006..................................................          1.2359          0.9223         27.2421         29.2104         30.3704         28.9041
530008..................................................          1.1650          0.9223         24.0090         26.5180         30.5992         27.0161
530009..................................................          0.9602          0.9223         24.6719         26.0490         27.0529         25.9191
530010..................................................          1.2145          0.9223         25.9852         27.4121         28.5518         27.3468
530011..................................................          1.1265          0.9223         27.8772         27.8613         31.1309         28.8654
530012..................................................          1.7040          0.9618         26.9582         28.7524         30.6085         28.7888
530014..................................................          1.5582          0.9611         26.7156         28.5469         29.6709         28.4442
530015..................................................          1.1779          0.9327         29.8310         29.8306         33.4886         31.0902
530017..................................................          0.9134          0.9223         29.8503         31.1105         25.8172         28.8536
530025..................................................          1.2876          0.9223         24.4392         29.4346         28.8951         27.4712
530032..................................................          1.0528          0.9223         23.9004         24.6580         25.4254         24.6844
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.D.2. of the preamble to this proposed rule.
\2\ The case-mix index is based on the billed DRGs in the FY 2007 MedPAR file. It is not transfer adjusted.
\3\ Provider 140010 is part of a multicampus 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 multicampus provider (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 multicampus provider (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.
*Denotes wage data not available for the provider for that year.
**Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009.
***Denotes MedPAR data not available for the provider for FY 2007.


  Table 3A.--FY 2009 and 3-Year* Average Hourly Wage for Urban Areas by
                                  CBSA
 [*Based on the salaries and hours computed for Federal FYs 2007, 2008,
                                and 2009]
------------------------------------------------------------------------
                                              FY 2009
    CBSA code           Urban area        average hourly  3-Year average
                                               wage         hourly wage
------------------------------------------------------------------------
10180...........  Abilene, TX...........         27.1004         25.7723
10380...........  Aguadilla-Isabela-San          10.6709         10.7622
                   Sebasti[aacute]n, PR.
10420...........  Akron, OH.............         28.3319         26.9292
10500...........  Albany, GA............         28.2617         27.2184
10580...........  Albany-Schenectady-            28.4655         27.2227
                   Troy, NY.
10740...........  Albuquerque, NM.......         30.6500         29.7201
10780...........  Alexandria, LA........         26.1655         24.7913
10900...........  Allentown-Bethlehem-           31.2097         30.7425
                   Easton, PA-NJ.
11020...........  Altoona, PA...........         26.7060         25.9824

[[Page 23782]]

 
11100...........  Amarillo, TX..........         29.0008         28.2619
11180...........  Ames, IA..............         30.4757         30.0901
11260...........  Anchorage, AK.........         38.0798         36.6236
11300...........  Anderson, IN..........         28.7750         27.5948
11340...........  Anderson, SC..........         31.3772         28.7401
11460...........  Ann Arbor, MI.........         33.6572         32.6579
11500...........  Anniston-Oxford, AL...         25.8029         24.6804
11540...........  Appleton, WI..........         30.0406         29.0241
11700...........  Asheville, NC.........         29.6273         28.5517
12020...........  Athens-Clarke County,          30.9008         29.8591
                   GA.
12060...........  Atlanta-Sandy Springs-         31.4502         30.3269
                   Marietta, GA.
12100...........  Atlantic City-                 38.0743         36.7794
                   Hammonton, NJ.
12220...........  Auburn-Opelika, AL....         24.3605         24.4407
12260...........  Augusta-Richmond               30.9498         29.7603
                   County, GA-SC.
12420...........  Austin-Round Rock, TX.         30.6888         29.3079
12540...........  Bakersfield, CA.......         36.5786         34.6045
12580...........  Baltimore-Towson, MD..         32.1655         30.9372
12620...........  Bangor, ME............         32.5961         30.6397
12700...........  Barnstable Town, MA...         40.8356         39.1326
12940...........  Baton Rouge, LA.......         26.2494         25.0384
12980...........  Battle Creek, MI......         32.3508         30.7409
13020...........  Bay City, MI..........         30.3060         28.7057
13140...........  Beaumont-Port Arthur,          27.7045         26.7778
                   TX.
13380...........  Bellingham, WA........         36.7964         34.7347
13460...........  Bend, OR..............         35.6036         33.2554
13644...........  Bethesda-Frederick-            33.9508         32.8571
                   Gaithersburg, MD.
13740...........  Billings, MT..........         29.1465         27.7805
13780...........  Binghamton, NY........         28.1030         27.6136
13820...........  Birmingham-Hoover, AL.         28.3138         27.3821
13900...........  Bismarck, ND..........         23.2350         22.4949
13980...........  Blacksburg-                    26.1759         25.2599
                   Christiansburg-
                   Radford, VA.
14020...........  Bloomington, IN.......         30.3742         28.6837
14060...........  Bloomington-Normal, IL         30.6807         29.0683
14260...........  Boise City-Nampa, ID..         29.9365         29.1371
14484...........  Boston-Quincy, MA.....         38.6504         36.7387
14500...........  Boulder, CO...........         32.3079         31.3052
14540...........  Bowling Green, KY.....         26.8895         25.3106
14600...........  Bradenton-Sarasota-            31.5095         30.2345
                   Venice, FL.
14740...........  Bremerton-Silverdale,          34.5710         33.5071
                   WA.
14860...........  Bridgeport-Stamford-           42.0944         39.8678
                   Norwalk, CT.
15180...........  Brownsville-Harlingen,         29.7382         29.0319
                   TX.
15260...........  Brunswick, GA.........         32.6731         31.3350
15380...........  Buffalo-Niagara Falls,         30.9123         29.5833
                   NY.
15500...........  Burlington, NC........         27.7660         26.6186
15540...........  Burlington-South               29.6973         29.1460
                   Burlington, VT.
15764...........  Cambridge-Newton-              35.6990         34.3809
                   Framingham, MA.
15804...........  Camden, NJ............         34.1250         32.6476
15940...........  Canton-Massillon, OH..         28.5297         27.6782
15980...........  Cape Coral-Fort Myers,         30.6869         29.4302
                   FL.
16180...........  Carson City, NV.......         32.3122         30.2124
16220...........  Casper, WY............         30.6085         28.7888
16300...........  Cedar Rapids, IA......         28.3050         27.0341
16580...........  Champaign-Urbana, IL..         30.1432         29.1751
16620...........  Charleston, WV........         27.1192         26.3071
16700...........  Charleston-North               29.7955         28.4097
                   Charleston-
                   Summerville, SC.
16740...........  Charlotte-Gastonia-            30.8456         29.4515
                   Concord, NC-SC.
16820...........  Charlottesville, VA...         31.3517         29.8273
16860...........  Chattanooga, TN-GA....         28.6158         27.6439
16940...........  Cheyenne, WY..........         29.6709         28.4442
16974...........  Chicago-Naperville-            33.3033         32.5973
                   Joliet, IL.
17020...........  Chico, CA.............         35.0695         34.2761
17140...........  Cincinnati-Middletown,         30.9027         29.7285
                   OH-KY-IN.
17300...........  Clarksville, TN-KY....         26.7544         25.7478
17420...........  Cleveland, TN.........         26.2909         25.3790
17460...........  Cleveland-Elyria-              29.8896         28.9336
                   Mentor, OH.
17660...........  Coeur d'Alene, ID.....         29.5998         28.7256
17780...........  College Station-Bryan,         29.6321         28.1756
                   TX.
17820...........  Colorado Springs, CO..         31.4793         29.6470
17860...........  Columbia, MO..........         27.2133         26.2863

[[Page 23783]]

 
17900...........  Columbia, SC..........         28.9948         27.6672
17980...........  Columbus, GA-AL.......         29.2007         27.4844
18020...........  Columbus, IN..........         31.7711         29.8902
18140...........  Columbus, OH..........         31.8334         30.9635
18580...........  Corpus Christi, TX....         27.3797         26.2260
18700...........  Corvallis, OR.........         35.7074         34.1739
19060...........  Cumberland, MD-WV.....         24.2686         24.3744
19124...........  Dallas-Plano-Irving,           31.7539         30.5827
                   TX.
19140...........  Dalton, GA............         27.3868         26.8521
19180...........  Danville, IL..........         31.2955         29.5310
19260...........  Danville, VA..........         27.3411         26.0795
19340...........  Davenport-Moline-Rock          27.2010         26.8964
                   Island, IA-IL.
19380...........  Dayton, OH............         30.0672         28.7100
19460...........  Decatur, AL...........         24.8584         24.2893
19500...........  Decatur, IL...........         26.3336         25.3091
19660...........  Deltona-Daytona Beach-         28.4632         27.8441
                   Ormond Beach, FL.
19740...........  Denver-Aurora, CO.....         34.1438         32.7970
19780...........  Des Moines-West Des            30.6173         28.7458
                   Moines, IA.
19804...........  Detroit-Livonia-               32.3846         31.4605
                   Dearborn, MI.
20020...........  Dothan, AL............         24.8722         23.3546
20100...........  Dover, DE.............         34.3823         32.3013
20220...........  Dubuque, IA...........         26.5562         26.9190
20260...........  Duluth, MN-WI.........         33.8981         31.7842
20500...........  Durham, NC............         31.2419         30.0944
20740...........  Eau Claire, WI........         30.9902         29.6325
20764...........  Edison-New Brunswick,          36.1487         34.5118
                   NJ.
20940...........  El Centro, CA.........         29.1074         28.1129
21060...........  Elizabethtown, KY.....         27.2829         26.5352
21140...........  Elkhart-Goshen, IN....         30.6988         29.4323
21300...........  Elmira, NY............         26.8991         25.8564
21340...........  El Paso, TX...........         28.5812         28.1095
21500...........  Erie, PA..............         28.0896         26.9188
21660...........  Eugene-Springfield, OR         35.9675         34.2186
21780...........  Evansville, IN-KY.....         27.4904         26.7119
21820...........  Fairbanks, AK.........         36.1891         34.2975
21940...........  Fajardo, PR...........         13.1075         12.8846
22020...........  Fargo, ND-MN..........         26.0887         24.9864
22140...........  Farmington, NM........         25.2152         26.1577
22180...........  Fayetteville, NC......         31.9846         30.2233
22220...........  Fayetteville-                  29.4256         27.9239
                   Springdale-Rogers, AR-
                   MO.
22380...........  Flagstaff, AZ.........         37.5481         35.8798
22420...........  Flint, MI.............         36.2781         34.1503
22500...........  Florence, SC..........         27.3900         26.5639
22520...........  Florence-Muscle                25.2619         24.0763
                   Shoals, AL.
22540...........  Fond du Lac, WI.......         30.7462         30.7188
22660...........  Fort Collins-Loveland,         30.8219         29.2764
                   CO.
22744...........  Fort Lauderdale-               31.6349         30.8485
                   Pompano Beach-
                   Deerfield Beach, FL.
22900...........  Fort Smith, AR-OK.....         25.2751         24.4937
23020...........  Fort Walton Beach-             28.1059         26.8450
                   Crestview-Destin, FL.
23060...........  Fort Wayne, IN........         28.8955         28.1729
23104...........  Fort Worth-Arlington,          31.2137         29.8330
                   TX.
23420...........  Fresno, CA............         35.7716         34.2816
23460...........  Gadsden, AL...........         25.7517         24.9688
23540...........  Gainesville, FL.......         30.4476         29.0940
23580...........  Gainesville, GA.......         30.0367         28.8932
23844...........  Gary, IN..............         30.0576         28.8628
24020...........  Glens Falls, NY.......         28.2938         26.8175
24140...........  Goldsboro, NC.........         29.5207         28.5197
24220...........  Grand Forks, ND-MN....         24.9880         24.4055
24300...........  Grand Junction, CO....         31.2200         29.9879
24340...........  Grand Rapids-Wyoming,          29.9037         29.1399
                   MI.
24500...........  Great Falls, MT.......         27.9340         26.5446
24540...........  Greeley, CO...........         32.4200         30.9988
24580...........  Green Bay, WI.........         30.6825         29.5078
24660...........  Greensboro-High Point,         29.4639         28.1363
                   NC.
24780...........  Greenville, NC........         30.1256         28.8796
24860...........  Greenville-Mauldin-            31.0004         29.7649
                   Easley, SC.
25020...........  Guayama, PR...........         10.1106         09.6176
25060...........  Gulfport-Biloxi, MS...         28.6731         27.0856

[[Page 23784]]

 
25180...........  Hagerstown-                    29.8828         28.7638
                   Martinsburg, MD-WV.
25260...........  Hanford-Corcoran, CA..         35.7293         33.4052
25420...........  Harrisburg-Carlisle,           29.4620         28.6481
                   PA.
25500...........  Harrisonburg, VA......         28.8643         27.8908
25540...........  Hartford-West Hartford-        36.0188         34.1981
                   East Hartford, CT.
25620...........  Hattiesburg, MS.......         24.2839         23.4139
25860...........  Hickory-Lenoir-                28.8353         27.7789
                   Morganton, NC.
25980...........  \1\ Hinesville-Fort
                   Stewart, GA.
26100...........  Holland-Grand Haven,           29.3296         28.2605
                   MI.
26180...........  Honolulu, HI..........         37.4061         34.9722
26300...........  Hot Springs, AR.......         29.4741         27.9457
26380...........  Houma-Bayou Cane-              25.3740         24.7942
                   Thibodaux, LA.
26420...........  Houston-Sugar Land-            31.9906         30.9869
                   Baytown, TX.
26580...........  Huntington-Ashland, WV-        29.4107         27.7644
                   KY-OH.
26620...........  Huntsville, AL........         28.9607         27.8624
26820...........  Idaho Falls, ID.......         29.3359         28.2699
26900...........  Indianapolis-Carmel,           31.6890         30.3105
                   IN.
26980...........  Iowa City, IA.........         30.2168         29.3116
27060...........  Ithaca, NY............         30.8103         29.9028
27100...........  Jackson, MI...........         30.5399         29.5811
27140...........  Jackson, MS...........         25.9122         24.9687
27180...........  Jackson, TN...........         27.3080         26.6865
27260...........  Jacksonville, FL......         29.3541         28.3904
27340...........  Jacksonville, NC......         27.0573         25.9214
27500...........  Janesville, WI........         31.7184         30.5036
27620...........  Jefferson City, MO....         29.1505         27.2519
27740...........  Johnson City, TN......         25.8452         24.5939
27780...........  Johnstown, PA.........         25.9505         24.9881
27860...........  Jonesboro, AR.........         26.0204         24.6491
27900...........  Joplin, MO............         31.3014         28.6510
28020...........  Kalamazoo-Portage, MI.         35.1589         33.2912
28100...........  Kankakee-Bradley, IL..         38.7329         33.0300
28140...........  Kansas City, MO-KS....         30.4624         29.0579
28420...........  Kennewick-Pasco-               31.3630         30.6561
                   Richland, WA.
28660...........  Killeen-Temple-Fort            28.5417         26.9557
                   Hood, TX.
28700...........  Kingsport-Bristol-             25.3719         24.5154
                   Bristol, TN-VA.
28740...........  Kingston, NY..........         30.3965         29.3492
28940...........  Knoxville, TN.........         25.4214         24.8943
29020...........  Kokomo, IN............         29.8433         29.2845
29100...........  La Crosse, WI-MN......         31.6291         30.0294
29140...........  Lafayette, IN.........         28.8946         27.2885
29180...........  Lafayette, LA.........         27.2063         25.9638
29340...........  Lake Charles, LA......         24.4720         24.0434
29404...........  Lake County-Kenosha            33.4390         32.6639
                   County, IL-WI.
29420...........  Lake Havasu City-              31.6370         29.6383
                   Kingman, AZ.
29460...........  Lakeland-Winter Haven,         28.1459         27.5004
                   FL.
29540...........  Lancaster, PA.........         31.0576         30.0449
29620...........  Lansing-East Lansing,          31.9010         30.9914
                   MI.
29700...........  Laredo, TX............         28.4147         26.3095
29740...........  Las Cruces, NM........         28.3851         27.2925
29820...........  Las Vegas-Paradise, NV         37.5945         35.4889
29940...........  Lawrence, KS..........         26.8014         25.6444
30020...........  Lawton, OK............         27.8148         26.3376
30140...........  Lebanon, PA...........         29.0022         26.8307
30300...........  Lewiston, ID-WA.......         29.8774         29.0074
30340...........  Lewiston-Auburn, ME...         30.0517         28.7720
30460...........  Lexington-Fayette, KY.         28.8431         27.8163
30620...........  Lima, OH..............         29.9606         28.3617
30700...........  Lincoln, NE...........         31.0009         30.3915
30780...........  Little Rock-North              28.2114         28.2530
                   Little Rock-Conway,
                   AR.
30860...........  Logan, UT-ID..........         28.3537         27.8958
30980...........  Longview, TX..........         27.3041         26.9355
31020...........  Longview, WA..........         36.9240         33.8434
31084...........  Los Angeles-Long Beach-        38.9626         36.6108
                   Glendale, CA.
31140...........  Louisville-Jefferson           29.7925         28.3269
                   County, KY-IN.
31180...........  Lubbock, TX...........         28.0803         26.7835
31340...........  Lynchburg, VA.........         27.7933         26.6660
31420...........  Macon, GA.............         31.6291         30.3409
31460...........  Madera, CA............         26.7719         26.0576

[[Page 23785]]

 
31540...........  Madison, WI...........         36.2618         34.3945
31700...........  Manchester-Nashua, NH.         33.0542         31.4821
31900...........  Mansfield, OH.........         29.9812         28.5726
32420...........  Mayag[uuml]ez, PR.....         12.5555         11.7170
32580...........  McAllen-Edinburg-              29.3886         27.9884
                   Mission, TX.
32780...........  Medford, OR...........         33.0786         32.3223
32820...........  Memphis, TN-MS-AR.....         30.0626         28.8798
32900...........  Merced, CA............         39.1381         36.7035
33124...........  Miami-Miami Beach-             31.8599         30.6911
                   Kendall, FL.
33140...........  Michigan City-La               29.1570         27.7380
                   Porte, IN.
33260...........  Midland, TX...........         30.8197         29.6993
33340...........  Milwaukee-Waukesha-            32.8741         31.8085
                   West Allis, WI.
33460...........  Minneapolis-St. Paul-          35.4391         33.7580
                   Bloomington, MN-WI.
33540...........  Missoula, MT..........         28.2291         26.9683
33660...........  Mobile, AL............         25.1640         24.3569
33700...........  Modesto, CA...........         39.1156         36.9865
33740...........  Monroe, LA............         25.6673         24.6843
33780...........  Monroe, MI............         28.7386         29.0350
33860...........  Montgomery, AL........         26.3999         25.1056
34060...........  Morgantown, WV........         27.8745         26.4870
34100...........  Morristown, TN........         23.5598         23.4073
34580...........  Mount Vernon-                  32.2055         31.3429
                   Anacortes, WA.
34620...........  Muncie, IN............         26.7339         25.4260
34740...........  Muskegon-Norton                32.9571         31.3172
                   Shores, MI.
34820...........  Myrtle Beach-North             28.0263         27.0772
                   Myrtle Beach-Conway,
                   SC.
34900...........  Napa, CA..............         45.2771         42.3405
34940...........  Naples-Marco Island,           31.7163         30.5323
                   FL.
34980...........  Nashville-Davidson-            30.5185         29.8356
                   Murfreesboro-
                   Franklin, TN.
35004...........  Nassau-Suffolk, NY....         41.0210         39.8184
35084...........  Newark-Union, NJ-PA...         37.3360         36.1271
35300...........  New Haven-Milford, CT.         38.1842         37.0168
35380...........  New Orleans-Metairie-          29.4715         27.1340
                   Kenner, LA.
35644...........  New York-White Plains-         42.0303         40.8866
                   Wayne, NY-NJ.
35660...........  Niles-Benton Harbor,           29.3085         28.0264
                   MI.
35980...........  Norwich-New London, CT         36.8468         36.0398
36084...........  Oakland-Fremont-               49.9560         47.7941
                   Hayward, CA.
36100...........  Ocala, FL.............         27.4049         26.5357
36140...........  Ocean City, NJ........         37.4820         34.3008
36220...........  Odessa, TX............         30.3782         30.3247
36260...........  Ogden-Clearfield, UT..         29.7855         28.2615
36420...........  Oklahoma City, OK.....         27.9928         27.1135
36500...........  Olympia, WA...........         37.0153         34.9710
36540...........  Omaha-Council Bluffs,          30.2913         29.2081
                   NE-IA.
36740...........  Orlando-Kissimmee, FL.         29.6766         28.9783
36780...........  Oshkosh-Neenah, WI....         30.0761         28.8544
36980...........  Owensboro, KY.........         28.2413         27.1328
37100...........  Oxnard-Thousand Oaks-          36.9286         35.1055
                   Ventura, CA.
37340...........  Palm Bay-Melbourne-            30.3622         29.2690
                   Titusville, FL.
37380...........  \2\ Palm Coast, FL....         28.3179         27.7197
37460...........  Panama City-Lynn               27.4719         25.9842
                   Haven, FL.
37620...........  Parkersburg-Marietta-          25.9281         25.2122
                   Vienna, WV-OH.
37700...........  Pascagoula, MS........         25.8776         25.5012
37764...........  Peabody, MA...........         34.6216         32.8179
37860...........  Pensacola-Ferry Pass-          26.1506         24.9081
                   Brent, FL.
37900...........  Peoria, IL............         29.1439         28.4392
37964...........  Philadelphia, PA......         35.4610         33.9583
38060...........  Phoenix-Mesa-                  33.0972         31.5810
                   Scottsdale, AZ.
38220...........  Pine Bluff, AR........         26.6629         25.9270
38300...........  Pittsburgh, PA........         27.6753         26.3759
38340...........  Pittsfield, MA........         33.6590         31.7762
38540...........  Pocatello, ID.........         29.3360         28.3737
38660...........  Ponce, PR.............         13.2835         13.4725
38860...........  Portland-South                 31.9890         30.7480
                   Portland-Biddeford,
                   ME.
38900...........  Portland-Vancouver-            36.1216         34.7569
                   Beaverton, OR-WA.
38940...........  Port St. Lucie, FL....         31.9898         30.8026
39100...........  Poughkeepsie-Newburgh-         35.2679         33.9878
                   Middletown, NY.
39140...........  Prescott, AZ..........         32.8634         30.9614
39300...........  Providence-New Bedford-        34.3817         33.0490
                   Fall River, RI-MA.
39340...........  Provo-Orem, UT........         29.1600         28.8274

[[Page 23786]]

 
39380...........  Pueblo, CO............         27.8188         26.8684
39460...........  Punta Gorda, FL.......         29.9874         29.4798
39540...........  Racine, WI............         28.8930         28.8892
39580...........  Raleigh-Cary, NC......         31.2156         30.0484
39660...........  Rapid City, SD........         30.6204         27.7643
39740...........  Reading, PA...........         30.0875         29.3819
39820...........  Redding, CA...........         41.6249         39.4241
39900...........  Reno-Sparks, NV.......         33.7604         34.6330
40060...........  Richmond, VA..........         29.6609         28.3807
40140...........  Riverside-San                  36.2653         34.0181
                   Bernardino-Ontario,
                   CA.
40220...........  Roanoke, VA...........         28.6468         27.4630
40340...........  Rochester, MN.........         35.3899         33.7865
40380...........  Rochester, NY.........         28.7144         27.8099
40420...........  Rockford, IL..........         31.7824         30.6686
40484...........  Rockingham County-             31.9359         31.0988
                   Strafford County, NH.
40580...........  Rocky Mount, NC.......         29.2288         27.8751
40660...........  Rome, GA..............         31.2559         29.9017
40900...........  Sacramento-Arden-              41.9426         40.3835
                   Arcade-Roseville, CA.
40980...........  Saginaw-Saginaw                29.1128         28.2485
                   Township North, MI.
41060...........  St. Cloud, MN.........         37.2177         34.8308
41100...........  St. George, UT........         29.7373         29.2069
41140...........  St. Joseph, MO-KS.....         33.7767         30.5981
41180...........  St. Louis, MO-IL......         28.9842         27.8523
41420...........  Salem, OR.............         34.3369         32.4058
41500...........  Salinas, CA...........         47.9744         45.4050
41540...........  Salisbury, MD.........         29.6266         27.8982
41620...........  Salt Lake City, UT....         29.8767         29.1422
41660...........  San Angelo, TX........         27.7212         26.5502
41700...........  San Antonio, TX.......         28.8457         27.6665
41740...........  San Diego-Carlsbad-San         36.2686         34.6834
                   Marcos, CA.
41780...........  Sandusky, OH..........         28.4754         27.6992
41884...........  San Francisco-San              48.5597         46.7826
                   Mateo-Redwood City,
                   CA.
41900...........  San Germ[aacute]n-Cabo         14.9779         14.5348
                   Rojo, PR.
41940...........  San Jose-Sunnyvale-            51.2569         48.2592
                   Santa Clara, CA.
41980...........  San Juan-Caguas-               14.1930         13.8050
                   Guaynabo, PR.
42020...........  San Luis Obispo-Paso           38.5623         36.3112
                   Robles, CA.
42044...........  Santa Ana-Anaheim-             38.1247         35.9846
                   Irvine, CA.
42060...........  Santa Barbara-Santa            37.7124         35.1162
                   Maria-Goleta, CA.
42100...........  Santa Cruz-                    51.5525         48.3881
                   Watsonville, CA.
42140...........  Santa Fe, NM..........         34.1580         33.1619
42220...........  Santa Rosa-Petaluma,           49.2189         45.6081
                   CA.
42340...........  Savannah, GA..........         28.8176         27.8424
42540...........  Scranton-Wilkes-Barre,         26.5201         25.6648
                   PA.
42644...........  Seattle-Bellevue-              37.3352         35.3387
                   Everett, WA.
42680...........  Sebastian-Vero Beach,          30.7417         30.0442
                   FL.
43100...........  Sheboygan, WI.........         29.1159         28.0863
43300...........  Sherman-Denison, TX...         29.9470         27.3065
43340...........  Shreveport-Bossier             27.5578         26.7863
                   City, LA.
43580...........  Sioux City, IA-NE-SD..         28.3024         27.7781
43620...........  Sioux Falls, SD.......         30.2235         29.2197
43780...........  South Bend-Mishawaka,          31.0993         30.1358
                   IN-MI.
43900...........  Spartanburg, SC.......         29.1025         28.3525
44060...........  Spokane, WA...........         33.9523         32.3332
44100...........  Springfield, IL.......         29.4330         27.9091
44140...........  Springfield, MA.......         33.3312         31.8950
44180...........  Springfield, MO.......         27.3178         26.6919
44220...........  Springfield, OH.......         27.8315         26.5028
44300...........  State College, PA.....         28.4188         27.0040
44700...........  Stockton, CA..........         38.6087         36.4711
44940...........  Sumter, SC............         27.6406         26.7218
45060...........  Syracuse, NY..........         31.7909         30.5763
45104...........  Tacoma, WA............         35.9647         33.8969
45220...........  Tallahassee, FL.......         29.0061         27.8746
45300...........  Tampa-St. Petersburg-          28.9032         28.1723
                   Clearwater, FL.
45460...........  Terre Haute, IN.......         29.4437         27.6736
45500...........  Texarkana, TX-                 26.4165         24.8363
                   Texarkana, AR.
45780...........  Toledo, OH............         29.8934         28.9126
45820...........  Topeka, KS............         28.5929         27.0599
45940...........  Trenton-Ewing, NJ.....         34.3697         33.3207

[[Page 23787]]

 
46060...........  Tucson, AZ............         30.4264         29.2232
46140...........  Tulsa, OK.............         27.8831         26.3265
46220...........  Tuscaloosa, AL........         28.0199         26.8295
46340...........  Tyler, TX.............         28.6912         27.8517
46540...........  Utica-Rome, NY........         28.1040         27.1057
46660...........  Valdosta, GA..........         26.3052         25.6427
46700...........  Vallejo-Fairfield, CA.         45.6926         44.8127
47020...........  Victoria, TX..........         25.6787         25.2869
47220...........  Vineland-Millville-            35.2379         33.0201
                   Bridgeton, NJ.
47260...........  Virginia Beach-Norfolk-        28.5838         27.2923
                   Newport News, VA-NC.
47300...........  Visalia-Porterville,           33.2020         31.5996
                   CA.
47380...........  Waco, TX..............         28.0515         26.9091
47580...........  Warner Robins, GA.....         30.5824         28.8902
47644...........  Warren-Troy-Farmington         32.1363         31.0932
                   Hills, MI.
47894...........  Washington-Arlington-          34.3840         33.3639
                   Alexandria, DC-VA-MD-
                   WV.
47940...........  Waterloo-Cedar Falls,          28.0510         26.9028
                   IA.
48140...........  Wausau, WI............         31.6785         30.5738
48260...........  Weirton-Steubenville,          25.8721         24.7386
                   WV-OH.
48300...........  Wenatchee, WA.........         30.3614         31.9688
48424...........  West Palm Beach-Boca           31.1027         29.7030
                   Raton-Boynton Beach,
                   FL.
48540...........  Wheeling, WV-OH.......         22.6472         21.8074
48620...........  Wichita, KS...........         28.9395         27.7964
48660...........  Wichita Falls, TX.....         29.5744         26.8201
48700...........  Williamsport, PA......         25.8784         24.8306
48864...........  Wilmington, DE-MD-NJ..         34.0940         32.8588
48900...........  Wilmington, NC........         29.1370         29.0123
49020...........  Winchester, VA-WV.....         31.4889         30.6457
49180...........  Winston-Salem, NC.....         29.0508         28.2246
49340...........  Worcester, MA.........         35.2688         34.2006
49420...........  Yakima, WA............         32.0317         30.9552
49500...........  Yauco, PR.............         10.8210         10.6067
49620...........  York-Hanover, PA......         31.1804         29.5691
49660...........  Youngstown-Warren-             28.8065         27.5854
                   Boardman, OH-PA.
49700...........  Yuba City, CA.........         34.7445         32.8688
49740...........  Yuma, AZ..............         31.9135        30.1305
------------------------------------------------------------------------
\1\ This area has no average hourly wage because there are no short-
  term, acute care hospitals in the area.
\2\ This is a new CBSA for FY 2008. To calculate the 3-year average
  hourly wage for this new area, we included the hospitals' data from
  their previous geographic location for FY 2006 and FY 2007.


  Table 3B.--FY 2009 and 3-Year* Average Hourly Wage for Rural Areas by
                                  CBSA
  [*Based on the sum of the salaries and hours computed for Federal FYs
                          2007, 2008, and 2009]
------------------------------------------------------------------------
                                              FY 2009
    CBSA code          Nonurban area      average hourly  3-Year average
                                               wage         hourly wage
------------------------------------------------------------------------
01..............  Alabama...............         24.6411         23.6242
02..............  Alaska................         38.4008         35.4138
03..............  Arizona...............         28.5407         27.4573
04..............  Arkansas..............         24.6204         23.3335
05..............  California............         38.6569         35.9246
06..............  Colorado..............         30.0754         28.7842
07..............  Connecticut...........         36.4301         35.6330
08..............  Delaware..............         32.6029         30.8226
10..............  Florida...............         27.8797         26.8062
11..............  Georgia...............         25.2642         24.2873
12..............  Hawaii................         36.0283         33.6508
13..............  Idaho.................         24.4380         24.1641
14..............  Illinois..............         27.1642         25.9705
15..............  Indiana...............         27.3432         26.4475
16..............  Iowa..................         28.1850         26.6791
17..............  Kansas................         25.9806         24.8089
18..............  Kentucky..............         25.2536         24.2249
19..............  Louisiana.............         24.7667         23.6881
20..............  Maine.................         27.7429         26.2711
21..............  Maryland..............         28.3407         27.4609
22..............  Massachusetts.........  ..............  ..............
23..............  Michigan..............         28.5656         27.6632

[[Page 23788]]

 
24..............  Minnesota.............         29.3894         28.3126
25..............  Mississippi...........         24.6569         23.9273
26..............  Missouri..............         26.3804         25.2174
27..............  Montana...............         27.8425         26.4700
28..............  Nebraska..............         28.0119         26.9486
29..............  Nevada................         31.6580         29.6483
30..............  New Hampshire.........         33.2526         32.8237
31..............  New Jersey \1\........  ..............  ..............
32..............  New Mexico............         28.5810         27.1089
33..............  New York..............         26.7717         25.8110
34..............  North Carolina........         27.8184         26.7060
35..............  North Dakota..........         23.7299         22.7358
36..............  Ohio..................         27.6801         26.8138
37..............  Oklahoma..............         25.8341         24.3148
38..............  Oregon................         33.1220         30.9016
39..............  Pennsylvania..........         26.9119         25.8178
40..............  Puerto Rico \1\.......  ..............  ..............
41..............  Rhode Island \1\......  ..............  ..............
42..............  South Carolina........         27.7889         26.8744
43..............  South Dakota..........         27.1581         25.8858
44..............  Tennessee.............         25.6634         24.6486
45..............  Texas.................         26.2796         25.3601
46..............  Utah..................         27.0526         25.6723
47..............  Vermont...............         32.0308         30.2935
49..............  Virginia..............         25.9700         24.9967
50..............  Washington............         32.6127         31.5030
51..............  West Virginia.........         24.6596         23.6988
52..............  Wisconsin.............         30.7058         29.7224
53..............  Wyoming...............         29.7219         28.3175
------------------------------------------------------------------------
\1\ All counties within the State or territory are classified as urban.


Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                Urban Areas by CBSA and by State--FY 2009
             [Constituent counties are listed in Table 4E.]
------------------------------------------------------------------------
                                                       Wage
     CBSA Code           Urban area        State      index       GAF
------------------------------------------------------------------------
10180..............  Abilene, TX......  TX........     0.8408     0.8880
10380..............  Aguadilla-Isabela- PR........     0.3311     0.4691
                      San
                      Sebasti[aacute]n
                      , PR.
10420..............  Akron, OH........  OH........     0.8784     0.9150
10500..............  Albany, GA.......  GA........     0.8770     0.9140
10580..............  Albany-            NY........     0.8833     0.9185
                      Schenectady-
                      Troy, NY.
10740..............  Albuquerque, NM..  NM........     0.9499     0.9654
10780..............  Alexandria, LA...  LA........     0.8127     0.8676
10900..............  Allentown-         NJ........     1.1221     1.0821
                      Bethlehem-
                      Easton, PA-NJ.
10900..............  Allentown-         PA........     0.9675     0.9776
                      Bethlehem-
                      Easton, PA-NJ.
11020..............  Altoona, PA......  PA........     0.8342     0.8833
11100..............  Amarillo, TX.....  TX........     0.8997     0.9302
11180..............  Ames, IA.........  IA........     0.9417     0.9597
11260..............  Anchorage, AK....  AK........     1.1884     1.1255
11300..............  Anderson, IN.....  IN........     0.8923     0.9249
11340..............  Anderson, SC.....  SC........     0.9721     0.9808
11460..............  Ann Arbor, MI....  MI........     1.0444     1.0302
11500..............  Anniston-Oxford,   AL........     0.8007     0.8588
                      AL.
11540..............  Appleton, WI.....  WI........     0.9511     0.9662
11700..............  Asheville, NC....  NC........     0.9192     0.9439
12020..............  Athens-Clarke      GA........     0.9589     0.9717
                      County, GA.
12060..............  Atlanta-Sandy      GA........     0.9760     0.9835
                      Springs-
                      Marietta, GA.
12100..............  Atlantic City-     NJ........     1.1666     1.1113
                      Hammonton, NJ.
12220..............  Auburn-Opelika,    AL........     0.7647     0.8322
                      AL.
12260..............  Augusta-Richmond   GA........     0.9604     0.9727
                      County, GA-SC.
12260..............  Augusta-Richmond   SC........     0.9589     0.9717
                      County, GA-SC.
12420..............  Austin-Round       TX........     0.9521     0.9669
                      Rock, TX.
12540..............  Bakersfield, CA..  CA........     1.1822     1.1214
12580..............  Baltimore-Towson,  MD........     0.9981     0.9987
                      MD.
12620..............  Bangor, ME.......  ME........     1.0115     1.0079

[[Page 23789]]

 
12700..............  Barnstable Town,   MA........     1.2672     1.1761
                      MA.
12940..............  Baton Rouge, LA..  LA........     0.8142     0.8687
12980..............  Battle Creek, MI.  MI........     1.0039     1.0027
13020..............  Bay City, MI.....  MI........     0.9472     0.9635
13140..............  Beaumont-Port      TX........     0.8595     0.9015
                      Arthur, TX.
13380..............  Bellingham, WA...  WA........     1.1395     1.0935
13460..............  Bend, OR.........  OR........     1.1043     1.0703
13644..............  Bethesda-          MD........     1.1018     1.0686
                      Frederick-
                      Gaithersburg, MD.
13740..............  Billings, MT.....  MT........     0.9045     0.9336
13780..............  Binghamton, NY...  NY........     0.8721     0.9105
13820..............  Birmingham-        AL........     0.8786     0.9152
                      Hoover, AL.
13900..............  Bismarck, ND.....  ND........     0.7336     0.8088
13980..............  Blacksburg-        VA........     0.8122     0.8672
                      Christiansburg-
                      Radford, VA.
14020..............  Bloomington, IN..  IN........     0.9419     0.9598
14060..............  Bloomington-       IL........     0.9520     0.9669
                      Normal, IL.
14260..............  Boise City-Nampa,  ID........     0.9290     0.9508
                      ID.
14484..............  Boston-Quincy, MA  MA........     1.1994     1.1326
14500..............  Boulder, CO......  CO........     0.9994     0.9996
14540..............  Bowling Green, KY  KY........     0.8344     0.8834
14600..............  Bradenton-         FL........     0.9757     0.9833
                      Sarasota-Venice,
                      FL.
14740..............  Bremerton-         WA........     1.0706     1.0478
                      Silverdale, WA.
14860..............  Bridgeport-        CT........     1.2591     1.1709
                      Stamford-
                      Norwalk, CT.
15180..............  Brownsville-       TX........     0.9226     0.9463
                      Harlingen, TX.
15260..............  Brunswick, GA....  GA........     1.0139     1.0095
15380..............  Buffalo-Niagara    NY........     0.9593     0.9719
                      Falls, NY.
15500..............  Burlington, NC...  NC........     0.8632     0.9042
15540..............  Burlington-South   VT........     0.9275     0.9498
                      Burlington, VT.
15764..............  Cambridge-Newton-  MA........     1.1078     1.0726
                      Framingham, MA.
15804..............  Camden, NJ.......  NJ........     1.1221     1.0821
15940..............  Canton-Massillon,  OH........     0.8845     0.9194
                      OH.
15980..............  Cape Coral-Fort    FL........     0.9502     0.9656
                      Myers, FL.
16180..............  Carson City, NV..  NV........     1.0027     1.0018
16220..............  Casper, WY.......  WY........     0.9618     0.9737
16300..............  Cedar Rapids, IA.  IA........     0.8746     0.9123
16580..............  Champaign-Urbana,  IL........     0.9353     0.9552
                      IL.
16620..............  Charleston, WV...  WV........     0.8398     0.8873
16700..............  Charleston-North   SC........     0.9231     0.9467
                      Charleston-
                      Summerville, SC.
16740..............  Charlotte-         NC........     0.9570     0.9704
                      Gastonia-
                      Concord, NC-SC.
16740..............  Charlotte-         SC........     0.9557     0.9694
                      Gastonia-
                      Concord, NC-SC.
16820..............  Charlottesville,   VA........     0.9728     0.9813
                      VA.
16860..............  Chattanooga, TN-   GA........     0.8880     0.9219
                      GA.
16860..............  Chattanooga, TN-   TN........     0.8857     0.9202
                      GA.
16940..............  Cheyenne, WY.....  WY........     0.9223     0.9461
16974..............  Chicago-           IL........     1.0334     1.0228
                      Naperville-
                      Joliet, IL.
17020..............  Chico, CA........  CA........     1.1822     1.1214
17140..............  Cincinnati-        IN........     0.9583     0.9713
                      Middletown, OH-
                      KY-IN.
17140..............  Cincinnati-        KY........     0.9590     0.9717
                      Middletown, OH-
                      KY-IN.
17140..............  Cincinnati-        OH........     0.9581     0.9711
                      Middletown, OH-
                      KY-IN.
17300..............  Clarksville, TN-   KY........     0.8302     0.8804
                      KY.
17300..............  Clarksville, TN-   TN........     0.8280     0.8788
                      KY.
17420..............  Cleveland, TN....  TN........     0.8137     0.8683
17460..............  Cleveland-Elyria-  OH........     0.9266     0.9491
                      Mentor, OH.
17660..............  Coeur d'Alene, ID  ID........     0.9185     0.9434
17780..............  College Station-   TX........     0.9193     0.9440
                      Bryan, TX.
17820..............  Colorado Springs,  CO........     0.9738     0.9820
                      CO.
17860..............  Columbia, MO.....  MO........     0.8470     0.8925
17900..............  Columbia, SC.....  SC........     0.8984     0.9293
17980..............  Columbus, GA-AL..  AL........     0.9061     0.9347
17980..............  Columbus, GA-AL..  GA........     0.9061     0.9347
18020..............  Columbus, IN.....  IN........     0.9852     0.9898
18140..............  Columbus, OH.....  OH........     0.9869     0.9910
18580..............  Corpus Christi,    TX........     0.8494     0.8942
                      TX.
18700..............  Corvallis, OR....  OR........     1.1076     1.0725
19060..............  Cumberland, MD-WV  MD........     0.8795     0.9158
19060..............  Cumberland, MD-WV  WV........     0.7635     0.8313
19124..............  Dallas-Plano-      TX........     0.9852     0.9898
                      Irving, TX.
19140..............  Dalton, GA.......  GA........     0.8499     0.8946
19180..............  Danville, IL.....  IL........     0.9711     0.9801
19260..............  Danville, VA.....  VA........     0.8483     0.8935

[[Page 23790]]

 
19340..............  Davenport-Moline-  IL........     0.8606     0.9023
                      Rock Island, IA-
                      IL.
19340..............  Davenport-Moline-  IA........     0.8709     0.9097
                      Rock Island, IA-
                      IL.
19380..............  Dayton, OH.......  OH........     0.9321     0.9530
19460..............  Decatur, AL......  AL........     0.7714     0.8372
19500..............  Decatur, IL......  IL........     0.8428     0.8895
19660..............  Deltona-Daytona    FL........     0.8814     0.9172
                      Beach-Ormond
                      Beach, FL.
19740..............  Denver-Aurora, CO  CO........     1.0561     1.0381
19780..............  Des Moines-West    IA........     0.9460     0.9627
                      Des Moines, IA.
19804..............  Detroit-Livonia-   MI........     1.0052     1.0036
                      Dearborn, MI.
20020..............  Dothan, AL.......  AL........     0.7718     0.8375
20100..............  Dover, DE........  DE........     1.0669     1.0453
20220..............  Dubuque, IA......  IA........     0.8709     0.9097
20260..............  Duluth, MN-WI....  MN........     1.0519     1.0353
20260..............  Duluth, MN-WI....  WI........     1.0499     1.0339
20500..............  Durham, NC.......  NC........     0.9693     0.9789
20740..............  Eau Claire, WI...  WI........     0.9599     0.9724
20764..............  Edison-New         NJ........     1.1221     1.0821
                      Brunswick, NJ.
20940..............  El Centro, CA....  CA........     1.1822     1.1214
21060..............  Elizabethtown, KY  KY........     0.8466     0.8922
21140..............  Elkhart-Goshen,    IN........     0.9547     0.9688
                      IN.
21300..............  Elmira, NY.......  NY........     0.8347     0.8836
21340..............  El Paso, TX......  TX........     0.8867     0.9210
21500..............  Erie, PA.........  PA........     0.8708     0.9096
21660..............  Eugene-            OR........     1.1157     1.0779
                      Springfield, OR.
21780..............  Evansville, IN-KY  IN........     0.8525     0.8965
21780..............  Evansville, IN-KY  KY........     0.8531     0.8969
21820..............  Fairbanks, AK....  AK........     1.1884     1.1255
21940..............  Fajardo, PR......  PR........     0.4067     0.5400
22020..............  Fargo, ND-MN.....  MN........     0.9120     0.9389
22020..............  Fargo, ND-MN.....  ND........     0.8212     0.8738
22140..............  Farmington, NM...  NM........     0.8858     0.9203
22180..............  Fayetteville, NC.  NC........     0.9923     0.9947
22220..............  Fayetteville-      AR........     0.9131     0.9396
                      Springdale-
                      Rogers, AR-MO.
22220..............  Fayetteville-      MO........     0.9123     0.9391
                      Springdale-
                      Rogers, AR-MO.
22380..............  Flagstaff, AZ....  AZ........     1.1652     1.1104
22420..............  Flint, MI........  MI........     1.1258     1.0845
22500..............  Florence, SC.....  SC........     0.8609     0.9025
22520..............  Florence-Muscle    AL........     0.7883     0.8497
                      Shoals, AL.
22540..............  Fond du Lac, WI..  WI........     0.9523     0.9671
22660..............  Fort Collins-      CO........     0.9581     0.9711
                      Loveland, CO.
22744..............  Fort Lauderdale-   FL........     1.0025     1.0017
                      Pompano Beach-
                      Deerfield Beach,
                      FL.
22900..............  Fort Smith, AR-OK  AR........     0.7843     0.8467
22900..............  Fort Smith, AR-OK  OK........     0.8016     0.8595
23020..............  Fort Walton Beach- FL........     0.8703     0.9093
                      Crestview-
                      Destin, FL.
23060..............  Fort Wayne, IN...  IN........     0.9004     0.9307
23104..............  Fort Worth-        TX........     0.9684     0.9783
                      Arlington, TX.
23420..............  Fresno, CA.......  CA........     1.1822     1.1214
23460..............  Gadsden, AL......  AL........     0.7991     0.8576
23540..............  Gainesville, FL..  FL........     0.9427     0.9604
23580..............  Gainesville, GA..  GA........     0.9321     0.9530
23844..............  Gary, IN.........  IN........     0.9320     0.9529
24020..............  Glens Falls, NY..  NY........     0.8780     0.9148
24140..............  Goldsboro, NC....  NC........     0.9159     0.9416
24220..............  Grand Forks, ND-   MN........     0.9120     0.9389
                      MN.
24220..............  Grand Forks, ND-   ND........     0.7709     0.8368
                      MN.
24300..............  Grand Junction,    CO........     0.9925     0.9949
                      CO.
24340..............  Grand Rapids-      MI........     0.9305     0.9519
                      Wyoming, MI.
24500..............  Great Falls, MT..  MT........     0.8679     0.9075
24540..............  Greeley, CO......  CO........     1.0028     1.0019
24580..............  Green Bay, WI....  WI........     0.9511     0.9662
24660..............  Greensboro-High    NC........     0.9141     0.9403
                      Point, NC.
24780..............  Greenville, NC...  NC........     0.9346     0.9547
24860..............  Greenville-        SC........     0.9605     0.9728
                      Mauldin-Easley,
                      SC.
25020..............  Guayama, PR......  PR........     0.3137     0.4521
25060..............  Gulfport-Biloxi,   MS........     0.8898     0.9232
                      MS.
25180..............  Hagerstown-        MD........     0.9273     0.9496
                      Martinsburg, MD-
                      WV.
25180..............  Hagerstown-        WV........     0.9253     0.9482
                      Martinsburg, MD-
                      WV.
25260..............  Hanford-Corcoran,  CA........     1.1822     1.1214
                      CA.
25420..............  Harrisburg-        PA........     0.9185     0.9434
                      Carlisle, PA.

[[Page 23791]]

 
25500..............  Harrisonburg, VA.  VA........     0.8956     0.9273
25540..............  Hartford-West      CT........     1.1897     1.1263
                      Hartford-East
                      Hartford, CT.
25620..............  Hattiesburg, MS..  MS........     0.7653     0.8326
25860..............  Hickory-Lenoir-    NC........     0.8946     0.9266
                      Morganton, NC.
26100..............  Holland-Grand      MI........     0.9101     0.9375
                      Haven, MI.
26180..............  Honolulu, HI.....  HI........     1.1608     1.1075
26300..............  Hot Springs, AR..  AR........     0.9146     0.9407
26380..............  Houma-Bayou Cane-  LA........     0.7870     0.8487
                      Thibodaux, LA.
26420..............  Houston-Sugar      TX........     0.9925     0.9949
                      Land-Baytown, TX.
26580..............  Huntington-        KY........     0.9127     0.9394
                      Ashland, WV-KY-
                      OH.
26580..............  Huntington-        OH........     0.9118     0.9387
                      Ashland, WV-KY-
                      OH.
26580..............  Huntington-        WV........     0.9107     0.9380
                      Ashland, WV-KY-
                      OH.
26620..............  Huntsville, AL...  AL........     0.8987     0.9295
26820..............  Idaho Falls, ID..  ID........     0.9327     0.9534
26900..............  Indianapolis-      IN........     0.9827     0.9881
                      Carmel, IN.
26980..............  Iowa City, IA....  IA........     0.9337     0.9541
27060..............  Ithaca, NY.......  NY........     0.9561     0.9697
27100..............  Jackson, MI......  MI........     0.9477     0.9639
27140..............  Jackson, MS......  MS........     0.8095     0.8653
27180..............  Jackson, TN......  TN........     0.8452     0.8912
27260..............  Jacksonville, FL.  FL........     0.9092     0.9369
27340..............  Jacksonville, NC.  NC........     0.8632     0.9042
27500..............  Janesville, WI...  WI........     0.9824     0.9879
27620..............  Jefferson City,    MO........     0.9038     0.9331
                      MO.
27740..............  Johnson City, TN.  TN........     0.7999     0.8582
27780..............  Johnstown, PA....  PA........     0.8342     0.8833
27860..............  Jonesboro, AR....  AR........     0.8291     0.8796
27900..............  Joplin, MO.......  MO........     0.9704     0.9796
28020..............  Kalamazoo-         MI........     1.0910     1.0615
                      Portage, MI.
28100..............  Kankakee-Bradley,  IL........     1.2018     1.1341
                      IL.
28140..............  Kansas City, MO-   KS........     0.9453     0.9622
                      KS.
28140..............  Kansas City, MO-   MO........     0.9444     0.9616
                      KS.
28420..............  Kennewick-Pasco-   WA........     1.0164     1.0112
                      Richland, WA.
28660..............  Killeen-Temple-    TX........     0.8855     0.9201
                      Fort Hood, TX.
28700..............  Kingsport-Bristol- TN........     0.7957     0.8551
                      Bristol, TN-VA.
28700..............  Kingsport-Bristol- VA........     0.8061     0.8628
                      Bristol, TN-VA.
28740..............  Kingston, NY.....  NY........     0.9433     0.9608
28940..............  Knoxville, TN....  TN........     0.7957     0.8551
29020..............  Kokomo, IN.......  IN........     0.9254     0.9483
29100..............  La Crosse, WI-MN.  MN........     0.9815     0.9873
29100..............  La Crosse, WI-MN.  WI........     0.9796     0.9860
29140..............  Lafayette, IN....  IN........     0.8960     0.9276
29180..............  Lafayette, LA....  LA........     0.8438     0.8902
29340..............  Lake Charles, LA.  LA........     0.7682     0.8348
29404..............  Lake County-       IL........     1.0376     1.0256
                      Kenosha County,
                      IL-WI.
29404..............  Lake County-       WI........     1.0357     1.0243
                      Kenosha County,
                      IL-WI.
29420..............  Lake Havasu City-  AZ........     0.9817     0.9874
                      Kingman, AZ.
29460..............  Lakeland-Winter    FL........     0.8715     0.9101
                      Haven, FL.
29540..............  Lancaster, PA....  PA........     0.9799     0.9862
29620..............  Lansing-East       MI........     0.9899     0.9931
                      Lansing, MI.
29700..............  Laredo, TX.......  TX........     0.8816     0.9173
29740..............  Las Cruces, NM...  NM........     0.8858     0.9203
29820..............  Las Vegas-         NV........     1.1666     1.1113
                      Paradise, NV.
29940..............  Lawrence, KS.....  KS........     0.8317     0.8814
30020..............  Lawton, OK.......  OK........     0.8630     0.9040
30140..............  Lebanon, PA......  PA........     0.8991     0.9298
30300..............  Lewiston, ID-WA..  ID........     0.9271     0.9495
30300..............  Lewiston, ID-WA..  WA........     1.0164     1.0112
30340..............  Lewiston-Auburn,   ME........     0.9326     0.9533
                      ME.
30460..............  Lexington-         KY........     0.8950     0.9268
                      Fayette, KY.
30620..............  Lima, OH.........  OH........     0.9299     0.9514
30700..............  Lincoln, NE......  NE........     0.9620     0.9738
30780..............  Little Rock-North  AR........     0.8754     0.9129
                      Little Rock-
                      Conway, AR.
30860..............  Logan, UT-ID.....  ID........     0.8827     0.9181
30860..............  Logan, UT-ID.....  UT........     0.8827     0.9181
30980..............  Longview, TX.....  TX........     0.8666     0.9066
31020..............  Longview, WA.....  WA........     1.1434     1.0961
31084..............  Los Angeles-Long   CA........     1.1916     1.1275
                      Beach-Glendale,
                      CA.
31140..............  Louisville-        IN........     0.9238     0.9472
                      Jefferson
                      County, KY-IN.

[[Page 23792]]

 
31140..............  Louisville-        KY........     0.9245     0.9477
                      Jefferson
                      County, KY-IN.
31180..............  Lubbock, TX......  TX........     0.8712     0.9099
31340..............  Lynchburg, VA....  VA........     0.8646     0.9052
31420..............  Macon, GA........  GA........     0.9815     0.9873
31460..............  Madera, CA.......  CA........     1.1822     1.1214
31540..............  Madison, WI......  WI........     1.1232     1.0828
31700..............  Manchester-        NH........     1.0807     1.0546
                      Nashua, NH.
31900..............  Mansfield, OH....  OH........     0.9295     0.9512
32420..............  Mayag[uuml]ez, PR  PR........     0.3896     0.5244
32580..............  McAllen-Edinburg-  TX........     0.9118     0.9387
                      Mission, TX.
32780..............  Medford, OR......  OR........     1.0298     1.0203
32820..............  Memphis, TN-MS-AR  AR........     0.9329     0.9535
32820..............  Memphis, TN-MS-AR  MS........     0.9329     0.9535
32820..............  Memphis, TN-MS-AR  TN........     0.9305     0.9519
32900..............  Merced, CA.......  CA........     1.1969     1.1310
33124..............  Miami-Miami Beach- FL........     0.9865     0.9907
                      Kendall, FL.
33140..............  Michigan City-La   IN........     0.9041     0.9333
                      Porte, IN.
33260..............  Midland, TX......  TX........     0.9562     0.9698
33340..............  Milwaukee-         WI........     1.0182     1.0124
                      Waukesha-West
                      Allis, WI.
33460..............  Minneapolis-St.    MN........     1.0997     1.0672
                      Paul-
                      Bloomington, MN-
                      WI.
33460..............  Minneapolis-St.    WI........     1.0976     1.0659
                      Paul-
                      Bloomington, MN-
                      WI.
33540..............  Missoula, MT.....  MT........     0.8909     0.9239
33660..............  Mobile, AL.......  AL........     0.7809     0.8442
33700..............  Modesto, CA......  CA........     1.1963     1.1306
33740..............  Monroe, LA.......  LA........     0.7961     0.8554
33780..............  Monroe, MI.......  MI........     0.8918     0.9246
33860..............  Montgomery, AL...  AL........     0.8192     0.8723
34060..............  Morgantown, WV...  WV........     0.8631     0.9041
34100..............  Morristown, TN...  TN........     0.7957     0.8551
34580..............  Mount Vernon-      WA........     1.0164     1.0112
                      Anacortes, WA.
34620..............  Muncie, IN.......  IN........     0.8479     0.8932
34740..............  Muskegon-Norton    MI........     1.0227     1.0155
                      Shores, MI.
34820..............  Myrtle Beach-      SC........     0.8683     0.9078
                      North Myrtle
                      Beach-Conway, SC.
34900..............  Napa, CA.........  CA........     1.3847     1.2497
34940..............  Naples-Marco       FL........     0.9820     0.9876
                      Island, FL.
34980..............  Nashville-         TN........     0.9445     0.9617
                      Davidson-
                      Murfreesboro-
                      Franklin, TN.
35004..............  Nassau-Suffolk,    NY........     1.2729     1.1797
                      NY.
35084..............  Newark-Union, NJ-  NJ........     1.1440     1.0965
                      PA.
35084..............  Newark-Union, NJ-  PA........     1.1574     1.1053
                      PA.
35300..............  New Haven-         CT........     1.1897     1.1263
                      Milford, CT.
35380..............  New Orleans-       LA........     0.9140     0.9403
                      Metairie-Kenner,
                      LA.
35644..............  New York-White     NJ........     1.2878     1.1891
                      Plains-Wayne, NY-
                      NJ.
35644..............  New York-White     NY........     1.3043     1.1995
                      Plains-Wayne, NY-
                      NJ.
35660..............  Niles-Benton       MI........     0.9095     0.9371
                      Harbor, MI.
35980..............  Norwich-New        CT........     1.1897     1.1263
                      London, CT.
36084..............  Oakland-Fremont-   CA........     1.5278     1.3367
                      Hayward, CA.
36100..............  Ocala, FL........  FL........     0.8633     0.9042
36140..............  Ocean City, NJ...  NJ........     1.1484     1.0994
36220..............  Odessa, TX.......  TX........     0.9425     0.9603
36260..............  Ogden-Clearfield,  UT........     0.9243     0.9475
                      UT.
36420..............  Oklahoma City, OK  OK........     0.8686     0.9080
36500..............  Olympia, WA......  WA........     1.1462     1.0979
36540..............  Omaha-Council      IA........     0.9360     0.9557
                      Bluffs, NE-IA.
36540..............  Omaha-Council      NE........     0.9400     0.9585
                      Bluffs, NE-IA.
36740..............  Orlando-           FL........     0.9189     0.9437
                      Kissimmee, FL.
36780..............  Oshkosh-Neenah,    WI........     0.9511     0.9662
                      WI.
36980..............  Owensboro, KY....  KY........     0.8764     0.9136
37100..............  Oxnard-Thousand    CA........     1.1822     1.1214
                      Oaks-Ventura, CA.
37340..............  Palm Bay-          FL........     0.9401     0.9586
                      Melbourne-
                      Titusville, FL.
37380..............  Palm Coast, FL...  FL........     0.8769     0.9140
37460..............  Panama City-Lynn   FL........     0.8633     0.9042
                      Haven, FL.
37620..............  Parkersburg-       OH........     0.8582     0.9006
                      Marietta-Vienna,
                      WV-OH.
37620..............  Parkersburg-       WV........     0.8028     0.8603
                      Marietta-Vienna,
                      WV-OH.
37700..............  Pascagoula, MS...  MS........     0.8030     0.8605
37764..............  Peabody, MA......  MA........     1.0744     1.0504
37860..............  Pensacola-Ferry    FL........     0.8633     0.9042
                      Pass-Brent, FL.
37900..............  Peoria, IL.......  IL........     0.9043     0.9334
37964..............  Philadelphia, PA.  PA........     1.0992     1.0669
38060..............  Phoenix-Mesa-      AZ........     1.0271     1.0185
                      Scottsdale, AZ.

[[Page 23793]]

 
38220..............  Pine Bluff, AR...  AR........     0.8274     0.8783
38300..............  Pittsburgh, PA...  PA........     0.8579     0.9004
38340..............  Pittsfield, MA...  MA........     1.0445     1.0303
38540..............  Pocatello, ID....  ID........     0.9103     0.9377
38660..............  Ponce, PR........  PR........     0.4122     0.5450
38860..............  Portland-South     ME........     0.9927     0.9950
                      Portland-
                      Biddeford, ME.
38900..............  Portland-          OR........     1.1204     1.0810
                      Vancouver-
                      Beaverton, OR-WA.
38900..............  Portland-          WA........     1.1186     1.0798
                      Vancouver-
                      Beaverton, OR-WA.
38940..............  Port St. Lucie,    FL........     0.9905     0.9935
                      FL.
39100..............  Poughkeepsie-      NY........     1.0944     1.0637
                      Newburgh-
                      Middletown, NY.
39140..............  Prescott, AZ.....  AZ........     1.0198     1.0135
39300..............  Providence-New     MA........     1.0669     1.0453
                      Bedford-Fall
                      River, RI-MA.
39300..............  Providence-New     RI........     1.0669     1.0453
                      Bedford-Fall
                      River, RI-MA.
39340..............  Provo-Orem, UT...  UT........     0.9052     0.9341
39380..............  Pueblo, CO.......  CO........     0.9303     0.9517
39460..............  Punta Gorda, FL..  FL........     0.9286     0.9505
39540..............  Racine, WI.......  WI........     0.9511     0.9662
39580..............  Raleigh-Cary, NC.  NC........     0.9685     0.9783
39660..............  Rapid City, SD...  SD........     0.9502     0.9656
39740..............  Reading, PA......  PA........     0.9327     0.9534
39820..............  Redding, CA......  CA........     1.2730     1.1797
39900..............  Reno-Sparks, NV..  NV........     1.0476     1.0324
40060..............  Richmond, VA.....  VA........     0.9203     0.9447
40140..............  Riverside-San      CA........     1.1822     1.1214
                      Bernardino-
                      Ontario, CA.
40220..............  Roanoke, VA......  VA........     0.8889     0.9225
40340..............  Rochester, MN....  MN........     1.0982     1.0662
40380..............  Rochester, NY....  NY........     0.8911     0.9241
40420..............  Rockford, IL.....  IL........     0.9862     0.9905
40484..............  Rockingham County- NH........     1.0807     1.0546
                      Strafford
                      County, NH.
40580..............  Rocky Mount, NC..  NC........     0.9068     0.9352
40660..............  Rome, GA.........  GA........     0.9699     0.9793
40900..............  Sacramento--Arden- CA........     1.2827     1.1859
                      Arcade--Rosevill
                      e, CA.
40980..............  Saginaw-Saginaw    MI........     0.9034     0.9328
                      Township North,
                      MI.
41060..............  St. Cloud, MN....  MN........     1.1549     1.1036
41100..............  St. George, UT...  UT........     0.9228     0.9465
41140..............  St. Joseph, MO-KS  KS........     1.0481     1.0327
41140..............  St. Joseph, MO-KS  MO........     1.0472     1.0321
41180..............  St. Louis, MO-IL.  IL........     0.8993     0.9299
41180..............  St. Louis, MO-IL.  MO........     0.8986     0.9294
41420..............  Salem, OR........  OR........     1.0650     1.0441
41500..............  Salinas, CA......  CA........     1.4671     1.3001
41540..............  Salisbury, MD....  MD........     0.9194     0.9441
41620..............  Salt Lake City,    UT........     0.9271     0.9495
                      UT.
41660..............  San Angelo, TX...  TX........     0.8600     0.9019
41700..............  San Antonio, TX..  TX........     0.8949     0.9268
41740..............  San Diego-         CA........     1.1822     1.1214
                      Carlsbad-San
                      Marcos, CA.
41780..............  Sandusky, OH.....  OH........     0.8828     0.9182
41884..............  San Francisco-San  CA........     1.4879     1.3127
                      Mateo-Redwood
                      City, CA.
41900..............  San Germ[aacute]n- PR........     0.4648     0.5918
                      Cabo Rojo, PR.
41940..............  San Jose-          CA........     1.5758     1.3654
                      Sunnyvale-Santa
                      Clara, CA.
41980..............  San Juan-Caguas-   PR........     0.4404     0.5703
                      Guaynabo, PR.
42020..............  San Luis Obispo-   CA........     1.1822     1.1214
                      Paso Robles, CA.
42044..............  Santa Ana-Anaheim- CA........     1.1822     1.1214
                      Irvine, CA.
42060..............  Santa Barbara-     CA........     1.1822     1.1214
                      Santa Maria-
                      Goleta, CA.
42100..............  Santa Cruz-        CA........     1.5766     1.3658
                      Watsonville, CA.
42140..............  Santa Fe, NM.....  NM........     1.0587     1.0398
42220..............  Santa Rosa-        CA........     1.5052     1.3232
                      Petaluma, CA.
42340..............  Savannah, GA.....  GA........     0.8943     0.9264
42540..............  Scranton--Wilkes-  PA........     0.8342     0.8833
                      Barre, PA.
42644..............  Seattle-Bellevue-  WA........     1.1562     1.1045
                      Everett, WA.
42680..............  Sebastian-Vero     FL........     0.9519     0.9668
                      Beach, FL.
43100..............  Sheboygan, WI....  WI........     0.9511     0.9662
43300..............  Sherman-Denison,   TX........     0.9291     0.9509
                      TX.
43340..............  Shreveport-        LA........     0.8547     0.8981
                      Bossier City, LA.
43580..............  Sioux City, IA-NE- IA........     0.8745     0.9123
                      SD.
43580..............  Sioux City, IA-NE- NE........     0.8783     0.9150
                      SD.
43580..............  Sioux City, IA-NE- SD........     0.8783     0.9150
                      SD.
43620..............  Sioux Falls, SD..  SD........     0.9379     0.9570
43780..............  South Bend-        IN........     0.9644     0.9755
                      Mishawaka, IN-MI.

[[Page 23794]]

 
43780..............  South Bend-        MI........     0.9651     0.9760
                      Mishawaka, IN-MI.
43900..............  Spartanburg, SC..  SC........     0.9017     0.9316
44060..............  Spokane, WA......  WA........     1.0514     1.0349
44100..............  Springfield, IL..  IL........     0.9133     0.9398
44140..............  Springfield, MA..  MA........     1.0343     1.0234
44180..............  Springfield, MO..  MO........     0.8470     0.8925
44220..............  Springfield, OH..  OH........     0.8629     0.9040
44300..............  State College, PA  PA........     0.8810     0.9169
44700..............  Stockton, CA.....  CA........     1.1822     1.1214
44940..............  Sumter, SC.......  SC........     0.8609     0.9025
45060..............  Syracuse, NY.....  NY........     0.9865     0.9907
45104..............  Tacoma, WA.......  WA........     1.1137     1.0765
45220..............  Tallahassee, FL..  FL........     0.8981     0.9290
45300..............  Tampa-St.          FL........     0.8993     0.9299
                      Petersburg-
                      Clearwater, FL.
45460..............  Terre Haute, IN..  IN........     0.9130     0.9396
45500..............  Texarkana, TX-     AR........     0.8197     0.8727
                      Texarkana, AR.
45500..............  Texarkana, TX-     TX........     0.8195     0.8726
                      Texarkana, AR.
45780..............  Toledo, OH.......  OH........     0.9267     0.9492
45820..............  Topeka, KS.......  KS........     0.8873     0.9214
45940..............  Trenton-Ewing, NJ  NJ........     1.1221     1.0821
46060..............  Tucson, AZ.......  AZ........     0.9442     0.9614
46140..............  Tulsa, OK........  OK........     0.8652     0.9056
46220..............  Tuscaloosa, AL...  AL........     0.8695     0.9087
46340..............  Tyler, TX........  TX........     0.8901     0.9234
46540..............  Utica-Rome, NY...  NY........     0.8721     0.9105
46660..............  Valdosta, GA.....  GA........     0.8163     0.8702
46700..............  Vallejo-           CA........     1.3974     1.2575
                      Fairfield, CA.
47020..............  Victoria, TX.....  TX........     0.8153     0.8695
47220..............  Vineland-          NJ........     1.1221     1.0821
                      Millville-
                      Bridgeton, NJ.
47260..............  Virginia Beach-    NC........     0.8868     0.9210
                      Norfolk-Newport
                      News, VA.
47260..............  Virginia Beach-    VA........     0.8869     0.9211
                      Norfolk-Newport
                      News, VA.
47300..............  Visalia-           CA........     1.1822     1.1214
                      Porterville, CA.
47380..............  Waco, TX.........  TX........     0.8703     0.9093
47580..............  Warner Robins, GA  GA........     0.9490     0.9648
47644..............  Warren-Troy-       MI........     0.9972     0.9981
                      Farmington-
                      Hills, MI.
47894..............  Washington-        DC........     1.0670     1.0454
                      Arlington-
                      Alexandria, DC-
                      VA-MD-WV.
47894..............  Washington-        MD........     1.0670     1.0454
                      Arlington-
                      Alexandria DC-VA-
                      MD-WV.
47894..............  Washington-        VA........     1.0669     1.0453
                      Arlington-
                      Alexandria DC-VA-
                      MD-WV.
47894..............  Washington-        WV........     1.0647     1.0439
                      Arlington-
                      Alexandria DC-VA-
                      MD-WV.
47940..............  Waterloo-Cedar     IA........     0.9248     0.9479
                      Falls, IA.
48140..............  Wausau, WI.......  WI........     0.9823     0.9878
48260..............  Weirton-           OH........     0.8582     0.9006
                      Steubenville, WV-
                      OH.
48260..............  Weirton-           WV........     0.8011     0.8591
                      Steubenville, WV-
                      OH.
48300..............  Wenatchee, WA....  WA........     1.0164     1.0112
48424..............  West Palm Beach-   FL........     0.9631     0.9746
                      Boca Raton-
                      Boynton Beach,
                      FL.
48540..............  Wheeling, WV-OH..  OH........     0.8582     0.9006
48540..............  Wheeling, WV-OH..  WV........     0.7635     0.8313
48620..............  Wichita, KS......  KS........     0.8980     0.9290
48660..............  Wichita Falls, TX  TX........     0.9175     0.9427
48700..............  Williamsport, PA.  PA........     0.8342     0.8833
48864..............  Wilmington, DE-MD- DE........     1.0645     1.0437
                      NJ.
48864..............  Wilmington, DE-MD- MD........     1.0645     1.0437
                      NJ.
48864..............  Wilmington, DE-MD- NJ........     1.1221     1.0821
                      NJ.
48900..............  Wilmington, NC...  NC........     0.9087     0.9365
49020..............  Winchester, VA-WV  VA........     0.9771     0.9843
49020..............  Winchester, VA-WV  WV........     0.9751     0.9829
49180..............  Winston-Salem, NC  NC........     0.9096     0.9372
49340..............  Worcester, MA....  MA........     1.0945     1.0638
49420..............  Yakima, WA.......  WA........     1.0164     1.0112
49500..............  Yauco, PR........  PR........     0.3358     0.4737
49620..............  York-Hanover, PA.  PA........     0.9666     0.9770
49660..............  Youngstown-Warren- OH........     0.8931     0.9255
                      Boardman, OH-PA.
49660..............  Youngstown-Warren- PA........     0.8930     0.9254
                      Boardman, OH-PA.
49700..............  Yuba City, CA....  CA........     1.1822     1.1214
49740..............  Yuma, AZ.........  AZ........     0.9903     0.9933
------------------------------------------------------------------------


[[Page 23795]]


Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                Rural Areas by CBSA and by State--FY 2009
------------------------------------------------------------------------
  CBSA code       Rural area      State     Wage index          GAF
------------------------------------------------------------------------
01...........  Alabama........  AL......          0.7647          0.8322
02...........  Alaska.........  AK......          1.1884          1.1255
03...........  Arizona........  AZ......          0.8857          0.9202
04...........  Arkansas.......  AR......          0.7641          0.8317
05...........  California.....  CA......          1.1822          1.1214
06...........  Colorado.......  CO......          0.9303          0.9517
07...........  Connecticut....  CT......          1.1897          1.1263
08...........  Delaware.......  DE......          1.0252          1.0172
10...........  Florida........  FL......          0.8633          0.9042
11...........  Georgia........  GA......          0.7840          0.8465
12...........  Hawaii.........  HI......          1.1219          1.0820
13...........  Idaho..........  ID......          0.7597          0.8284
14...........  Illinois.......  IL......          0.8428          0.8895
15...........  Indiana........  IN......          0.8479          0.8932
16...........  Iowa...........  IA......          0.8709          0.9097
17...........  Kansas.........  KS......          0.8086          0.8646
18...........  Kentucky.......  KY......          0.7837          0.8463
19...........  Louisiana......  LA......          0.7682          0.8348
20...........  Maine..........  ME......          0.8609          0.9025
21...........  Maryland.......  MD......          0.8795          0.9158
22...........  Massachusetts..  MA......          1.0199          1.0136
23...........  Michigan.......  MI......          0.8864          0.9207
24...........  Minnesota......  MN......          0.9120          0.9389
25...........  Mississippi....  MS......          0.7653          0.8326
26...........  Missouri.......  MO......          0.8470          0.8925
27...........  Montana........  MT......          0.8640          0.9047
28...........  Nebraska.......  NE......          0.8761          0.9134
29...........  Nevada.........  NV......          0.9824          0.9879
30...........  New Hampshire..  NH......          1.0807          1.0546
31...........  New Jersey \1\.  NJ......          1.1221          1.0821
32...........  New Mexico.....  NM......          0.8858          0.9203
33...........  New York.......  NY......          0.8308          0.8808
34...........  North Carolina.  NC......          0.8632          0.9042
35...........  North Dakota...  ND......          0.7336          0.8088
36...........  Ohio...........  OH......          0.8582          0.9006
37...........  Oklahoma.......  OK......          0.8016          0.8595
38...........  Oregon.........  OR......          1.0298          1.0203
39...........  Pennsylvania...  PA......          0.8342          0.8833
40...........  Puerto Rico \1\  PR......  ..............  ..............
41...........  Rhode Island     RI......  ..............  ..............
                \1\.
42...........  South Carolina.  SC......          0.8609          0.9025
43...........  South Dakota...  SD......          0.8428          0.8895
44...........  Tennessee......  TN......          0.7957          0.8551
45...........  Texas..........  TX......          0.8153          0.8695
46...........  Utah...........  UT......          0.8395          0.8871
47...........  Vermont........  VT......          0.9275          0.9498
49...........  Virginia.......  VA......          0.8061          0.8628
50...........  Washington.....  WA......          1.0164          1.0112
51...........  West Virginia..  WV......          0.7635          0.8313
52...........  Wisconsin......  WI......          0.9511          0.9662
53...........  Wyoming........  WY......          0.9223         0.9461
------------------------------------------------------------------------
\1\ All counties in the State or Territory are classified as urban. The
  New Jersey floor is imputed as specified in Sec.  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 this proposed rule.


Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA
                                              and by State--FY 2009
----------------------------------------------------------------------------------------------------------------
        CBSA code                        Area                       State           Wage index          GAF
----------------------------------------------------------------------------------------------------------------
10420....................  Akron, OH.......................  OH.................          0.8784          0.9150
10500....................  Albany, GA......................  AL.................          0.8397          0.8872
10500....................  Albany, GA......................  GA.................          0.8397          0.8872
10580....................  Albany-Schenectady-Troy, NY.....  NY.................          0.8833          0.9185
10740....................  Albuquerque, NM.................  NM.................          0.9295          0.9512
10780....................  Alexandria, LA..................  LA.................          0.8127          0.8676
10900....................  Allentown-Bethlehem-Easton, PA-   PA.................          0.9675          0.9776
                            NJ.
11100....................  Amarillo, TX....................  KS.................          0.8885          0.9222
11100....................  Amarillo, TX....................  TX.................          0.8883          0.9221

[[Page 23796]]

 
11180....................  Ames, IA........................  IA.................          0.8881          0.9219
11260....................  Anchorage, AK...................  AK.................          1.1884          1.1255
11460....................  Ann Arbor, MI...................  MI.................          1.0113          1.0077
12060....................  Atlanta-Sandy Springs-Marietta,   AL.................          0.9760          0.9835
                            GA.
12060....................  Atlanta-Sandy Springs-Marietta,   GA.................          0.9760          0.9835
                            GA.
12420....................  Austin-Round Rock, TX...........  TX.................          0.9521          0.9669
12620....................  Bangor, ME......................  ME.................          1.0115          1.0079
12940....................  Baton Rouge, LA.................  MS.................          0.8146          0.8690
13020....................  Bay City, MI....................  MI.................          0.9472          0.9635
13644....................  Bethesda-Frederick-Gaithersburg,  DC.................          1.1018          1.0686
                            MD.
13644....................  Bethesda-Frederick-Gaithersburg,  PA.................          1.1006          1.0678
                            MD.
13644....................  Bethesda-Frederick-Gaithersburg,  VA.................          1.1017          1.0686
                            MD.
13780....................  Binghamton, NY..................  PA.................          0.8560          0.8990
13820....................  Birmingham-Hoover, AL...........  AL.................          0.8786          0.9152
13900....................  Bismarck, ND....................  ND.................          0.7336          0.8088
13980....................  Blacksburg-Christiansburg-        WV.................          0.7795          0.8432
                            Radford, VA.
14020....................  Bloomington, IN.................  IN.................          0.8791          0.9155
14260....................  Boise City-Nampa, ID............  ID.................          0.9100          0.9375
14260....................  Boise City-Nampa, ID............  NV.................          0.9824          0.9879
14484....................  Boston-Quincy, MA...............  MA.................          1.1338          1.0898
14484....................  Boston-Quincy, MA...............  RI.................          1.1338          1.0898
14600....................  Bradenton-Sarasota-Venice, FL...  FL.................          0.9648          0.9758
14740....................  Bremerton-Silverdale, WA........  WA.................          1.0576          1.0391
14860....................  Bridgeport-Stamford-Norwalk, CT.  NY.................          1.2694          1.1775
15380....................  Buffalo-Niagara Falls, NY.......  NY.................          0.9593          0.9719
15540....................  Burlington-South Burlington, VT.  NY.................          0.9216          0.9456
15764....................  Cambridge-Newton-Framingham, MA.  NH.................          1.0807          1.0546
16180....................  Carson City, NV.................  NV.................          0.9837          0.9888
16220....................  Casper, WY......................  SD.................          0.9618          0.9737
16580....................  Champaign-Urbana, IL............  IL.................          0.8840          0.9190
16620....................  Charleston, WV..................  WV.................          0.8398          0.8873
16700....................  Charleston-North Charleston-      SC.................          0.9231          0.9467
                            Summerville, SC.
16740....................  Charlotte-Gastonia-Concord, NC-   NC.................          0.9570          0.9704
                            SC.
16740....................  Charlotte-Gastonia-Concord, NC-   SC.................          0.9557          0.9694
                            SC.
16820....................  Charlottesville, VA.............  VA.................          0.9449          0.9619
16860....................  Chattanooga, TN-GA..............  AL.................          0.8740          0.9119
16860....................  Chattanooga, TN-GA..............  GA.................          0.8740          0.9119
16860....................  Chattanooga, TN-GA..............  TN.................          0.8717          0.9103
16974....................  Chicago-Naperville-Joliet, IL...  IL.................          1.0334          1.0228
16974....................  Chicago-Naperville-Joliet, IL...  IN.................          1.0328          1.0223
16974....................  Chicago-Naperville-Joliet, IL...  WI.................          1.0315          1.0215
17140....................  Cincinnati-Middletown, OH-KY-IN.  IN.................          0.9583          0.9713
17140....................  Cincinnati-Middletown, OH-KY-IN.  OH.................          0.9581          0.9711
17300....................  Clarksville, TN-KY..............  KY.................          0.8302          0.8804
17460....................  Cleveland-Elyria-Mentor, OH.....  OH.................          0.9266          0.9491
17660....................  Coeur d'Alene, ID...............  MT.................          0.8992          0.9298
17820....................  Colorado Springs, CO............  CO.................          0.9738          0.9820
17860....................  Columbia, MO....................  MO.................          0.8470          0.8925
17900....................  Columbia, SC....................  SC.................          0.8984          0.9293
17980....................  Columbus, GA-AL.................  AL.................          0.8495          0.8943
17980....................  Columbus, GA-AL.................  GA.................          0.8495          0.8943
18140....................  Columbus, OH....................  OH.................          0.9657          0.9764
18700....................  Corvallis, OR...................  OR.................          1.0572          1.0388
19124....................  Dallas-Plano-Irving, TX.........  TX.................          0.9852          0.9898
19340....................  Davenport-Moline-Rock Island, IA- IL.................          0.8606          0.9023
                            IL.
19340....................  Davenport-Moline-Rock Island, IA- IA.................          0.8709          0.9097
                            IL.
19380....................  Dayton, OH......................  OH.................          0.9321          0.9530
19740....................  Denver-Aurora, CO...............  CO.................          1.0409          1.0278
19804....................  Detroit-Livonia-Dearborn, MI....  MI.................          1.0052          1.0036
20100....................  Dover, DE.......................  DE.................          1.0304          1.0207
20260....................  Duluth, MN-WI...................  MN.................          1.0401          1.0273
20500....................  Durham, NC......................  NC.................          0.9693          0.9789
20500....................  Durham, NC......................  VA.................          0.9694          0.9789
20764....................  Edison-New Brunswick, NJ........  NJ.................          1.1221          1.0821
21060....................  Elizabethtown, KY...............  KY.................          0.8230          0.8751
21140....................  Elkhart-Goshen, IN..............  IN.................          0.9547          0.9688
21500....................  Erie, PA........................  NY.................          0.8420          0.8889
21660....................  Eugene-Springfield, OR..........  OR.................          1.1157          1.0779
21780....................  Evansville, IN-KY...............  IN.................          0.8479          0.8932
21780....................  Evansville, IN-KY...............  KY.................          0.8131          0.8679

[[Page 23797]]

 
22020....................  Fargo, ND-MN....................  ND.................          0.8212          0.8738
22020....................  Fargo, ND-MN....................  SD.................          0.8428          0.8895
22180....................  Fayetteville, NC................  NC.................          0.9567          0.9701
22220....................  Fayetteville-Springdale-Rogers,   AR.................          0.8952          0.9270
                            AR-MO.
22220....................  Fayetteville-Springdale-Rogers,   OK.................          0.8950          0.9268
                            AR-MO.
22380....................  Flagstaff, AZ...................  AZ.................          1.1305          1.0876
22420....................  Flint, MI.......................  MI.................          1.0810          1.0548
22520....................  Florence-Muscle Shoals, AL......  AL.................          0.7883          0.8497
22520....................  Florence-Muscle Shoals, AL......  MS.................          0.7883          0.8497
22540....................  Fond du Lac, WI.................  WI.................          0.9523          0.9671
22660....................  Fort Collins-Loveland, CO.......  CO.................          0.9581          0.9711
22744....................  Ft Lauderdale-Pompano Beach-      FL.................          1.0025          1.0017
                            Deerfield Beach, FL.
23020....................  Fort Walton Beach-Crestview-      FL.................          0.8633          0.9042
                            Destin, FL.
23060....................  Fort Wayne, IN..................  IN.................          0.9004          0.9307
23104....................  Fort Worth-Arlington, TX........  TX.................          0.9684          0.9783
23540....................  Gainesville, FL.................  FL.................          0.9427          0.9604
23844....................  Gary, IN........................  IN.................          0.9320          0.9529
24300....................  Grand Junction, CO..............  CO.................          0.9925          0.9949
24340....................  Grand Rapids-Wyoming, MI........  MI.................          0.9305          0.9519
24500....................  Great Falls, MT.................  MT.................          0.8679          0.9075
24540....................  Greeley, CO.....................  NE.................          0.9611          0.9732
24540....................  Greeley, CO.....................  WY.................          0.9611          0.9732
24580....................  Green Bay, WI...................  MI.................          0.9412          0.9594
24580....................  Green Bay, WI...................  WI.................          0.9511          0.9662
24660....................  Greensboro-High Point, NC.......  NC.................          0.8984          0.9293
24660....................  Greensboro-High Point, NC.......  VA.................          0.8985          0.9293
24780....................  Greenville, NC..................  NC.................          0.9174          0.9427
24860....................  Greenville-Mauldin-Easley, SC...  NC.................          0.9307          0.9520
24860....................  Greenville-Mauldin-Easley, SC...  SC.................          0.9294          0.9511
25060....................  Gulfport-Biloxi, MS.............  MS.................          0.8156          0.8697
25420....................  Harrisburg-Carlisle, PA.........  PA.................          0.9185          0.9434
25540....................  Hartford-West Hartford-East       CT.................          1.1897          1.1263
                            Hartford, CT.
25540....................  Hartford-West Hartford-East       MA.................          1.0972          1.0656
                            Hartford, CT.
25860....................  Hickory-Lenoir-Morganton, NC....  NC.................          0.8794          0.9158
26180....................  Honolulu, HI....................  HI.................          1.1608          1.1075
26420....................  Houston-Sugar Land-Baytown, TX..  TX.................          0.9925          0.9949
26580....................  Huntington-Ashland, WV-KY-OH....  KY.................          0.8767          0.9138
26580....................  Huntington-Ashland, WV-KY-OH....  OH.................          0.8759          0.9133
26580....................  Huntington-Ashland, WV-KY-OH....  WV.................          0.8748          0.9125
26620....................  Huntsville, AL..................  AL.................          0.8636          0.9045
26620....................  Huntsville, AL..................  TN.................          0.8614          0.9029
26820....................  Idaho Falls, ID.................  ID.................          0.9327          0.9534
26820....................  Idaho Falls, ID.................  WY.................          0.9327          0.9534
26900....................  Indianapolis-Carmel, IN.........  IN.................          0.9707          0.9798
26980....................  Iowa City, IA...................  IA.................          0.9107          0.9380
27060....................  Ithaca, NY......................  NY.................          0.9101          0.9375
27140....................  Jackson, MS.....................  MS.................          0.8095          0.8653
27180....................  Jackson, TN.....................  MS.................          0.8361          0.8846
27180....................  Jackson, TN.....................  TN.................          0.8339          0.8830
27260....................  Jacksonville, FL................  FL.................          0.9092          0.9369
27260....................  Jacksonville, FL................  GA.................          0.9112          0.9383
27620....................  Jefferson City, MO..............  MO.................          0.8736          0.9116
27780....................  Johnstown, PA...................  PA.................          0.8342          0.8833
27860....................  Jonesboro, AR...................  AR.................          0.8291          0.8796
27860....................  Jonesboro, AR...................  MO.................          0.8470          0.8925
27900....................  Joplin, MO......................  KS.................          0.9351          0.9551
27900....................  Joplin, MO......................  OK.................          0.9349          0.9549
28020....................  Kalamazoo-Portage, MI...........  MI.................          1.0365          1.0249
28140....................  Kansas City, MO-KS..............  MO.................          0.9444          0.9616
28420....................  Kennewick-Pasco-Richland, WA....  ID.................          0.9560          0.9697
28420....................  Kennewick-Pasco-Richland, WA....  WA.................          1.0164          1.0112
28700....................  Kingsport-Bristol-Bristol, TN-VA  KY.................          0.7919          0.8523
28700....................  Kingsport-Bristol-Bristol, TN-VA  TN.................          0.7957          0.8551
28940....................  Knoxville, TN...................  KY.................          0.7889          0.8501
28940....................  Knoxville, TN...................  TN.................          0.7957          0.8551
29180....................  Lafayette, LA...................  LA.................          0.8438          0.8902
29460....................  Lakeland-Winter Haven, FL.......  FL.................          0.8715          0.9101
29540....................  Lancaster, PA...................  PA.................          0.9799          0.9862
29620....................  Lansing-East Lansing, MI........  MI.................          0.9652          0.9760
29820....................  Las Vegas-Paradise, NV..........  AZ.................          1.1388          1.0931

[[Page 23798]]

 
29820....................  Las Vegas-Paradise, NV..........  UT.................          1.1388          1.0931
30460....................  Lexington-Fayette, KY...........  KY.................          0.8756          0.9130
30620....................  Lima, OH........................  OH.................          0.9299          0.9514
30700....................  Lincoln, NE.....................  NE.................          0.9336          0.9540
30780....................  Little Rock-North Little Rock-    AR.................          0.8650          0.9055
                            Conway, AR.
30860....................  Logan, UT-ID....................  UT.................          0.8827          0.9181
30980....................  Longview, TX....................  TX.................          0.8666          0.9066
31084....................  Los Angeles-Long Beach-Glendale,  CA.................          1.1822          1.1214
                            CA.
31140....................  Louisville-Jefferson County, KY-  KY.................          0.9123          0.9391
                            IN.
31340....................  Lynchburg, VA...................  VA.................          0.8646          0.9052
31420....................  Macon, GA.......................  GA.................          0.9618          0.9737
31540....................  Madison, WI.....................  WI.................          1.1014          1.0684
31700....................  Manchester-Nashua, NH...........  NH.................          1.0807          1.0546
32780....................  Medford, OR.....................  OR.................          1.0298          1.0203
32820....................  Memphis, TN-MS-AR...............  AR.................          0.8909          0.9239
32820....................  Memphis, TN-MS-AR...............  MS.................          0.8909          0.9239
32820....................  Memphis, TN-MS-AR...............  TN.................          0.8886          0.9223
33124....................  Miami-Miami Beach-Kendall, FL...  FL.................          0.9865          0.9907
33340....................  Milwaukee-Waukesha-West Allis,    WI.................          1.0026          1.0018
                            WI.
33460....................  Minneapolis-St. Paul-             MN.................          1.0997          1.0672
                            Bloomington, MN-WI.
33460....................  Minneapolis-St. Paul-             WI.................          1.0976          1.0659
                            Bloomington, MN-WI.
33540....................  Missoula, MT....................  MT.................          0.8909          0.9239
33700....................  Modesto, CA.....................  CA.................          1.1963          1.1306
33740....................  Monroe, LA......................  AR.................          0.7789          0.8427
33740....................  Monroe, LA......................  LA.................          0.7785          0.8424
33860....................  Montgomery, AL..................  AL.................          0.8192          0.8723
34060....................  Morgantown, WV..................  WV.................          0.8631          0.9041
34740....................  Muskegon-Norton Shores, MI......  MI.................          0.9455          0.9623
34820....................  Myrtle Beach-North Myrtle Beach-  NC.................          0.8632          0.9042
                            Conway, SC.
34820....................  Myrtle Beach-North Myrtle Beach-  SC.................          0.8609          0.9025
                            Conway, SC.
34980....................  Nashville-Davidson-Murfreesboro-  KY.................          0.9276          0.9498
                            Franklin, TN.
34980....................  Nashville-Davidson-Murfreesboro-  TN.................          0.9252          0.9482
                            Franklin, TN.
35004....................  Nassau-Suffolk, NY..............  CT.................          1.2038          1.1354
35084....................  Newark-Union, NJ-PA.............  NJ.................          1.1316          1.0884
35084....................  Newark-Union, NJ-PA.............  NY.................          1.1461          1.0979
35084....................  Newark-Union, NJ-PA.............  PA.................          1.1449          1.0971
35300....................  New Haven-Milford, CT...........  CT.................          1.1897          1.1263
35380....................  New Orleans-Metairie-Kenner, LA.  LA.................          0.9140          0.9403
35644....................  New York-White Plains-Wayne, NY-  CT.................          1.2391          1.1581
                            NJ.
35644....................  New York-White Plains-Wayne, NY-  NJ.................          1.2693          1.1774
                            NJ.
35644....................  New York-White Plains-Wayne, NY-  NY.................          1.2855          1.1877
                            NJ.
35980....................  Norwich-New London, CT..........  RI.................          1.1587          1.1061
36084....................  Oakland-Fremont-Hayward, CA.....  CA.................          1.5278          1.3367
36140....................  Ocean City, NJ..................  DE.................          1.0909          1.0614
36220....................  Odessa, TX......................  NM.................          0.9273          0.9496
36220....................  Odessa, TX......................  TX.................          0.9283          0.9503
36420....................  Oklahoma City, OK...............  OK.................          0.8686          0.9080
36500....................  Olympia, WA.....................  WA.................          1.1297          1.0871
36740....................  Orlando-Kissimmee, FL...........  FL.................          0.9073          0.9356
37460....................  Panama City-Lynn Haven, FL......  AL.................          0.8322          0.8818
37700....................  Pascagoula, MS..................  AL.................          0.8030          0.8605
37764....................  Peabody, MA.....................  NH.................          1.0807          1.0546
37860....................  Pensacola-Ferry Pass-Brent, FL..  AL.................          0.8115          0.8667
37900....................  Peoria, IL......................  IL.................          0.9043          0.9334
37964....................  Philadelphia, PA................  DE.................          1.0799          1.0540
37964....................  Philadelphia, PA................  NJ.................          1.1221          1.0821
37964....................  Philadelphia, PA................  PA.................          1.0788          1.0533
38220....................  Pine Bluff, AR..................  MS.................          0.8150          0.8693
38300....................  Pittsburgh, PA..................  OH.................          0.8582          0.9006
38300....................  Pittsburgh, PA..................  PA.................          0.8579          0.9004
38300....................  Pittsburgh, PA..................  WV.................          0.8569          0.8996
38340....................  Pittsfield, MA..................  NY.................          0.9901          0.9932
38340....................  Pittsfield, MA..................  VT.................          0.9275          0.9498
38860....................  Portland-South Portland-          ME.................          0.9644          0.9755
                            Biddeford, ME.
38900....................  Portland-Vancouver-Beaverton, OR- OR.................          1.1204          1.0810
                            WA.
38900....................  Portland-Vancouver-Beaverton, OR- WA.................          1.1186          1.0798
                            WA.
38940....................  Port St. Lucie, FL..............  FL.................          0.9741          0.9822
39100....................  Poughkeepsie-Newburgh-            NY.................          1.0709          1.0480
                            Middletown, NY.
39140....................  Prescott, AZ....................  AZ.................          1.0011          1.0008
39340....................  Provo-Orem, UT..................  UT.................          0.9052          0.9341

[[Page 23799]]

 
39580....................  Raleigh-Cary, NC................  NC.................          0.9557          0.9694
39740....................  Reading, PA.....................  PA.................          0.9204          0.9448
39820....................  Redding, CA.....................  CA.................          1.2730          1.1797
39900....................  Reno-Sparks, NV.................  NV.................          1.0476          1.0324
40060....................  Richmond, VA....................  VA.................          0.9203          0.9447
40140....................  Riverside-San Bernardino-         AZ.................          1.1254          1.0843
                            Ontario, CA.
40220....................  Roanoke, VA.....................  VA.................          0.8750          0.9126
40220....................  Roanoke, VA.....................  WV.................          0.8732          0.9113
40380....................  Rochester, NY...................  NY.................          0.8911          0.9241
40420....................  Rockford, IL....................  IL.................          0.9756          0.9832
40484....................  Rockingham County-Strafford       ME.................          1.0007          1.0005
                            County, NH.
40660....................  Rome, GA........................  AL.................          0.9524          0.9672
40900....................  Sacramento--Arden-Arcade--        CA.................          1.2710          1.1785
                            Roseville, CA.
40980....................  Saginaw-Saginaw Township North,   MI.................          0.8864          0.9207
                            MI.
41060....................  St. Cloud, MN...................  MN.................          1.0638          1.0433
41100....................  St. George, UT..................  UT.................          0.9228          0.9465
41140....................  St. Joseph, MO-KS...............  MO.................          1.0267          1.0182
41180....................  St. Louis, MO-IL................  IL.................          0.8993          0.9299
41180....................  St. Louis, MO-IL................  MO.................          0.8986          0.9294
41620....................  Salt Lake City, UT..............  UT.................          0.9271          0.9495
41700....................  San Antonio, TX.................  TX.................          0.8949          0.9268
41884....................  San Francisco-San Mateo-Redwood   CA.................          1.4879          1.3127
                            City, CA.
41940....................  San Jose-Sunnyvale-Santa Clara,   CA.................          1.5758          1.3654
                            CA.
42044....................  Santa Ana-Anaheim-Irvine, CA....  CA.................          1.1822          1.1214
42100....................  Santa Cruz-Watsonville, CA......  CA.................          1.5766          1.3658
42140....................  Santa Fe, NM....................  NM.................          1.0207          1.0141
42220....................  Santa Rosa-Petaluma, CA.........  CA.................          1.4497          1.2896
42340....................  Savannah, GA....................  GA.................          0.8841          0.9191
42340....................  Savannah, GA....................  SC.................          0.8827          0.9181
42644....................  Seattle-Bellevue-Everett, WA....  WA.................          1.1377          1.0924
43300....................  Sherman-Denison, TX.............  OK.................          0.9291          0.9509
43340....................  Shreveport-Bossier City, LA.....  LA.................          0.8547          0.8981
43580....................  Sioux City, IA-NE-SD............  NE.................          0.8761          0.9134
43620....................  Sioux Falls, SD.................  SD.................          0.9262          0.9489
43780....................  South Bend-Mishawaka, IN-MI.....  IN.................          0.9353          0.9552
43900....................  Spartanburg, SC.................  SC.................          0.9017          0.9316
44060....................  Spokane, WA.....................  ID.................          1.0315          1.0215
44180....................  Springfield, MO.................  AR.................          0.8477          0.8930
44180....................  Springfield, MO.................  MO.................          0.8470          0.8925
44940....................  Sumter, SC......................  SC.................          0.8609          0.9025
45060....................  Syracuse, NY....................  NY.................          0.9471          0.9635
45220....................  Tallahassee, FL.................  GA.................          0.8397          0.8872
45300....................  Tampa-St. Petersburg-Clearwater,  FL.................          0.8993          0.9299
                            FL.
45500....................  Texarkana, TX-Texarkana, AR.....  AR.................          0.8093          0.8651
45780....................  Toledo, OH......................  OH.................          0.9267          0.9492
45820....................  Topeka, KS......................  KS.................          0.8720          0.9105
46140....................  Tulsa, OK.......................  OK.................          0.8652          0.9056
46220....................  Tuscaloosa, AL..................  MS.................          0.8280          0.8788
46340....................  Tyler, TX.......................  TX.................          0.8901          0.9234
46700....................  Vallejo-Fairfield, CA...........  CA.................          1.3974          1.2575
47260....................  Virginia Beach-Norfolk-Newport    NC.................          0.8868          0.9210
                            News, VA.
47644....................  Warren-Troy-Farmington-Hills, MI  MI.................          0.9972          0.9981
47894....................  Washington-Arlington-Alexandria,  VA.................          1.0669          1.0453
                            DC-VA.
47940....................  Waterloo-Cedar Falls, IA........  IA.................          0.9248          0.9479
48140....................  Wausau, WI......................  WI.................          0.9823          0.9878
48620....................  Wichita, KS.....................  KS.................          0.8785          0.9151
48620....................  Wichita, KS.....................  OK.................          0.8784          0.9150
48700....................  Williamsport, PA................  PA.................          0.8342          0.8833
48864....................  Wilmington, DE-MD-NJ............  DE.................          1.0645          1.0437
48864....................  Wilmington, DE-MD-NJ............  NJ.................          1.1221          1.0821
48900....................  Wilmington, NC..................  SC.................          0.9074          0.9356
49180....................  Winston-Salem, NC...............  NC.................          0.9096          0.9372
49340....................  Worcester, MA...................  NH.................          1.0807          1.0546
49660....................  Youngstown-Warren-Boardman, OH-   OH.................          0.8582          0.9006
                            PA.
49660....................  Youngstown-Warren-Boardman, OH-   PA.................          0.8559          0.8989
                            PA.
04.......................  Arkansas........................  LA.................          0.7682          0.8348
05.......................  California......................  CA.................          1.1822          1.1214
10.......................  Florida.........................  FL.................          0.8633          0.9042
14.......................  Illinois........................  IL.................          0.8428          0.8895
14.......................  Illinois........................  KY.................          0.8320          0.8817

[[Page 23800]]

 
14.......................  Illinois........................  MO.................          0.8470          0.8925
16.......................  Iowa............................  MO.................          0.8738          0.9118
17.......................  Kansas..........................  KS.................          0.8086          0.8646
22.......................  Massachusetts...................  MA.................          1.0199          1.0136
23.......................  Michigan........................  MI.................          0.8864          0.9207
25.......................  Mississippi.....................  MS.................          0.7653          0.8326
26.......................  Missouri........................  MO.................          0.8470          0.8925
30.......................  New Hampshire...................  VT.................          0.9297          0.9513
33.......................  New York........................  NY.................          0.8308          0.8808
34.......................  North Carolina..................  TN.................          0.8611          0.9027
36.......................  Ohio............................  OH.................          0.8582          0.9006
37.......................  Oklahoma........................  OK.................          0.8016          0.8595
38.......................  Oregon..........................  OR.................          1.0298          1.0203
39.......................  Pennsylvania....................  NY.................          0.8351          0.8839
39.......................  Pennsylvania....................  PA.................          0.8342          0.8833
44.......................  Tennessee.......................  KY.................          0.7978          0.8567
44.......................  Tennessee.......................  TN.................          0.7957          0.8551
45.......................  Texas...........................  TX.................          0.8153          0.8695
49.......................  Virginia........................  KY.................          0.8062          0.8628
49.......................  Virginia........................  VA.................          0.8061          0.8628
50.......................  Washington......................  WA.................          1.0164          1.0112
53.......................  Wyoming.........................  NE.................          0.9223          0.9461
----------------------------------------------------------------------------------------------------------------


       Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009
------------------------------------------------------------------------
                                                            Rural floor
                                                              budget
                          State                             neutrality
                                                             ajustment
                                                              factor
------------------------------------------------------------------------
Alabama.................................................         1.00000
Alaska..................................................         0.99734
Arizona.................................................         1.00000
Arkansas................................................         1.00000
California..............................................         0.98552
Colorado................................................         0.99683
Connecticut.............................................         0.96390
Delaware................................................         1.00000
Washington, DC..........................................         1.00000
Florida.................................................         0.99781
Georgia.................................................         1.00000
Hawaii..................................................         1.00000
Idaho...................................................         1.00000
Illinois................................................         0.99993
Indiana.................................................         0.99928
Iowa....................................................         0.99572
Kansas..................................................         1.00000
Kentucky................................................         1.00000
Louisiana...............................................         0.99945
Maine...................................................         1.00000
Maryland................................................  ..............
Massachusetts...........................................         1.00000
Michigan................................................         1.00000
Minnesota...............................................         1.00000
Mississippi.............................................         1.00000
Missouri................................................         0.99910
Montana.................................................         1.00000
Nebraska................................................         1.00000
Nevada..................................................         1.00000
New Hampshire...........................................         0.97787
New Jersey..............................................         0.98738
New Mexico..............................................         0.99875
New York................................................         1.00000
North Carolina..........................................         0.99983
North Dakota............................................         0.99424
Ohio....................................................         0.99906
Oklahoma................................................         0.99983
Oregon..................................................         0.99955
Pennsylvania............................................         0.99895
Puerto Rico.............................................         1.00000
Rhode Island............................................         1.00000
South Carolina..........................................         0.99840
South Dakota............................................         1.00000
Tennessee...............................................         0.99741
Texas...................................................         0.99980
Utah....................................................         1.00000
Vermont.................................................         0.90100
Virginia................................................         0.99991
Washington..............................................         0.99791
West Virginia...........................................         0.99782
Wisconsin...............................................         0.99809
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).


Table 4D-2.--Urban Areas With Hospitals Receiving the Statewide Rural Floor or Imputed Floor Wage Index--FY 2009
  [*Only hospitals that are geographically located in the specified State receive the State's rural or imputed
                                               floor wage index.]
----------------------------------------------------------------------------------------------------------------
                                                                                          Rural or imputed floor
              CBSA code                       Urban area                State *                 wage index
----------------------------------------------------------------------------------------------------------------
10900................................  Allentown-Bethlehem-     NJ.....................                   1.1221
                                        Easton, PA-NJ.
11020................................  Altoona, PA............  PA.....................                   0.8342
11260................................  Anchorage, AK..........  AK.....................                   1.1884
11540................................  Appleton, WI...........  WI.....................                   0.9511
12220................................  Auburn-Opelika, AL.....  AL.....................                   0.7647
12540................................  Bakersfield, CA........  CA.....................                   1.1822
13900................................  Bismarck, ND...........  ND.....................                   0.7336
15500................................  Burlington, NC.........  NC.....................                   0.8632

[[Page 23801]]

 
15540................................  Burlington-South         VT.....................                   0.9275
                                        Burlington, VT.
15804................................  Camden, NJ.............  NJ.....................                   1.1221
16940................................  Cheyenne, WY...........  WY.....................                   0.9223
17020................................  Chico, CA..............  CA.....................                   1.1822
17860................................  Columbia, MO...........  MO.....................                   0.8470
19060................................  Cumberland, MD-WV......  MD.....................                   0.8795
19060................................  Cumberland, MD-WV......  WV.....................                   0.7635
19340................................  Davenport-Moline-Rock    IA.....................                   0.8709
                                        Island, IA-IL.
19500................................  Decatur, IL............  IL.....................                   0.8428
20220................................  Dubuque, IA............  IA.....................                   0.8709
20764................................  Edison-New Brunswick,    NJ.....................                   1.1221
                                        NJ.
20940................................  El Centro, CA..........  CA.....................                   1.1822
21820................................  Fairbanks, AK..........  AK.....................                   1.1884
22020................................  Fargo, ND-MN...........  MN.....................                   0.9120
22140................................  Farmington, NM.........  NM.....................                   0.8858
22500................................  Florence, SC...........  SC.....................                   0.8609
22900................................  Fort Smith, AR-OK......  OK.....................                   0.8016
23420................................  Fresno, CA.............  CA.....................                   1.1822
24220................................  Grand Forks, ND-MN.....  MN.....................                   0.9120
24580................................  Green Bay, WI..........  WI.....................                   0.9511
25260................................  Hanford-Corcoran, CA...  CA.....................                   1.1822
25540................................  Hartford-West Hartford-  CT.....................                   1.1897
                                        East Hartford, CT.
25620................................  Hattiesburg, MS........  MS.....................                   0.7653
27340................................  Jacksonville, NC.......  NC.....................                   0.8632
27780................................  Johnstown, PA..........  PA.....................                   0.8342
28420................................  Kennewick-Pasco-         WA.....................                   1.0164
                                        Richland, WA.
28700................................  Kingsport-Bristol-       TN.....................                   0.7957
                                        Bristol, TN-VA.
28700................................  Kingsport-Bristol-       VA.....................                   0.8061
                                        Bristol, TN-VA.
28940................................  Knoxville, TN..........  TN.....................                   0.7957
29340................................  Lake Charles, LA.......  LA.....................                   0.7682
29740................................  Las Cruces, NM.........  NM.....................                   0.8858
30300................................  Lewiston, ID-WA........  WA.....................                   1.0164
31460................................  Madera, CA.............  CA.....................                   1.1822
31700................................  Manchester-Nashua, NH..  NH.....................                   1.0807
32780................................  Medford, OR............  OR.....................                   1.0298
34100................................  Morristown, TN.........  TN.....................                   0.7957
34580................................  Mount Vernon-Anacortes,  WA.....................                   1.0164
                                        WA.
34620................................  Muncie, IN.............  IN.....................                   0.8479
35300................................  New Haven-Milford, CT..  CT.....................                   1.1897
35980................................  Norwich-New London, CT.  CT.....................                   1.1897
36100................................  Ocala, FL..............  FL.....................                   0.8633
36780................................  Oshkosh-Neenah, WI.....  WI.....................                   0.9511
37100................................  Oxnard-Thousand Oaks-    CA.....................                   1.1822
                                        Ventura, CA.
37460................................  Panama City-Lynn Haven,  FL.....................                   0.8633
                                        FL.
37620................................  Parkersburg-Marietta-    OH.....................                   0.8582
                                        Vienna, WV-OH.
37860................................  Pensacola-Ferry Pass-    FL.....................                   0.8633
                                        Brent, FL.
39380................................  Pueblo, CO.............  CO.....................                   0.9303
39540................................  Racine, WI.............  WI.....................                   0.9511
40140................................  Riverside-San            CA.....................                   1.1822
                                        Bernardino-Ontario, CA.
40484................................  Rockingham County-       NH.....................                   1.0807
                                        Strafford County, NH.
41740................................  San Diego-Carlsbad-San   CA.....................                   1.1822
                                        Marcos, CA.
42020................................  San Luis Obispo-Paso     CA.....................                   1.1822
                                        Robles, CA.
42044................................  Santa Ana-Anaheim-       CA.....................                   1.1822
                                        Irvine, CA.
42060................................  Santa Barbara-Santa      CA.....................                   1.1822
                                        Maria-Goleta, CA.
42540................................  Scranton-Wilkes-Barre,   PA.....................                   0.8342
                                        PA.
43100................................  Sheboygan, WI..........  WI.....................                   0.9511
44180................................  Springfield, MO........  MO.....................                   0.8470
44700................................  Stockton, CA...........  CA.....................                   1.1822
44940................................  Sumter, SC.............  SC.....................                   0.8609
45940................................  Trenton-Ewing, NJ......  NJ.....................                   1.1221
47020................................  Victoria, TX...........  TX.....................                   0.8153
47220................................  Vineland-Millville-      NJ.....................                   1.1221
                                        Bridgeton, NJ.
47300................................  Visalia-Porterville, CA  CA.....................                   1.1822
48260................................  Weirton-Steubenville,    OH.....................                   0.8582
                                        WV-OH.
48300................................  Wenatchee, WA..........  WA.....................                   1.0164
48540................................  Wheeling, WV-OH........  OH.....................                   0.8582
48540................................  Wheeling, WV-OH........  WV.....................                   0.7635
48700................................  Williamsport, PA.......  PA.....................                   0.8342
48864................................  Wilmington, DE-MD-NJ...  NJ.....................                   1.1221

[[Page 23802]]

 
49420................................  Yakima, WA.............  WA.....................                   1.0164
49700................................  Yuba City, CA..........  CA.....................                   1.1822
----------------------------------------------------------------------------------------------------------------


        Table 4E.--Urban CBSAs and Constituent Counties--FY 2009
------------------------------------------------------------------------
                                               Urban area (constituent
                 CBSA code                            counties)
------------------------------------------------------------------------
10180.....................................  Abilene, TX
                                             Callahan County, TX
                                             Jones County, TX
                                             Taylor County, TX
10380.....................................  Aguadilla-Isabela-San
                                             Sebasti[aacute]n, PR
                                             Aguada Municipio, PR
                                             Aguadilla Municipio, PR
                                             A[ntilde]asco Municipio, PR
                                             Isabela Municipio, PR
                                             Lares Municipio, PR
                                             Moca Municipio, PR
                                             Rinc[oacute]n Municipio, PR
                                             San Sebasti[aacute]n
                                             Municipio, PR
10420.....................................  Akron, OH
                                             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
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-SusitnaBorough,
                                             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
12060.....................................  \1\ 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
12420.....................................  \1\ Austin-Round Rock, TX
                                             Bastrop County, TX
                                             Caldwell County, TX
                                             Hays County, TX
                                             Travis County, TX
                                             Williamson County, TX
12540.....................................  Bakersfield, CA
                                             Kern County, CA
12580.....................................  \1\ 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
13644.....................................  \1\ Bethesda-Frederick-
                                             Gaithersburg, 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.....................................  \1\ Birmingham-Hoover, AL
                                             Bibb County, AL
                                             Blount County, AL

[[Page 23803]]

 
                                             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.....................................  \1\ Boston-Quincy, MA
                                             Norfolk County, MA
                                             Plymouth County, MA
                                             Suffolk County, MA
14500.....................................  Boulder, CO
                                             Boulder County, CO
14540.....................................  Bowling Green, KY
                                             Edmonson County, KY
                                             Warren County, KY
14600.....................................  Bradenton-Sarasota-Venice,
                                             FL
                                             Bradenton County, FL
                                             Manatee County, FL
                                             Sarasota County, FL
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.....................................  \1\ 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.....................................  \1\ Cambridge-Newton-
                                             Framingham, MA
                                             Middlesex County, MA
15804.....................................  \1\ 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
16180.....................................  Carson City, NV
                                             Carson City, NV
16220.....................................  Casper, WY
                                             Natrona County, WY
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.....................................  \1\ Charlotte-Gastonia-
                                             Concord, 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
16974.....................................  \1\ Chicago-Naperville-
                                             Joliet, IL
                                             Cook County, IL
                                             DeKalb County, IL
                                             DuPage County, IL
                                             Grundy County, IL
                                             Kane County, IL
                                             Kendall County, IL
                                             McHenry County, IL
                                             Will County, IL
17020.....................................  Chico, CA
                                             Butte County, CA
17140.....................................  \1\ 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.....................................  \1\ 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
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.....................................  \1\ 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
19060.....................................  Cumberland, MD-WV
                                             Allegany County, MD
                                             Mineral County, WV
19124.....................................  \1\ Dallas-Plano-Irving, TX
                                             Collin County, TX

[[Page 23804]]

 
                                             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
19740.....................................  \1\ Denver-Aurora, 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.....................................  \1\ 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, NC
                                             Chatham County, NC
                                             Durham County, NC
                                             Orange County, NC
                                             Person County, NC
20740.....................................  Eau Claire, WI
                                             Chippewa County, WI
                                             Eau Claire County, WI
20764.....................................  \1\ 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
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.....................................  \1\ 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
23020.....................................  Fort Walton Beach-Crestview-
                                             Destin, FL
                                             Okaloosa County, FL
23060.....................................  Fort Wayne, IN
                                             Allen County, IN
                                             Wells County, IN
                                             Whitley County, IN
23104.....................................  \1\ 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
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

[[Page 23805]]

 
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.....................................  \1\ 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
26380.....................................  Houma-Bayou Cane-Thibodaux,
                                             LA
                                             Lafourche Parish, LA
                                             Terrebonne Parish, LA
26420.....................................  \1\ 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.....................................  \1\ 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
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.....................................  \1\ 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
28140.....................................  \1\ 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
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.....................................  \1\ Las Vegas-Paradise, NV
                                             Clark County, NV
29940.....................................  Lawrence, KS

[[Page 23806]]

 
                                             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
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.....................................  \1\ Los Angeles-Long Beach-
                                             Glendale, CA
                                             Los Angeles County, CA
31140.....................................  \1\ 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
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, CA
                                             Madera County, CA
31540.....................................  Madison, WI
                                             Columbia County, WI
                                             Dane County, WI
                                             Iowa County, WI
31700.....................................  Manchester-Nashua, NH
                                             Hillsborough County, NH
31900.....................................  Mansfield, OH
                                             Richland County, OH
32420.....................................  Mayag[uuml]ez, PR
                                             Hormigueros Municipio, PR
                                             Mayag[uuml]ez Municipio, PR
32580.....................................  McAllen-Edinburg-Mission, TX
                                             Hidalgo County, TX
32780.....................................  Medford, OR
                                             Jackson County, OR
32820.....................................  \1\ 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.....................................  \1\ 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.....................................  \1\ Milwaukee-Waukesha-West
                                             Allis, WI
                                             Milwaukee County, WI
                                             Ozaukee County, WI
                                             Washington County, WI
                                             Waukesha County, WI
33460.....................................  \1\ 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
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.....................................  \1\ 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
35004.....................................  \1\ Nassau-Suffolk, NY
                                             Nassau County, NY
                                             Suffolk County, NY
35084.....................................  \1\ 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.....................................  \1\ 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.....................................  \1\ New York-White Plains-
                                             Wayne, NY-NJ
                                             Bergen County, NJ
                                             Hudson County, NJ
                                             Passaic County, NJ
                                             Bronx County, NY
                                             Kings County, NY

[[Page 23807]]

 
                                             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
35980.....................................  Norwich-New London, CT
                                             New London County, CT
36084.....................................  \1\ Oakland-Fremont-Hayward,
                                             CA
                                             Alameda County, CA
                                             Contra Costa County, CA
36100.....................................  Ocala, FL
                                             Marion County, FL
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.....................................  \1\ 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.....................................  \1\ Orlando-Kissimmee, 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
37460.....................................  Panama City-Lynn Haven, 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.....................................  \1\ Philadelphia, PA
                                             Bucks County, PA
                                             Chester County, PA
                                             Delaware County, PA
                                             Montgomery County, PA
                                             Philadelphia County, PA
38060.....................................  \1\ Phoenix-Mesa-Scottsdale,
                                             AZ
                                             Maricopa County, AZ
                                             Pinal County, AZ
38220.....................................  Pine Bluff, AR
                                             Cleveland County, AR
                                             Jefferson County, AR
                                             Lincoln County, AR
38300.....................................  \1\ 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
38540.....................................  Pocatello, ID
                                             Bannock County, ID
                                             Power County, ID
38660.....................................  Ponce, PR
                                             Juana D[iacute]az
                                             Municipio, PR
                                             Ponce Municipio, PR
                                             Villalba Municipio, PR
38860.....................................  Portland-South Portland-
                                             Biddeford, ME
                                             Cumberland County, ME
                                             Sagadahoc County, ME
                                             York County, ME
38900.....................................  \1\ Portland-Vancouver-
                                             Beaverton, OR-WA
                                             Clackamas County, OR
                                             Columbia County, OR
                                             Multnomah County, OR
                                             Washington County, OR
                                             Yamhill County, OR
                                             Clark County, WA
                                             Skamania County, WA
38940.....................................  Port St. Lucie, 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.....................................  \1\ 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
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.....................................  \1\ 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.....................................  \1\ Riverside-San Bernardino-
                                             Ontario, CA
                                             Riverside County, CA
                                             San Bernardino County, CA
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.....................................  \1\ Rochester, NY
                                             Livingston County, NY
                                             Monroe County, NY
                                             Ontario County, NY

[[Page 23808]]

 
                                             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.....................................  \1\ 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
41140.....................................  St. Joseph, MO-KS
                                             Doniphan County, KS
                                             Andrew County, MO
                                             Buchanan County, MO
                                             DeKalb County, MO
41180.....................................  \1\ 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
41700.....................................  \1\ San Antonio, 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.....................................  \1\ San Diego-Carlsbad-San
                                             Marcos, CA
                                             San Diego County, CA
41780.....................................  Sandusky, OH
                                             Erie County, OH
41884.....................................  \1\ San Francisco-San Mateo-
                                             Redwood City, CA
                                             Marin County, CA
                                             San Francisco County, CA
                                             San Mateo County, CA
41900.....................................  San Germ[aacute]n-Cabo Rojo,
                                             PR
                                             Cabo Rojo Municipio, PR
                                             Lajas Municipio, PR
                                             Sabana Grande Municipio, PR
                                             San Germ[aacute]n
                                             Municipio, PR
41940.....................................  \1\ San Jose-Sunnyvale-Santa
                                             Clara, CA
                                             San Benito County, CA
                                             Santa Clara County, CA
41980.....................................  \1\ San Juan-Caguas-
                                             Guaynabo, PR
                                             Aguas Buenas Municipio, PR
                                             Aibonito Municipio, PR
                                             Arecibo Municipio, PR
                                             Barceloneta Municipio, PR
                                             Barranquitas Municipio, PR
                                             Bayam[oacute]n Municipio,
                                             PR
                                             Caguas Municipio, PR
                                             Camuy Municipio, PR
                                             Can[oacute]vanas Municipio,
                                             PR
                                             Carolina Municipio, PR
                                             Cata[ntilde]o Municipio, PR
                                             Cayey Municipio, PR
                                             Ciales Municipio, PR
                                             Cidra Municipio, PR
                                             Comer[iacute]o Municipio,
                                             PR
                                             Corozal Municipio, PR
                                             Dorado Municipio, PR
                                             Florida Municipio, PR
                                             Guaynabo Municipio, PR
                                             Gurabo Municipio, PR
                                             Hatillo Municipio, PR
                                             Humacao Municipio, PR
                                             Juncos Municipio, PR
                                             Las Piedras Municipio, PR
                                             Lo[iacute]za Municipio, PR
                                             Manat[iacute] Municipio, PR
                                             Maunabo Municipio, PR
                                             Morovis Municipio, PR
                                             Naguabo Municipio, PR
                                             Naranjito Municipio, PR
                                             Orocovis Municipio, PR
                                             Quebradillas Municipio, PR
                                             R[iacute]o Grande
                                             Municipio, PR
                                             San Juan Municipio, PR
                                             San Lorenzo Municipio, PR
                                             Toa Alta Municipio, PR
                                             Toa Baja Municipio, PR
                                             Trujillo Alto Municipio, PR
                                             Vega Alta Municipio, PR
                                             Vega Baja Municipio, PR
                                             Yabucoa Municipio, PR
42020.....................................  San Luis Obispo-Paso Robles,
                                             CA
                                             San Luis Obispo County, CA
42044.....................................  \1\ 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.....................................  \1\ 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
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

[[Page 23809]]

 
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
45300.....................................  \1\ 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
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.....................................  \1\ 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
47644.....................................  \1\ Warren-Troy-Farmington
                                             Hills, MI
                                             Lapeer County, MI
                                             Livingston County, MI
                                             Macomb County, MI
                                             Oakland County, MI
                                             St. Clair County, MI
47894.....................................  \1\ 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
48260.....................................  Weirton-Steubenville, WV-OH
                                             Jefferson County, OH
                                             Brooke County, WV
                                             Hancock County, WV
48300.....................................  Wenatchee, WA
                                             Chelan County, WA
                                             Douglas County, WA
48424.....................................  \1\ 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
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
                                             Gu[aacute]nica Municipio,
                                             PR
                                             Guayanilla Municipio, PR
                                             Pe[ntilde]uelas 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
49700.....................................  Yuba City, CA
                                             Sutter County, CA
                                             Yuba County, CA
49740.....................................  Yuma, AZ
                                             Yuma County, AZ
------------------------------------------------------------------------
\1\ Large urban area.


[[Page 23810]]


        Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2009
 [Note: The rural floor budget neutrality adjustment is not applicable to the Puerto Rico-specific wage index.]
----------------------------------------------------------------------------------------------------------------
                                                                              Wage index--
     CBSA code                  Area             Wage index      GAF          reclassified     GAF--reclassified
                                                                               hospitals           hospitals
----------------------------------------------------------------------------------------------------------------
10380..............  Aguadilla-Isabela-San           0.7845       0.8469  ...................  .................
                      Sebasti[aacute]n, PR.
21940..............  Fajardo, PR..............       0.9572       0.9705  ...................  .................
25020..............  Guayama, PR..............       0.7472       0.8191  ...................  .................
32420..............  Mayag[uuml]ez, PR........       0.9236       0.9470  ...................  .................
38660..............  Ponce, PR................       0.9757       0.9833  ...................  .................
41900..............  San Germ[aacute]n-Cabo          1.0864       1.0584  ...................  .................
                      Rojo, PR.
41980..............  San Juan-Caguas-Guaynabo,       1.0348       1.0237  ...................  .................
                      PR.
49500..............  Yauco, PR................       0.7969       0.8560  ...................  .................
----------------------------------------------------------------------------------------------------------------

    The following list represents all hospitals that are eligible to 
have their wage index increased by the out-migration adjustment 
listed in this table. Hospitals cannot receive the out-migration 
adjustment if they are reclassified under section 1886(d)(10) of the 
Act or redesignated under section 1886(d)(8)(B) of the Act. 
Hospitals that have already been reclassified under section 
1886(d)(10) of the Act or redesignated under section 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 out-migration adjustment, 
unless they explicitly notify 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.

                                  Table 4J.--Out-Migration Adjustment--FY 2009
----------------------------------------------------------------------------------------------------------------
                                      Reclassified for FY    Out-migration    Qualifying county
           Provider No.                      2009             adjustment            name            County code
----------------------------------------------------------------------------------------------------------------
010005............................  *.....................          0.0296  MARSHALL............           01470
010008............................  ......................          0.0174  CRENSHAW............           01200
010009............................  *.....................          0.0092  MORGAN..............           01510
010010............................  *.....................          0.0296  MARSHALL............           01470
010012............................  *.....................          0.0186  DE KALB.............           01240
010015............................  ......................          0.0046  CLARKE..............           01120
010021............................  ......................          0.0030  DALE................           01220
010022............................  *.....................          0.1128  CHEROKEE............           01090
010025............................  *.....................          0.0235  CHAMBERS............           01080
010027............................  ......................          0.0015  COFFEE..............           01150
010029............................  *.....................          0.0289  LEE.................           01400
010032............................  ......................          0.0325  RANDOLPH............           01550
010035............................  *.....................          0.0254  CULLMAN.............           01210
010038............................  ......................          0.0047  CALHOUN.............           01070
010040............................  ......................          0.0061  ETOWAH..............           01270
010045............................  ......................          0.0222  FAYETTE.............           01280
010046............................  ......................          0.0061  ETOWAH..............           01270
010047............................  ......................          0.0127  BUTLER..............           01060
010049............................  ......................          0.0015  COFFEE..............           01150
010052............................  *.....................          0.0103  TALLAPOOSA..........           01610
010054............................  *.....................          0.0092  MORGAN..............           01510
010059............................  *.....................          0.0069  LAWRENCE............           01390
010061............................  *.....................          0.0542  JACKSON.............           01350
010065............................  *.....................          0.0103  TALLAPOOSA..........           01610
010078............................  ......................          0.0047  CALHOUN.............           01070
010083............................  *.....................          0.0134  BALDWIN.............           01010
010085............................  *.....................          0.0092  MORGAN..............           01510
010091............................  ......................          0.0046  CLARKE..............           01120
010100............................  *.....................          0.0134  BALDWIN.............           01010
010101............................  *.....................          0.0211  TALLADEGA...........           01600
010109............................  ......................          0.0451  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

[[Page 23811]]

 
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
050008............................  ......................          0.0026  SAN FRANCISCO.......           05480
050009............................  *.....................          0.0180  NAPA................           05380
050013............................  *.....................          0.0180  NAPA................           05380
050014............................  *.....................          0.0139  AMADOR..............           05020
050016............................  ......................          0.0103  SAN LUIS OBISPO.....           05500
050042............................  *.....................          0.0162  TEHAMA..............           05620
050043............................  ......................          0.0010  ALAMEDA.............           05000
050047............................  ......................          0.0026  SAN FRANCISCO.......           05480
050055............................  ......................          0.0026  SAN FRANCISCO.......           05480
050069............................  *.....................          0.0020  ORANGE..............           05400
050070............................  ......................          0.0146  SAN MATEO...........           05510
050073............................  *.....................          0.0171  SOLANO..............           05580
050075............................  ......................          0.0010  ALAMEDA.............           05000
050076............................  *.....................          0.0026  SAN FRANCISCO.......           05480
050084............................  ......................          0.0132  SAN JOAQUIN.........           05490
050089............................  *.....................          0.0017  SAN BERNARDINO......           05460
050090............................  *.....................          0.0058  SONOMA..............           05590
050099............................  *.....................          0.0017  SAN BERNARDINO......           05460
050101............................  *.....................          0.0171  SOLANO..............           05580
050113............................  ......................          0.0146  SAN MATEO...........           05510
050118............................  *.....................          0.0132  SAN JOAQUIN.........           05490
050122............................  ......................          0.0132  SAN JOAQUIN.........           05490
050129............................  *.....................          0.0017  SAN BERNARDINO......           05460
050133............................  *.....................          0.0178  YUBA................           05680
050136............................  *.....................          0.0058  SONOMA..............           05590
050140............................  *.....................          0.0017  SAN BERNARDINO......           05460
050150............................  *.....................          0.0342  NEVADA..............           05390
050152............................  ......................          0.0026  SAN FRANCISCO.......           05480
050167............................  ......................          0.0132  SAN JOAQUIN.........           05490
050168............................  *.....................          0.0020  ORANGE..............           05400
050173............................  *.....................          0.0020  ORANGE..............           05400
050174............................  *.....................          0.0058  SONOMA..............           05590
050193............................  *.....................          0.0020  ORANGE..............           05400
050194............................  *.....................          0.0052  SANTA CRUZ..........           05540
050195............................  ......................          0.0010  ALAMEDA.............           05000
050197............................  *.....................          0.0146  SAN MATEO...........           05510
050211............................  ......................          0.0010  ALAMEDA.............           05000
050224............................  *.....................          0.0020  ORANGE..............           05400
050226............................  *.....................          0.0020  ORANGE..............           05400
050228............................  ......................          0.0026  SAN FRANCISCO.......           05480
050230............................  *.....................          0.0020  ORANGE..............           05400
050232............................  ......................          0.0103  SAN LUIS OBISPO.....           05500
050242............................  *.....................          0.0052  SANTA CRUZ..........           05540
050245............................  *.....................          0.0017  SAN BERNARDINO......           05460
050264............................  ......................          0.0010  ALAMEDA.............           05000
050272............................  *.....................          0.0017  SAN BERNARDINO......           05460
050279............................  *.....................          0.0017  SAN BERNARDINO......           05460
050283............................  ......................          0.0010  ALAMEDA.............           05000
050289............................  ......................          0.0146  SAN MATEO...........           05510
050291............................  *.....................          0.0058  SONOMA..............           05590
050298............................  ......................          0.0017  SAN BERNARDINO......           05460
050300............................  *.....................          0.0017  SAN BERNARDINO......           05460
050305............................  ......................          0.0010  ALAMEDA.............           05000
050313............................  ......................          0.0132  SAN JOAQUIN.........           05490
050320............................  ......................          0.0010  ALAMEDA.............           05000
050325............................  ......................          0.0033  TUOLUMNE............           05650
050327............................  *.....................          0.0017  SAN BERNARDINO......           05460

[[Page 23812]]

 
050335............................  *.....................          0.0033  TUOLUMNE............           05650
050336............................  ......................          0.0132  SAN JOAQUIN.........           05490
050348............................  *.....................          0.0020  ORANGE..............           05400
050366............................  ......................          0.0015  CALAVERAS...........           05040
050367............................  *.....................          0.0171  SOLANO..............           05580
050385............................  *.....................          0.0058  SONOMA..............           05590
050407............................  ......................          0.0026  SAN FRANCISCO.......           05480
050426............................  *.....................          0.0020  ORANGE..............           05400
050444............................  ......................          0.0233  MERCED..............           05340
050454............................  ......................          0.0026  SAN FRANCISCO.......           05480
050457............................  ......................          0.0026  SAN FRANCISCO.......           05480
050476............................  *.....................          0.0278  LAKE................           05160
050488............................  ......................          0.0010  ALAMEDA.............           05000
050494............................  *.....................          0.0342  NEVADA..............           05390
050506............................  ......................          0.0103  SAN LUIS OBISPO.....           05500
050512............................  ......................          0.0010  ALAMEDA.............           05000
050517............................  *.....................          0.0017  SAN BERNARDINO......           05460
050526............................  *.....................          0.0020  ORANGE..............           05400
050528............................  *.....................          0.0233  MERCED..............           05340
050541............................  *.....................          0.0146  SAN MATEO...........           05510
050543............................  *.....................          0.0020  ORANGE..............           05400
050547............................  *.....................          0.0058  SONOMA..............           05590
050548............................  *.....................          0.0020  ORANGE..............           05400
050551............................  *.....................          0.0020  ORANGE..............           05400
050567............................  *.....................          0.0020  ORANGE..............           05400
050570............................  *.....................          0.0020  ORANGE..............           05400
050580............................  *.....................          0.0020  ORANGE..............           05400
050584............................  ......................          0.0017  SAN BERNARDINO......           05460
050586............................  *.....................          0.0017  SAN BERNARDINO......           05460
050589............................  *.....................          0.0020  ORANGE..............           05400
050603............................  *.....................          0.0020  ORANGE..............           05400
050609............................  *.....................          0.0020  ORANGE..............           05400
050618............................  *.....................          0.0017  SAN BERNARDINO......           05460
050633............................  ......................          0.0103  SAN LUIS OBISPO.....           05500
050667............................  *.....................          0.0180  NAPA................           05380
050668............................  ......................          0.0026  SAN FRANCISCO.......           05480
050678............................  *.....................          0.0020  ORANGE..............           05400
050680............................  *.....................          0.0171  SOLANO..............           05580
050690............................  *.....................          0.0058  SONOMA..............           05590
050693............................  *.....................          0.0020  ORANGE..............           05400
050714............................  ......................          0.0052  SANTA CRUZ..........           05540
050720............................  *.....................          0.0020  ORANGE..............           05400
050744............................  *.....................          0.0020  ORANGE..............           05400
050745............................  *.....................          0.0020  ORANGE..............           05400
050746............................  *.....................          0.0020  ORANGE..............           05400
050747............................  *.....................          0.0020  ORANGE..............           05400
050748............................  ......................          0.0132  SAN JOAQUIN.........           05490
050754............................  ......................          0.0146  SAN MATEO...........           05510
050758............................  *.....................          0.0017  SAN BERNARDINO......           05460
060001............................  ......................          0.0042  WELD................           06610
060003............................  *.....................          0.0069  BOULDER.............           06060
060010............................  ......................          0.0153  LARIMER.............           06340
060027............................  *.....................          0.0069  BOULDER.............           06060
060030............................  ......................          0.0153  LARIMER.............           06340
060103............................  *.....................          0.0069  BOULDER.............           06060
060116............................  *.....................          0.0069  BOULDER.............           06060
060119............................  ......................          0.0153  LARIMER.............           06340
070006............................  *.....................          0.0045  FAIRFIELD...........           07000
070010............................  *.....................          0.0045  FAIRFIELD...........           07000
070018............................  *.....................          0.0045  FAIRFIELD...........           07000
070028............................  *.....................          0.0045  FAIRFIELD...........           07000
070033............................  *.....................          0.0045  FAIRFIELD...........           07000
070034............................  *.....................          0.0045  FAIRFIELD...........           07000
080001............................  *.....................          0.0063  NEW CASTLE..........           08010
080003............................  *.....................          0.0063  NEW CASTLE..........           08010
100014............................  *.....................          0.0047  VOLUSIA.............           10630
100017............................  *.....................          0.0047  VOLUSIA.............           10630
100045............................  *.....................          0.0047  VOLUSIA.............           10630
100047............................  *.....................          0.0028  CHARLOTTE...........           10070
100068............................  *.....................          0.0047  VOLUSIA.............           10630
100072............................  *.....................          0.0047  VOLUSIA.............           10630

[[Page 23813]]

 
100077............................  *.....................          0.0028  CHARLOTTE...........           10070
100081............................  *.....................          0.0022  WALTON..............           10650
100102............................  ......................          0.0125  COLUMBIA............           10110
100118............................  *.....................          0.0177  FLAGLER.............           10170
100156............................  *.....................          0.0125  COLUMBIA............           10110
100232............................  *.....................          0.0054  PUTNAM..............           10530
100236............................  *.....................          0.0028  CHARLOTTE...........           10070
100252............................  *.....................          0.0151  OKEECHOBEE..........           10460
100290............................  ......................          0.0582  SUMTER..............           10590
100292............................  *.....................          0.0022  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............................  *.....................          0.0805  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
140110............................  *.....................          0.0315  LA SALLE............           14580
140116............................  ......................          0.0007  MC HENRY............           14640
140160............................  *.....................          0.0332  STEPHENSON..........           14970
140161............................  ......................          0.0168  LIVINGSTON..........           14610
140167............................  *.....................          0.0632  IROQUOIS............           14460
140176............................  ......................          0.0007  MC HENRY............           14640
140234............................  ......................          0.0315  LA SALLE............           14580
150006............................  *.....................          0.0113  LA PORTE............           15450
150015............................  *.....................          0.0113  LA PORTE............           15450
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............................  *.....................          0.0319  NOBLE...............           15560
160013............................  ......................          0.0179  MUSCATINE...........           16690
160030............................  ......................          0.0040  STORY...............           16840
160032............................  ......................          0.0235  JASPER..............           16490
160080............................  *.....................          0.0066  CLINTON.............           16220
170137............................  *.....................          0.0336  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  JEFFERSON DAVIS.....           19260

[[Page 23814]]

 
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
190133............................  ......................          0.0102  ALLEN...............           19010
190140............................  ......................          0.0035  FRANKLIN............           19200
190144............................  *.....................          0.0387  WEBSTER.............           19590
190145............................  ......................          0.0090  LA SALLE............           19290
190184............................  *.....................          0.0161  CALDWELL............           19100
190190............................  ......................          0.0161  CALDWELL............           19100
190191............................  *.....................          0.0187  ST. LANDRY..........           19480
190246............................  ......................          0.0161  CALDWELL............           19100
190257............................  *.....................          0.0061  LINCOLN.............           19300
190277............................  ......................          0.0387  WEBSTER.............           19590
200024............................  *.....................          0.0094  ANDROSCOGGIN........           20000
200032............................  ......................          0.0466  OXFORD..............           20080
200034............................  *.....................          0.0094  ANDROSCOGGIN........           20000
200050............................  *.....................          0.0227  HANCOCK.............           20040
210001............................  ......................          0.0187  WASHINGTON..........           21210
210023............................  ......................          0.0079  ANNE ARUNDEL........           21010
210028............................  ......................          0.0512  ST. MARYS...........           21180
210043............................  ......................          0.0079  ANNE ARUNDEL........           21010
210061............................  ......................          0.0188  WORCESTER...........           21230
220001............................  *.....................          0.0067  WORCESTER...........           22170
220002............................  *.....................          0.0271  MIDDLESEX...........           22090
220010............................  *.....................          0.0355  ESSEX...............           22040
220011............................  *.....................          0.0271  MIDDLESEX...........           22090
220019............................  *.....................          0.0067  WORCESTER...........           22170
220025............................  *.....................          0.0067  WORCESTER...........           22170
220029............................  *.....................          0.0355  ESSEX...............           22040
220033............................  *.....................          0.0355  ESSEX...............           22040
220035............................  *.....................          0.0355  ESSEX...............           22040
220049............................  *.....................          0.0271  MIDDLESEX...........           22090
220058............................  *.....................          0.0067  WORCESTER...........           22170
220062............................  *.....................          0.0067  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............................  *.....................          0.0067  WORCESTER...........           22170
220095............................  *.....................          0.0067  WORCESTER...........           22170
220098............................  *.....................          0.0271  MIDDLESEX...........           22090
220101............................  *.....................          0.0271  MIDDLESEX...........           22090
220105............................  *.....................          0.0271  MIDDLESEX...........           22090
220163............................  *.....................          0.0067  WORCESTER...........           22170
220171............................  *.....................          0.0271  MIDDLESEX...........           22090
220174............................  *.....................          0.0355  ESSEX...............           22040
220176............................  *.....................          0.0067  WORCESTER...........           22170
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
230021............................  *.....................          0.0101  BERRIEN.............           23100
230022............................  *.....................          0.0212  BRANCH..............           23110
230029............................  *.....................          0.0025  OAKLAND.............           23620
230035............................  *.....................          0.0095  MONTCALM............           23580
230037............................  *.....................          0.0210  HILLSDALE...........           23290
230047............................  *.....................          0.0021  MACOMB..............           23490
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
230092............................  *.....................          0.0223  JACKSON.............           23370
230093............................  ......................          0.0058  MECOSTA.............           23530
230096............................  *.....................          0.0295  ST. JOSEPH..........           23740

[[Page 23815]]

 
230099............................  *.....................          0.0231  MONROE..............           23570
230121............................  *.....................          0.0678  SHIAWASSEE..........           23770
230130............................  *.....................          0.0025  OAKLAND.............           23620
230151............................  *.....................          0.0025  OAKLAND.............           23620
230174............................  *.....................          0.0220  OTTAWA..............           23690
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
230223............................  *.....................          0.0025  OAKLAND.............           23620
230227............................  *.....................          0.0021  MACOMB..............           23490
230254............................  *.....................          0.0025  OAKLAND.............           23620
230257............................  *.....................          0.0021  MACOMB..............           23490
230264............................  *.....................          0.0021  MACOMB..............           23490
230269............................  *.....................          0.0025  OAKLAND.............           23620
230277............................  *.....................          0.0025  OAKLAND.............           23620
230279............................  *.....................          0.0210  LIVINGSTON..........           23460
230301............................  *.....................          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
260163............................  ......................          0.0087  ST. FRANCOIS........           26930
280077............................  ......................          0.0080  DODGE...............           28260
280123............................  ......................          0.0123  GAGE................           28330
290002............................  *.....................          0.0277  LYON................           29090
300011............................  *.....................          0.0069  HILLSBOROUGH........           30050
300012............................  *.....................          0.0069  HILLSBOROUGH........           30050
300017............................  *.....................          0.0102  ROCKINGHAM..........           30070
300020............................  *.....................          0.0069  HILLSBOROUGH........           30050
300023............................  *.....................          0.0102  ROCKINGHAM..........           30070
300029............................  *.....................          0.0102  ROCKINGHAM..........           30070
300034............................  *.....................          0.0069  HILLSBOROUGH........           30050
310002............................  *.....................          0.0268  ESSEX...............           31200
310009............................  *.....................          0.0268  ESSEX...............           31200
310010............................  ......................          0.0092  MERCER..............           31260
310011............................  ......................          0.0115  CAPE MAY............           31180
310015............................  *.....................          0.0203  MORRIS..............           31300
310017............................  *.....................          0.0203  MORRIS..............           31300
310018............................  *.....................          0.0268  ESSEX...............           31200
310021............................  *.....................          0.0092  MERCER..............           31260
310031............................  *.....................          0.0153  BURLINGTON..........           31150
310038............................  *.....................          0.0209  MIDDLESEX...........           31270
310039............................  *.....................          0.0209  MIDDLESEX...........           31270
310044............................  ......................          0.0092  MERCER..............           31260
310050............................  *.....................          0.0203  MORRIS..............           31300
310054............................  *.....................          0.0268  ESSEX...............           31200
310057............................  *.....................          0.0153  BURLINGTON..........           31150
310061............................  *.....................          0.0153  BURLINGTON..........           31150
310069............................  *.....................          0.0096  SALEM...............           31340
310070............................  *.....................          0.0209  MIDDLESEX...........           31270
310076............................  *.....................          0.0268  ESSEX...............           31200
310083............................  *.....................          0.0268  ESSEX...............           31200
310091............................  *.....................          0.0096  SALEM...............           31340
310092............................  ......................          0.0092  MERCER..............           31260
310093............................  *.....................          0.0268  ESSEX...............           31200
310096............................  *.....................          0.0268  ESSEX...............           31200

[[Page 23816]]

 
310108............................  *.....................          0.0209  MIDDLESEX...........           31270
310110............................  ......................          0.0092  MERCER..............           31260
310119............................  *.....................          0.0268  ESSEX...............           31200
320003............................  *.....................          0.0629  SAN MIGUEL..........           32230
320011............................  ......................          0.0442  RIO ARRIBA..........           32190
320018............................  ......................          0.0024  DONA ANA............           32060
320085............................  ......................          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............................  ......................          0.0054  STEUBEN.............           33690
330151............................  ......................          0.0054  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
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............................  *.....................          0.0054  STEUBEN.............           33690
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
340104............................  ......................          0.0162  CLEVELAND...........           34220
340114............................  *.....................          0.0015  WAKE................           34910
340126............................  *.....................          0.0100  WILSON..............           34970
340129............................  *.....................          0.0101  IREDELL.............           34480
340133............................  ......................          0.0308  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

[[Page 23817]]

 
360065............................  *.....................          0.0075  HURON...............           36400
360071............................  ......................          0.0035  VAN WERT............           36820
360086............................  *.....................          0.0186  CLARK...............           36110
360096............................  *.....................          0.0071  COLUMBIANA..........           36140
360107............................  *.....................          0.0119  SANDUSKY............           36730
360125............................  *.....................          0.0133  ASHTABULA...........           36030
360156............................  ......................          0.0119  SANDUSKY............           36730
360175............................  *.....................          0.0183  CLINTON.............           36130
360185............................  *.....................          0.0071  COLUMBIANA..........           36140
360187............................  *.....................          0.0186  CLARK...............           36110
360245............................  *.....................          0.0133  ASHTABULA...........           36030
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
380029............................  ......................          0.0075  MARION..............           38230
380051............................  *.....................          0.0075  MARION..............           38230
380056............................  ......................          0.0075  MARION..............           38230
390008............................  ......................          0.0060  LAWRENCE............           39450
390016............................  *.....................          0.0060  LAWRENCE............           39450
390030............................  ......................          0.0284  SCHUYLKILL..........           39650
390031............................  *.....................          0.0284  SCHUYLKILL..........           39650
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
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
390146............................  ......................          0.0022  WARREN..............           39740
390150............................  *.....................          0.0031  GREENE..............           39370
390151............................  *.....................          0.0218  FRANKLIN............           39350
390162............................  *.....................          0.0200  NORTHAMPTON.........           39590
390183............................  *.....................          0.0284  SCHUYLKILL..........           39650
390201............................  ......................          0.1170  MONROE..............           39550
390236............................  ......................          0.0003  BRADFORD............           39130
390313............................  *.....................          0.0284  SCHUYLKILL..........           39650
390316............................  ......................          0.0191  BERKS...............           39110
420002............................  ......................          0.0004  YORK................           42450
420007............................  *.....................          0.0027  SPARTANBURG.........           42410
420009............................  *.....................          0.0113  OCONEE..............           42360
420019............................  ......................          0.0158  CHESTER.............           42110
420020............................  *.....................          0.0007  GEORGETOWN..........           42210
420027............................  *.....................          0.0108  ANDERSON............           42030
420030............................  *.....................          0.0069  COLLETON............           42140
420036............................  *.....................          0.0064  LANCASTER...........           42280
420039............................  *.....................          0.0153  UNION...............           42430
420043............................  ......................          0.0157  CHEROKEE............           42100
420053............................  ......................          0.0035  NEWBERRY............           42350
420054............................  ......................          0.0003  MARLBORO............           42340
420062............................  *.....................          0.0109  CHESTERFIELD........           42120
420068............................  *.....................          0.0027  ORANGEBURG..........           42370
420069............................  *.....................          0.0052  CLARENDON...........           42130
420070............................  *.....................          0.0052  SUMTER..............           42420

[[Page 23818]]

 
420082............................  ......................          0.0008  AIKEN...............           42010
420083............................  *.....................          0.0027  SPARTANBURG.........           42410
420098............................  *.....................          0.0007  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
440012............................  ......................          0.0007  SULLIVAN............           44810
440016............................  ......................          0.0144  CARROLL.............           44080
440017............................  ......................          0.0007  SULLIVAN............           44810
440024............................  *.....................          0.0230  BRADLEY.............           44050
440025............................  *.....................          0.0007  GREENE..............           44290
440030............................  ......................          0.0056  HAMBLEN.............           44310
440031............................  ......................          0.0019  ROANE...............           44720
440033............................  ......................          0.0027  CAMPBELL............           44060
440035............................  *.....................          0.0301  MONTGOMERY..........           44620
440047............................  ......................          0.0338  GIBSON..............           44260
440050............................  ......................          0.0007  GREENE..............           44290
440051............................  ......................          0.0082  MC NAIRY............           44540
440057............................  ......................          0.0021  CLAIBORNE...........           44120
440060............................  *.....................          0.0338  GIBSON..............           44260
440067............................  *.....................          0.0056  HAMBLEN.............           44310
440070............................  ......................          0.0109  DECATUR.............           44190
440081............................  ......................          0.0052  SEVIER..............           44770
440084............................  ......................          0.0025  MONROE..............           44610
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
440153............................  ......................          0.0007  COCKE...............           44140
440174............................  ......................          0.0312  HAYWOOD.............           44370
440176............................  ......................          0.0007  SULLIVAN............           44810
440180............................  ......................          0.0027  CAMPBELL............           44060
440181............................  ......................          0.0365  HARDEMAN............           44340
440182............................  ......................          0.0144  CARROLL.............           44080
440185............................  *.....................          0.0230  BRADLEY.............           44050
450032............................  ......................          0.0254  HARRISON............           45620
450039............................  *.....................          0.0024  TARRANT.............           45910
450052............................  *.....................          0.0276  BOSQUE..............           45160
450059............................  ......................          0.0075  COMAL...............           45320
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
450324............................  *.....................          0.0132  GRAYSON.............           45564
450347............................  *.....................          0.0370  WALKER..............           45949
450348............................  *.....................          0.0059  FALLS...............           45500
450370............................  ......................          0.0235  COLORADO............           45312
450389............................  *.....................          0.0618  HENDERSON...........           45640
450393............................  *.....................          0.0132  GRAYSON.............           45564
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
450469............................  *.....................          0.0132  GRAYSON.............           45564
450497............................  ......................          0.0375  MONTAGUE............           45800
450539............................  ......................          0.0067  HALE................           45582

[[Page 23819]]

 
450547............................  *.....................          0.0195  WOOD................           45974
450563............................  *.....................          0.0024  TARRANT.............           45910
450565............................  *.....................          0.0486  PALO PINTO..........           45841
450573............................  ......................          0.0126  JASPER..............           45690
450596............................  *.....................          0.0743  HOOD................           45653
450615............................  ......................          0.0032  CASS................           45260
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
450838............................  ......................          0.0126  JASPER..............           45690
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............................  ......................          0.0023  UTAH................           46240
460013............................  ......................          0.0023  UTAH................           46240
460017............................  ......................          0.0383  BOX ELDER...........           46010
460023............................  ......................          0.0023  UTAH................           46240
460039............................  *.....................          0.0383  BOX ELDER...........           46010
460043............................  ......................          0.0023  UTAH................           46240
460052............................  ......................          0.0023  UTAH................           46240
460055............................  ......................          0.0023  UTAH................           46240
490019............................  *.....................          0.1088  CULPEPER............           49230
490084............................  ......................          0.0187  ESSEX...............           49280
490110............................  ......................          0.0185  MONTGOMERY..........           49600
500003............................  *.....................          0.0166  SKAGIT..............           50280
500007............................  *.....................          0.0166  SKAGIT..............           50280
500019............................  ......................          0.0131  LEWIS...............           50200
500039............................  *.....................          0.0094  KITSAP..............           50170
500041............................  *.....................          0.0020  COWLITZ.............           50070
510012............................  ......................          0.0124  MASON...............           51260
510018............................  *.....................          0.0188  JACKSON.............           51170
510047............................  *.....................          0.0269  MARION..............           51240
510077............................  *.....................          0.0021  MINGO...............           51290
520028............................  *.....................          0.0286  GREEN...............           52220
520035............................  ......................          0.0076  SHEBOYGAN...........           52580
520044............................  ......................          0.0076  SHEBOYGAN...........           52580
520057............................  ......................          0.0193  SAUK................           52550
520059............................  *.....................          0.0195  RACINE..............           52500
520071............................  *.....................          0.0161  JEFFERSON...........           52270
520076............................  *.....................          0.0146  DODGE...............           52130
520095............................  ......................          0.0193  SAUK................           52550
520096............................  *.....................          0.0195  RACINE..............           52500
520102............................  *.....................          0.0242  WALWORTH............           52630
520116............................  *.....................          0.0161  JEFFERSON...........           52270
670015............................  ......................          0.0024  TARRANT.............           45910
670023............................  ......................          0.0024  TARRANT.............           45910
----------------------------------------------------------------------------------------------------------------


  Table 5.--List of Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay
--------------------------------------------------------------------------------------------------------------------------------------------------------
                      FY 2009 proposed    FY 2009 proposed
       MS-DRG          rule post-acute    rule special pay    MDC          Type                MS-DRG title          Weights     Geometric    Arithmetic
                             DRG                 DRG                                                                              mean LOS     mean LOS
--------------------------------------------------------------------------------------------------------------------------------------------------------
001................  No................  No................    PRE  SURG..............  Heart transplant or            23.4061         29.1         40.2
                                                                                         implant of heart assist
                                                                                         system w MCC.
002................  No................  No................    PRE  SURG..............  Heart transplant or            12.8956         18.4         24.7
                                                                                         implant of heart assist
                                                                                         system w/o MCC.

[[Page 23820]]

 
003................  Yes...............  No................    PRE  SURG..............  ECMO or trach w MV 96+         18.3635         32.5         39.6
                                                                                         hrs or PDX exc face,
                                                                                         mouth & neck w maj O.R.
004................  Yes...............  No................    PRE  SURG..............  Trach w MV 96+ hrs or PDX      11.1684         23.5         28.8
                                                                                         exc face, mouth & neck w/
                                                                                         o maj O.R..
005................  No................  No................    PRE  SURG..............  Liver transplant w MCC or      10.7436         15.9         21.2
                                                                                         intestinal transplant.
006................  No................  No................    PRE  SURG..............  Liver transplant w/o MCC.       4.8292          8.9         10.2
007................  No................  No................    PRE  SURG..............  Lung transplant..........       9.7325         15.9         19.7
008................  No................  No................    PRE  SURG..............  Simultaneous pancreas/          4.8917         10.1         11.9
                                                                                         kidney transplant.
009................  No................  No................    PRE  SURG..............  Bone marrow transplant...       6.6398         18.2         21.9
010................  No................  No................    PRE  SURG..............  Pancreas transplant......       3.7508          9.1         10.8
011................  No................  No................    PRE  SURG..............  Tracheostomy for                4.8900         13.1         16.7
                                                                                         face,mouth & neck
                                                                                         diagnoses w MCC.
012................  No................  No................    PRE  SURG..............  Tracheostomy for                3.0563          8.9         10.7
                                                                                         face,mouth & neck
                                                                                         diagnoses w CC.
013................  No................  No................    PRE  SURG..............  Tracheostomy for                1.9057          5.9          6.9
                                                                                         face,mouth & neck
                                                                                         diagnoses w/o CC/MCC.
020................  No................  No................     01  SURG..............  Intracranial vascular           8.3276         14.8         18.4
                                                                                         procedures w PDX
                                                                                         hemorrhage w MCC.
021................  No................  No................     01  SURG..............  Intracranial vascular           6.3534         13.7         15.4
                                                                                         procedures w PDX
                                                                                         hemorrhage w CC.
022................  No................  No................     01  SURG..............  Intracranial vascular           4.2072          7.6          9.4
                                                                                         procedures w PDX
                                                                                         hemorrhage w/o CC/MCC.
023................  No................  No................     01  SURG..............  Cranio w major dev impl/        5.0763          8.9         12.7
                                                                                         acute complex CNS PDX w
                                                                                         MCC or chemo implant.
024................  No................  No................     01  SURG..............  Cranio w major dev impl/        3.4757          6.3          9.0
                                                                                         acute complex CNS PDX w/
                                                                                         o MCC.
025................  Yes...............  No................     01  SURG..............  Craniotomy & endovascular       5.0324          9.9         13.0
                                                                                         intracranial procedures
                                                                                         w MCC.
026................  Yes...............  No................     01  SURG..............  Craniotomy & endovascular       3.0107          6.5          8.2
                                                                                         intracranial procedures
                                                                                         w CC.
027................  Yes...............  No................     01  SURG..............  Craniotomy & endovascular       2.1083          3.5          4.5
                                                                                         intracranial procedures
                                                                                         w/o CC/MCC.
028................  Yes...............  Yes...............     01  SURG..............  Spinal procedures w MCC..       5.1853         10.7         14.3
029................  Yes...............  Yes...............     01  SURG..............  Spinal procedures w CC or       2.7949          5.1          7.1
                                                                                         spinal neurostimulators.
030................  Yes...............  Yes...............     01  SURG..............  Spinal procedures w/o CC/       1.5395          2.8          3.7
                                                                                         MCC.
031................  Yes...............  No................     01  SURG..............  Ventricular shunt               4.3899          9.4         13.1
                                                                                         procedures w MCC.
032................  Yes...............  No................     01  SURG..............  Ventricular shunt               1.9471          4.0          6.0
                                                                                         procedures w CC.
033................  Yes...............  No................     01  SURG..............  Ventricular shunt               1.3334          2.3          3.0
                                                                                         procedures w/o CC/MCC.
034................  No................  No................     01  SURG..............  Carotid artery stent            3.2182          4.6          7.2
                                                                                         procedure w MCC.
035................  No................  No................     01  SURG..............  Carotid artery stent            2.0258          2.1          3.3
                                                                                         procedure w CC.
036................  No................  No................     01  SURG..............  Carotid artery stent            1.5706          1.3          1.6
                                                                                         procedure w/o CC/MCC.
037................  No................  No................     01  SURG..............  Extracranial procedures w       3.0208          5.9          8.5
                                                                                         MCC.
038................  No................  No................     01  SURG..............  Extracranial procedures w       1.5585          2.5          3.8
                                                                                         CC.
039................  No................  No................     01  SURG..............  Extracranial procedures w/      1.0057          1.5          1.8
                                                                                         o CC/MCC.
040................  Yes...............  Yes...............     01  SURG..............  Periph/cranial nerve &          3.9691          9.7         13.3
                                                                                         other nerv syst proc w
                                                                                         MCC.
041................  Yes...............  Yes...............     01  SURG..............  Periph/cranial nerve &          2.1517          5.3          7.2
                                                                                         other nerv syst proc w
                                                                                         CC or periph neurostim.
042................  Yes...............  Yes...............     01  SURG..............  Periph/cranial nerve &          1.6771          2.5          3.6
                                                                                         other nerv syst proc w/o
                                                                                         CC/MCC.
052................  No................  No................     01  MED...............  Spinal disorders &              1.6271          4.9          6.7
                                                                                         injuries w CC/MCC.
053................  No................  No................     01  MED...............  Spinal disorders &              0.8617          3.2          4.0
                                                                                         injuries w/o CC/MCC.
054................  Yes...............  No................     01  MED...............  Nervous system neoplasms        1.5844          5.2          7.0
                                                                                         w MCC.
055................  Yes...............  No................     01  MED...............  Nervous system neoplasms        1.0781          3.8          5.1
                                                                                         w/o MCC.
056................  Yes...............  No................     01  MED...............  Degenerative nervous            1.6311          5.7          7.8
                                                                                         system disorders w MCC.
057................  Yes...............  No................     01  MED...............  Degenerative nervous            0.8755          3.9          5.0
                                                                                         system disorders w/o MCC.

[[Page 23821]]

 
058................  No................  No................     01  MED...............  Multiple sclerosis &            1.5373          5.7          7.6
                                                                                         cerebellar ataxia w MCC.
059................  No................  No................     01  MED...............  Multiple sclerosis &            0.9404          4.2          5.1
                                                                                         cerebellar ataxia w CC.
060................  No................  No................     01  MED...............  Multiple sclerosis &            0.6978          3.4          4.0
                                                                                         cerebellar ataxia w/o CC/
                                                                                         MCC.
061................  No................  No................     01  MED...............  Acute ischemic stroke w         2.8759          6.8          8.9
                                                                                         use of thrombolytic
                                                                                         agent w MCC.
062................  No................  No................     01  MED...............  Acute ischemic stroke w         1.9505          5.3          6.3
                                                                                         use of thrombolytic
                                                                                         agent w CC.
063................  No................  No................     01  MED...............  Acute ischemic stroke w         1.5168          3.9          4.5
                                                                                         use of thrombolytic
                                                                                         agent w/o CC/MCC.
064................  Yes...............  No................     01  MED...............  Intracranial hemorrhage         1.8446          5.5          7.5
                                                                                         or cerebral infarction w
                                                                                         MCC.
065................  Yes...............  No................     01  MED...............  Intracranial hemorrhage         1.1748          4.3          5.2
                                                                                         or cerebral infarction w
                                                                                         CC.
066................  Yes...............  No................     01  MED...............  Intracranial hemorrhage         0.8426          3.1          3.7
                                                                                         or cerebral infarction w/
                                                                                         o CC/MCC.
067................  No................  No................     01  MED...............  Nonspecific cva &               1.3899          4.4          5.8
                                                                                         precerebral occlusion w/
                                                                                         o infarct w MCC.
068................  No................  No................     01  MED...............  Nonspecific cva &               0.8449          2.7          3.4
                                                                                         precerebral occlusion w/
                                                                                         o infarct w/o MCC.
069................  No................  No................     01  MED...............  Transient ischemia.......       0.7143          2.4          3.0
070................  Yes...............  No................     01  MED...............  Nonspecific                     1.8241          6.0          7.9
                                                                                         cerebrovascular
                                                                                         disorders w MCC.
071................  Yes...............  No................     01  MED...............  Nonspecific                     1.1307          4.4          5.6
                                                                                         cerebrovascular
                                                                                         disorders w CC.
072................  Yes...............  No................     01  MED...............  Nonspecific                     0.7629          2.8          3.5
                                                                                         cerebrovascular
                                                                                         disorders w/o CC/MCC.
073................  No................  No................     01  MED...............  Cranial & peripheral            1.3037          4.7          6.2
                                                                                         nerve disorders w MCC.
074................  No................  No................     01  MED...............  Cranial & peripheral            0.8406          3.4          4.3
                                                                                         nerve disorders w/o MCC.
075................  No................  No................     01  MED...............  Viral meningitis w CC/MCC       1.6738          5.7          7.3
076................  No................  No................     01  MED...............  Viral meningitis w/o CC/        0.8544          3.4          4.1
                                                                                         MCC.
077................  No................  No................     01  MED...............  Hypertensive                    1.6225          5.2          6.7
                                                                                         encephalopathy w MCC.
078................  No................  No................     01  MED...............  Hypertensive                    1.0050          3.6          4.4
                                                                                         encephalopathy w CC.
079................  No................  No................     01  MED...............  Hypertensive                    0.7377          2.8          3.4
                                                                                         encephalopathy w/o CC/
                                                                                         MCC.
080................  No................  No................     01  MED...............  Nontraumatic stupor &           1.1007          3.8          5.1
                                                                                         coma w MCC.
081................  No................  No................     01  MED...............  Nontraumatic stupor &           0.7094          2.7          3.5
                                                                                         coma w/o MCC.
082................  No................  No................     01  MED...............  Traumatic stupor & coma,        2.0177          3.7          6.4
                                                                                         coma >1 hr w MCC.
083................  No................  No................     01  MED...............  Traumatic stupor & coma,        1.3027          3.7          5.0
                                                                                         coma >1 hr w CC.
084................  No................  No................     01  MED...............  Traumatic stupor & coma,        0.8720          2.4          3.1
                                                                                         coma >1 hr w/o CC/MCC.
085................  Yes...............  No................     01  MED...............  Traumatic stupor & coma,        2.0942          5.5          7.6
                                                                                         coma <1 hr w MCC.
086................  Yes...............  No................     01  MED...............  Traumatic stupor & coma,        1.2049          3.9          5.0
                                                                                         coma <1 hr w CC.
087................  Yes...............  No................     01  MED...............  Traumatic stupor & coma,        0.8008          2.6          3.3
                                                                                         coma <1 hr w/o CC/MCC.
088................  No................  No................     01  MED...............  Concussion w MCC.........       1.5774          4.2          5.9
089................  No................  No................     01  MED...............  Concussion w CC..........       0.9162          3.0          3.8
090................  No................  No................     01  MED...............  Concussion w/o CC/MCC....       0.6736          2.0          2.5
091................  Yes...............  No................     01  MED...............  Other disorders of              1.5641          4.6          6.4
                                                                                         nervous system w MCC.
092................  Yes...............  No................     01  MED...............  Other disorders of              0.9195          3.5          4.5
                                                                                         nervous system w CC.
093................  Yes...............  No................     01  MED...............  Other disorders of              0.6753          2.6          3.2
                                                                                         nervous system w/o CC/
                                                                                         MCC.
094................  No................  No................     01  MED...............  Bacterial & tuberculous         3.3477          9.2         11.9
                                                                                         infections of nervous
                                                                                         system w MCC.
095................  No................  No................     01  MED...............  Bacterial & tuberculous         2.1934          6.9          8.6
                                                                                         infections of nervous
                                                                                         system w CC.

[[Page 23822]]

 
096................  No................  No................     01  MED...............  Bacterial & tuberculous         1.8297          5.0          6.2
                                                                                         infections of nervous
                                                                                         system w/o CC/MCC.
097................  No................  No................     01  MED...............  Non-bacterial infect of         3.2101          9.9         12.6
                                                                                         nervous sys exc viral
                                                                                         meningitis w MCC.
098................  No................  No................     01  MED...............  Non-bacterial infect of         1.8564          6.8          8.4
                                                                                         nervous sys exc viral
                                                                                         meningitis w CC.
099................  No................  No................     01  MED...............  Non-bacterial infect of         1.2533          4.6          5.9
                                                                                         nervous sys exc viral
                                                                                         meningitis w/o CC/MCC.
100................  Yes...............  No................     01  MED...............  Seizures w MCC...........       1.5064          4.7          6.4
101................  Yes...............  No................     01  MED...............  Seizures w/o MCC.........       0.7594          2.9          3.7
102................  No................  No................     01  MED...............  Headaches w MCC..........       0.9594          3.3          4.5
103................  No................  No................     01  MED...............  Headaches w/o MCC........       0.6224          2.5          3.1
113................  No................  No................     02  SURG..............  Orbital procedures w CC/        1.5656          3.8          5.6
                                                                                         MCC.
114................  No................  No................     02  SURG..............  Orbital procedures w/o CC/      0.8313          1.9          2.6
                                                                                         MCC.
115................  No................  No................     02  SURG..............  Extraocular procedures          1.0625          3.3          4.3
                                                                                         except orbit.
116................  No................  No................     02  SURG..............  Intraocular procedures w        1.1338          2.6          4.1
                                                                                         CC/MCC.
117................  No................  No................     02  SURG..............  Intraocular procedures w/       0.6699          1.6          2.2
                                                                                         o CC/MCC.
121................  No................  No................     02  MED...............  Acute major eye                 0.9556          4.4          5.5
                                                                                         infections w CC/MCC.
122................  No................  No................     02  MED...............  Acute major eye                 0.6127          3.4          4.0
                                                                                         infections w/o CC/MCC.
123................  No................  No................     02  MED...............  Neurological eye                0.6840          2.3          2.9
                                                                                         disorders.
124................  No................  No................     02  MED...............  Other disorders of the          1.0620          3.9          5.3
                                                                                         eye w MCC.
125................  No................  No................     02  MED...............  Other disorders of the          0.6660          2.8          3.5
                                                                                         eye w/o MCC.
129................  No................  No................     03  SURG..............  Major head & neck               2.0147          3.7          5.2
                                                                                         procedures w CC/MCC or
                                                                                         major device.
130................  No................  No................     03  SURG..............  Major head & neck               1.1588          2.4          2.9
                                                                                         procedures w/o CC/MCC.
131................  No................  No................     03  SURG..............  Cranial/facial procedures       1.9768          4.0          5.7
                                                                                         w CC/MCC.
132................  No................  No................     03  SURG..............  Cranial/facial procedures       1.1041          2.1          2.7
                                                                                         w/o CC/MCC.
133................  No................  No................     03  SURG..............  Other ear, nose, mouth &        1.5491          3.6          5.3
                                                                                         throat O.R. procedures w
                                                                                         CC/MCC.
134................  No................  No................     03  SURG..............  Other ear, nose, mouth &        0.8243          1.7          2.2
                                                                                         throat O.R. procedures w/
                                                                                         o CC/MCC.
135................  No................  No................     03  SURG..............  Sinus & mastoid                 1.6842          3.8          5.8
                                                                                         procedures w CC/MCC.
136................  No................  No................     03  SURG..............  Sinus & mastoid                 0.9023          1.7          2.3
                                                                                         procedures w/o CC/MCC.
137................  No................  No................     03  SURG..............  Mouth procedures w CC/MCC       1.2668          3.8          5.4
138................  No................  No................     03  SURG..............  Mouth procedures w/o CC/        0.7368          1.9          2.5
                                                                                         MCC.
139................  No................  No................     03  SURG..............  Salivary gland procedures       0.8176          1.4          1.8
146................  No................  No................     03  MED...............  Ear, nose, mouth & throat       2.0489          6.7          9.4
                                                                                         malignancy w MCC.
147................  No................  No................     03  MED...............  Ear, nose, mouth & throat       1.2486          4.3          6.1
                                                                                         malignancy w CC.
148................  No................  No................     03  MED...............  Ear, nose, mouth & throat       0.8181          2.7          3.8
                                                                                         malignancy w/o CC/MCC.
149................  No................  No................     03  MED...............  Dysequilibrium...........       0.6086          2.2          2.7
150................  No................  No................     03  MED...............  Epistaxis w MCC..........       1.2243          3.7          5.2
151................  No................  No................     03  MED...............  Epistaxis w/o MCC........       0.6018          2.3          2.9
152................  No................  No................     03  MED...............  Otitis media & URI w MCC.       0.8976          3.4          4.5
153................  No................  No................     03  MED...............  Otitis media & URI w/o          0.5948          2.6          3.2
                                                                                         MCC.
154................  No................  No................     03  MED...............  Other ear, nose, mouth &        1.3768          4.6          6.3
                                                                                         throat diagnoses w MCC.
155................  No................  No................     03  MED...............  Other ear, nose, mouth &        0.8779          3.5          4.4
                                                                                         throat diagnoses w CC.
156................  No................  No................     03  MED...............  Other ear, nose, mouth &        0.6306          2.5          3.2
                                                                                         throat diagnoses w/o CC/
                                                                                         MCC.
157................  No................  No................     03  MED...............  Dental & oral diseases w        1.4793          4.7          6.7
                                                                                         MCC.
158................  No................  No................     03  MED...............  Dental & oral diseases w        0.8615          3.4          4.5
                                                                                         CC.
159................  No................  No................     03  MED...............  Dental & oral diseases w/       0.5952          2.4          3.1
                                                                                         o CC/MCC.
163................  Yes...............  No................     04  SURG..............  Major chest procedures w        4.9951         12.2         14.9
                                                                                         MCC.
164................  Yes...............  No................     04  SURG..............  Major chest procedures w        2.5982          6.7          8.1
                                                                                         CC.
165................  Yes...............  No................     04  SURG..............  Major chest procedures w/       1.8086          4.3          5.1
                                                                                         o CC/MCC.
166................  Yes...............  No................     04  SURG..............  Other resp system O.R.          3.6865         10.0         12.9
                                                                                         procedures w MCC.

[[Page 23823]]

 
167................  Yes...............  No................     04  SURG..............  Other resp system O.R.          2.0256          6.3          8.0
                                                                                         procedures w CC.
168................  Yes...............  No................     04  SURG..............  Other resp system O.R.          1.3443          3.9          5.3
                                                                                         procedures w/o CC/MCC.
175................  Yes...............  No................     04  MED...............  Pulmonary embolism w MCC.       1.5777          6.0          7.3
176................  Yes...............  No................     04  MED...............  Pulmonary embolism w/o          1.0696          4.6          5.3
                                                                                         MCC.
177................  Yes...............  No................     04  MED...............  Respiratory infections &        2.0391          7.2          9.1
                                                                                         inflammations w MCC.
178................  Yes...............  No................     04  MED...............  Respiratory infections &        1.4979          6.0          7.4
                                                                                         inflammations w CC.
179................  Yes...............  No................     04  MED...............  Respiratory infections &        1.0409          4.6          5.6
                                                                                         inflammations w/o CC/MCC.
180................  No................  No................     04  MED...............  Respiratory neoplasms w         1.6938          6.0          7.9
                                                                                         MCC.
181................  No................  No................     04  MED...............  Respiratory neoplasms w         1.2293          4.5          5.9
                                                                                         CC.
182................  No................  No................     04  MED...............  Respiratory neoplasms w/o       0.8712          3.2          4.2
                                                                                         CC/MCC.
183................  No................  No................     04  MED...............  Major chest trauma w MCC.       1.5304          5.8          7.2
184................  No................  No................     04  MED...............  Major chest trauma w CC..       0.9405          3.8          4.6
185................  No................  No................     04  MED...............  Major chest trauma w/o CC/      0.6755          2.9          3.4
                                                                                         MCC.
186................  Yes...............  No................     04  MED...............  Pleural effusion w MCC...       1.6200          5.7          7.4
187................  Yes...............  No................     04  MED...............  Pleural effusion w CC....       1.0940          4.1          5.3
188................  Yes...............  No................     04  MED...............  Pleural effusion w/o CC/        0.8121          3.1          4.0
                                                                                         MCC.
189................  No................  No................     04  MED...............  Pulmonary edema &               1.3473          4.8          6.1
                                                                                         respiratory failure.
190................  Yes...............  No................     04  MED...............  Chronic obstructive             1.3004          5.0          6.3
                                                                                         pulmonary disease w MCC.
191................  Yes...............  No................     04  MED...............  Chronic obstructive             0.9734          4.1          5.0
                                                                                         pulmonary disease w CC.
192................  Yes...............  No................     04  MED...............  Chronic obstructive             0.7239          3.3          4.0
                                                                                         pulmonary disease w/o CC/
                                                                                         MCC.
193................  Yes...............  No................     04  MED...............  Simple pneumonia &              1.4303          5.4          6.8
                                                                                         pleurisy w MCC.
194................  Yes...............  No................     04  MED...............  Simple pneumonia &              1.0041          4.4          5.3
                                                                                         pleurisy w CC.
195................  Yes...............  No................     04  MED...............  Simple pneumonia &              0.7301          3.5          4.1
                                                                                         pleurisy w/o CC/MCC.
196................  Yes...............  No................     04  MED...............  Interstitial lung disease       1.6006          5.9          7.4
                                                                                         w MCC.
197................  Yes...............  No................     04  MED...............  Interstitial lung disease       1.0973          4.4          5.4
                                                                                         w CC.
198................  Yes...............  No................     04  MED...............  Interstitial lung disease       0.8158          3.3          4.1
                                                                                         w/o CC/MCC.
199................  No................  No................     04  MED...............  Pneumothorax w MCC.......       1.7383          6.4          8.3
200................  No................  No................     04  MED...............  Pneumothorax w CC........       1.0118          3.9          5.1
201................  No................  No................     04  MED...............  Pneumothorax w/o CC/MCC..       0.7399          3.1          4.1
202................  No................  No................     04  MED...............  Bronchitis & asthma w CC/       0.8135          3.5          4.4
                                                                                         MCC.
203................  No................  No................     04  MED...............  Bronchitis & asthma w/o         0.5938          2.8          3.4
                                                                                         CC/MCC.
204................  No................  No................     04  MED...............  Respiratory signs &             0.6533          2.2          2.9
                                                                                         symptoms.
205................  Yes...............  No................     04  MED...............  Other respiratory system        1.2427          4.0          5.5
                                                                                         diagnoses w MCC.
206................  Yes...............  No................     04  MED...............  Other respiratory system        0.7266          2.7          3.4
                                                                                         diagnoses w/o MCC.
207................  Yes...............  No................     04  MED...............  Respiratory system              5.1153         12.8         15.1
                                                                                         diagnosis w ventilator
                                                                                         support 96+ hours.
208................  No................  No................     04  MED...............  Respiratory system              2.1827          5.2          7.2
                                                                                         diagnosis w ventilator
                                                                                         support <96 hours.
215................  No................  No................     05  SURG..............  Other heart assist system      12.3351          7.8         14.2
                                                                                         implant.
216................  Yes...............  No................     05  SURG..............  Cardiac valve & oth maj        1..1072         15.7         18.4
                                                                                         cardiothoracic proc w
                                                                                         card cath w MCC.
217................  Yes...............  No................     05  SURG..............  Cardiac valve & oth maj         7.0028         10.9         12.3
                                                                                         cardiothoracic proc w
                                                                                         card cath w CC.
218................  Yes...............  No................     05  SURG..............  Cardiac valve & oth maj         5.4355          8.4          9.1
                                                                                         cardiothoracic proc w
                                                                                         card cath w/o CC/MCC.
219................  Yes...............  Yes...............     05  SURG..............  Cardiac valve & oth maj         8.0764         11.5         14.0
                                                                                         cardiothoracic proc w/o
                                                                                         card cath w MCC.
220................  Yes...............  Yes...............     05  SURG..............  Cardiac valve & oth maj         5.3066          7.7          8.6
                                                                                         cardiothoracic proc w/o
                                                                                         card cath w CC.

[[Page 23824]]

 
221................  Yes...............  Yes...............     05  SURG..............  Cardiac valve & oth maj         4.4089          6.0          6.4
                                                                                         cardiothoracic proc w/o
                                                                                         card cath w/o CC/MCC.
222................  No................  No................     05  SURG..............  Cardiac defib implant w         8.6586         10.7         13.1
                                                                                         cardiac cath w AMI/HF/
                                                                                         shock w MCC.
223................  No................  No................     05  SURG..............  Cardiac defib implant w         6.3035          4.6          6.3
                                                                                         cardiac cath w AMI/HF/
                                                                                         shock w/o MCC.
224................  No................  No................     05  SURG..............  Cardiac defib implant w         7.9767          9.2         11.4
                                                                                         cardiac cath w/o AMI/HF/
                                                                                         shock w MCC.
225................  No................  No................     05  SURG..............  Cardiac defib implant w         5.9123          4.5          5.6
                                                                                         cardiac cath w/o AMI/HF/
                                                                                         shock w/o MCC.
226................  No................  No................     05  SURG..............  Cardiac defibrillator           6.7278          6.2          9.3
                                                                                         implant w/o cardiac cath
                                                                                         w MCC.
227................  No................  No................     05  SURG..............  Cardiac defibrillator           5.0145          1.8          2.8
                                                                                         implant w/o cardiac cath
                                                                                         w/o MCC.
228................  Yes...............  No................     05  SURG..............  Other cardiothoracic            7.8191         12.1         14.7
                                                                                         procedures w MCC.
229................  Yes...............  No................     05  SURG..............  Other cardiothoracic            5.0358          7.9          9.1
                                                                                         procedures w CC.
230................  Yes...............  No................     05  SURG..............  Other cardiothoracic            4.0677          5.6          6.5
                                                                                         procedures w/o CC/MCC.
231................  No................  No................     05  SURG..............  Coronary bypass w PTCA w        7.6801         11.2         13.3
                                                                                         MCC.
232................  No................  No................     05  SURG..............  Coronary bypass w PTCA w/       5.5460          8.3          9.2
                                                                                         o MCC.
233................  Yes...............  No................     05  SURG..............  Coronary bypass w cardiac       7.0378         12.4         14.2
                                                                                         cath w MCC.
234................  Yes...............  No................     05  SURG..............  Coronary bypass w cardiac       4.6193          8.3          8.9
                                                                                         cath w/o MCC.
235................  Yes...............  No................     05  SURG..............  Coronary bypass w/o             5.6992          9.5         11.2
                                                                                         cardiac cath w MCC.
236................  Yes...............  No................     05  SURG..............  Coronary bypass w/o             3.6122          6.1          6.6
                                                                                         cardiac cath w/o MCC.
237................  No................  No................     05  SURG..............  Major cardiovasc                5.0881          7.5         10.8
                                                                                         procedures w MCC or
                                                                                         thoracic aortic aneurysm
                                                                                         repair.
238................  No................  No................     05  SURG..............  Major cardiovasc                2.8962          3.2          4.6
                                                                                         procedures w/o MCC.
239................  Yes...............  No................     05  SURG..............  Amputation for circ sys         4.4798         12.0         15.3
                                                                                         disorders exc upper limb
                                                                                         & toe w MCC.
240................  Yes...............  No................     05  SURG..............  Amputation for circ sys         2.6706          8.3         10.4
                                                                                         disorders exc upper limb
                                                                                         & toe w CC.
241................  Yes...............  No................     05  SURG..............  Amputation for circ sys         1.5740          5.6          6.8
                                                                                         disorders exc upper limb
                                                                                         & toe w/o CC/MCC.
242................  Yes...............  No................     05  SURG..............  Permanent cardiac               3.7041          6.7          8.8
                                                                                         pacemaker implant w MCC.
243................  Yes...............  No................     05  SURG..............  Permanent cardiac               2.5934          3.8          5.1
                                                                                         pacemaker implant w CC.
244................  Yes...............  No................     05  SURG..............  Permanent cardiac               2.0098          2.2          2.9
                                                                                         pacemaker implant w/o CC/
                                                                                         MCC.
245................  No................  No................     05  SURG..............  AICD generator procedures       4.0022          2.1          3.2
246................  No................  No................     05  SURG..............  Perc cardiovasc proc w          3.1498          3.6          5.3
                                                                                         drug-eluting stent w MCC
                                                                                         or 4+ vessels/stents.
247................  No................  No................     05  SURG..............  Perc cardiovasc proc w          1.9134          1.7          2.2
                                                                                         drug-eluting stent w/o
                                                                                         MCC.
248................  No................  No................     05  SURG..............  Perc cardiovasc proc w          2.8065          4.2          6.0
                                                                                         non-drug-eluting stent w
                                                                                         MCC or 4+ ves/stents.
249................  No................  No................     05  SURG..............  Perc cardiovasc proc w          1.6397          1.9          2.5
                                                                                         non-drug-eluting stent w/
                                                                                         o MCC.
250................  No................  No................     05  SURG..............  Perc cardiovasc proc w/o        2.9923          5.4          7.8
                                                                                         coronary artery stent w
                                                                                         MCC.
251................  No................  No................     05  SURG..............  Perc cardiovasc proc w/o        1.6023          2.1          2.8
                                                                                         coronary artery stent w/
                                                                                         o MCC.
252................  No................  No................     05  SURG..............  Other vascular procedures       2.9526          5.5          8.5
                                                                                         w MCC.
253................  No................  No................     05  SURG..............  Other vascular procedures       2.2593          4.2          6.0
                                                                                         w CC.
254................  No................  No................     05  SURG..............  Other vascular procedures       1.5485          2.0          2.7
                                                                                         w/o CC/MCC.
255................  Yes...............  No................     05  SURG..............  Upper limb & toe                2.4040          7.1          9.7
                                                                                         amputation for circ
                                                                                         system disorders w MCC.

[[Page 23825]]

 
256................  Yes...............  No................     05  SURG..............  Upper limb & toe                1.5895          5.8          7.5
                                                                                         amputation for circ
                                                                                         system disorders w CC.
257................  Yes...............  No................     05  SURG..............  Upper limb & toe                1.0216          3.6          4.8
                                                                                         amputation for circ
                                                                                         system disorders w/o CC/
                                                                                         MCC.
258................  No................  No................     05  SURG..............  Cardiac pacemaker device        2.8434          5.4          7.4
                                                                                         replacement w MCC.
259................  No................  No................     05  SURG..............  Cardiac pacemaker device        1.6944          2.0          2.8
                                                                                         replacement w/o MCC.
260................  No................  No................     05  SURG..............  Cardiac pacemaker               3.4221          8.1         11.2
                                                                                         revision except device
                                                                                         replacement w MCC.
261................  No................  No................     05  SURG..............  Cardiac pacemaker               1.4398          3.0          4.2
                                                                                         revision except device
                                                                                         replacement w CC.
262................  No................  No................     05  SURG..............  Cardiac pacemaker               1.0173          2.0          2.6
                                                                                         revision except device
                                                                                         replacement w/o CC/MCC.
263................  No................  No................     05  SURG..............  Vein ligation & stripping       1.5392          3.4          5.4
264................  Yes...............  No................     05  SURG..............  Other circulatory system        2.5265          5.8          8.9
                                                                                         O.R. procedures.
265................  No................  No................     05  SURG..............  AICD lead procedures.....       2.2140          2.2          3.5
280................  Yes...............  No................     05  MED...............  Acute myocardial                1.9395          5.8          7.3
                                                                                         infarction, discharged
                                                                                         alive w MCC.
281................  Yes...............  No................     05  MED...............  Acute myocardial                1.2210          3.9          4.8
                                                                                         infarction, discharged
                                                                                         alive w CC.
282................  Yes...............  No................     05  MED...............  Acute myocardial                0.8698          2.6          3.2
                                                                                         infarction, discharged
                                                                                         alive w/o CC/MCC.
283................  No................  No................     05  MED...............  Acute myocardial                1.6979          3.4          5.5
                                                                                         infarction, expired w
                                                                                         MCC.
284................  No................  No................     05  MED...............  Acute myocardial                0.9130          2.2          3.2
                                                                                         infarction, expired w CC.
285................  No................  No................     05  MED...............  Acute myocardial                0.6059          1.7          2.2
                                                                                         infarction, expired w/o
                                                                                         CC/MCC.
286................  No................  No................     05  MED...............  Circulatory disorders           1.9745          5.2          6.9
                                                                                         except AMI, w card cath
                                                                                         w MCC.
287................  No................  No................     05  MED...............  Circulatory disorders           1.0225          2.4          3.1
                                                                                         except AMI, w card cath
                                                                                         w/o MCC.
288................  Yes...............  No................     05  MED...............  Acute & subacute                3.0720          9.2         11.8
                                                                                         endocarditis w MCC.
289................  Yes...............  No................     05  MED...............  Acute & subacute                1.9524          7.0          8.7
                                                                                         endocarditis w CC.
290................  Yes...............  No................     05  MED...............  Acute & subacute                1.4507          5.2          6.5
                                                                                         endocarditis w/o CC/MCC.
291................  Yes...............  No................     05  MED...............  Heart failure & shock w         1.4576          5.0          6.5
                                                                                         MCC.
292................  Yes...............  No................     05  MED...............  Heart failure & shock w         1.0053          4.1          5.0
                                                                                         CC.
293................  Yes...............  No................     05  MED...............  Heart failure & shock w/o       0.7205          3.1          3.7
                                                                                         CC/MCC.
294................  No................  No................     05  MED...............  Deep vein                       0.9564          4.6          5.5
                                                                                         thrombophlebitis w CC/
                                                                                         MCC.
295................  No................  No................     05  MED...............  Deep vein                       0.6347          3.7          4.3
                                                                                         thrombophlebitis w/o CC/
                                                                                         MCC.
296................  No................  No................     05  MED...............  Cardiac arrest,                 1.1910          1.9          3.0
                                                                                         unexplained w MCC.
297................  No................  No................     05  MED...............  Cardiac arrest,                 0.6502          1.4          1.8
                                                                                         unexplained w CC.
298................  No................  No................     05  MED...............  Cardiac arrest,                 0.4438          1.1          1.3
                                                                                         unexplained w/o CC/MCC.
299................  Yes...............  No................     05  MED...............  Peripheral vascular             1.4326          5.0          6.7
                                                                                         disorders w MCC.
300................  Yes...............  No................     05  MED...............  Peripheral vascular             0.9245          4.1          5.0
                                                                                         disorders w CC.
301................  Yes...............  No................     05  MED...............  Peripheral vascular             0.6580          3.0          3.7
                                                                                         disorders w/o CC/MCC.
302................  No................  No................     05  MED...............  Atherosclerosis w MCC....       1.0307          3.2          4.4
303................  No................  No................     05  MED...............  Atherosclerosis w/o MCC..       0.5666          2.0          2.5
304................  No................  No................     05  MED...............  Hypertension w MCC.......       1.0808          3.9          5.2
305................  No................  No................     05  MED...............  Hypertension w/o MCC.....       0.5900          2.3          2.9
306................  No................  No................     05  MED...............  Cardiac congenital &            1.5655          4.4          6.3
                                                                                         valvular disorders w MCC.
307................  No................  No................     05  MED...............  Cardiac congenital &            0.7476          2.7          3.4
                                                                                         valvular disorders w/o
                                                                                         MCC.
308................  No................  No................     05  MED...............  Cardiac arrhythmia &            1.2981          4.1          5.5
                                                                                         conduction disorders w
                                                                                         MCC.
309................  No................  No................     05  MED...............  Cardiac arrhythmia &            0.8320          3.1          3.9
                                                                                         conduction disorders w
                                                                                         CC.

[[Page 23826]]

 
310................  No................  No................     05  MED...............  Cardiac arrhythmia &            0.5829          2.3          2.8
                                                                                         conduction disorders w/o
                                                                                         CC/MCC.
311................  No................  No................     05  MED...............  Angina pectoris..........       0.4969          1.9          2.3
312................  No................  No................     05  MED...............  Syncope & collapse.......       0.7082          2.5          3.1
313................  No................  No................     05  MED...............  Chest pain...............       0.5312          1.7          2.1
314................  Yes...............  No................     05  MED...............  Other circulatory system        1.7517          5.0          7.0
                                                                                         diagnoses w MCC.
315................  Yes...............  No................     05  MED...............  Other circulatory system        0.9922          3.5          4.6
                                                                                         diagnoses w CC.
316................  Yes...............  No................     05  MED...............  Other circulatory system        0.6513          2.4          3.0
                                                                                         diagnoses w/o CC/MCC.
326................  Yes...............  No................     06  SURG..............  Stomach, esophageal &           5.8025         13.2         17.1
                                                                                         duodenal proc w MCC.
327................  Yes...............  No................     06  SURG..............  Stomach, esophageal &           2.8389          7.8         10.1
                                                                                         duodenal proc w CC.
328................  Yes...............  No................     06  SURG..............  Stomach, esophageal &           1.4576          3.2          4.4
                                                                                         duodenal proc w/o CC/MCC.
329................  Yes...............  No................     06  SURG..............  Major small & large bowel       5.1793         12.8         16.0
                                                                                         procedures w MCC.
330................  Yes...............  No................     06  SURG..............  Major small & large bowel       2.5644          8.3          9.7
                                                                                         procedures w CC.
331................  Yes...............  No................     06  SURG..............  Major small & large bowel       1.6250          5.2          5.9
                                                                                         procedures w/o CC/MCC.
332................  Yes...............  No................     06  SURG..............  Rectal resection w MCC...       4.5358         12.0         14.3
333................  Yes...............  No................     06  SURG..............  Rectal resection w CC....       2.4487          7.7          8.8
334................  Yes...............  No................     06  SURG..............  Rectal resection w/o CC/        1.6247          4.7          5.5
                                                                                         MCC.
335................  Yes...............  No................     06  SURG..............  Peritoneal adhesiolysis w       4.0903         11.6         14.1
                                                                                         MCC.
336................  Yes...............  No................     06  SURG..............  Peritoneal adhesiolysis w       2.2387          7.5          9.1
                                                                                         CC.
337................  Yes...............  No................     06  SURG..............  Peritoneal adhesiolysis w/      1.4519          4.4          5.6
                                                                                         o CC/MCC.
338................  No................  No................     06  SURG..............  Appendectomy w                  3.1787          8.8         10.7
                                                                                         complicated principal
                                                                                         diag w MCC.
339................  No................  No................     06  SURG..............  Appendectomy w                  1.8625          6.0          7.0
                                                                                         complicated principal
                                                                                         diag w CC.
340................  No................  No................     06  SURG..............  Appendectomy w                  1.2267          3.5          4.2
                                                                                         complicated principal
                                                                                         diag w/o CC/MCC.
341................  No................  No................     06  SURG..............  Appendectomy w/o                2.1659          5.3          7.1
                                                                                         complicated principal
                                                                                         diag w MCC.
342................  No................  No................     06  SURG..............  Appendectomy w/o                1.3154          3.2          4.1
                                                                                         complicated principal
                                                                                         diag w CC.
343................  No................  No................     06  SURG..............  Appendectomy w/o                0.9067          1.8          2.2
                                                                                         complicated principal
                                                                                         diag w/o CC/MCC.
344................  No................  No................     06  SURG..............  Minor small & large bowel       3.0822          9.2         11.8
                                                                                         procedures w MCC.
345................  No................  No................     06  SURG..............  Minor small & large bowel       1.6391          6.2          7.2
                                                                                         procedures w CC.
346................  No................  No................     06  SURG..............  Minor small & large bowel       1.1869          4.4          4.9
                                                                                         procedures w/o CC/MCC.
347................  No................  No................     06  SURG..............  Anal & stomal procedures        2.1823          6.4          8.8
                                                                                         w MCC.
348................  No................  No................     06  SURG..............  Anal & stomal procedures        1.2860          4.4          5.7
                                                                                         w CC.
349................  No................  No................     06  SURG..............  Anal & stomal procedures        0.7681          2.4          3.1
                                                                                         w/o CC/MCC.
350................  No................  No................     06  SURG..............  Inguinal & femoral hernia       2.2486          5.8          8.0
                                                                                         procedures w MCC.
351................  No................  No................     06  SURG..............  Inguinal & femoral hernia       1.2638          3.4          4.6
                                                                                         procedures w CC.
352................  No................  No................     06  SURG..............  Inguinal & femoral hernia       0.8131          2.0          2.5
                                                                                         procedures w/o CC/MCC.
353................  No................  No................     06  SURG..............  Hernia procedures except        2.4935          6.4          8.4
                                                                                         inguinal & femoral w MCC.
354................  No................  No................     06  SURG..............  Hernia procedures except        1.4046          4.0          5.1
                                                                                         inguinal & femoral w CC.
355................  No................  No................     06  SURG..............  Hernia procedures except        0.9675          2.4          2.9
                                                                                         inguinal & femoral w/o
                                                                                         CC/MCC.
356................  Yes...............  No................     06  SURG..............  Other digestive system          3.8574          9.5         12.9
                                                                                         O.R. procedures w MCC.
357................  Yes...............  No................     06  SURG..............  Other digestive system          2.1703          6.2          8.1
                                                                                         O.R. procedures w CC.

[[Page 23827]]

 
358................  Yes...............  No................     06  SURG..............  Other digestive system          1.3493          3.3          4.5
                                                                                         O.R. procedures w/o CC/
                                                                                         MCC.
368................  No................  No................     06  MED...............  Major esophageal                1.6184          5.1          6.6
                                                                                         disorders w MCC.
369................  No................  No................     06  MED...............  Major esophageal                1.0703          3.8          4.7
                                                                                         disorders w CC.
370................  No................  No................     06  MED...............  Major esophageal                0.7835          2.8          3.4
                                                                                         disorders w/o CC/MCC.
371................  Yes...............  No................     06  MED...............  Major gastrointestinal          1.9062          6.7          8.7
                                                                                         disorders & peritoneal
                                                                                         infections w MCC.
372................  Yes...............  No................     06  MED...............  Major gastrointestinal          1.3025          5.6          6.9
                                                                                         disorders & peritoneal
                                                                                         infections w CC.
373................  Yes...............  No................     06  MED...............  Major gastrointestinal          0.8646          4.2          4.9
                                                                                         disorders & peritoneal
                                                                                         infections w/o CC/MCC.
374................  Yes...............  No................     06  MED...............  Digestive malignancy w          1.9057          6.3          8.6
                                                                                         MCC.
375................  Yes...............  No................     06  MED...............  Digestive malignancy w CC       1.2523          4.6          6.0
376................  Yes...............  No................     06  MED...............  Digestive malignancy w/o        0.8820          3.2          4.2
                                                                                         CC/MCC.
377................  Yes...............  No................     06  MED...............  G.I. hemorrhage w MCC....       1.6069          4.9          6.4
378................  Yes...............  No................     06  MED...............  G.I. hemorrhage w CC.....       1.0048          3.7          4.4
379................  Yes...............  No................     06  MED...............  G.I. hemorrhage w/o CC/         0.7567          2.9          3.4
                                                                                         MCC.
380................  Yes...............  No................     06  MED...............  Complicated peptic ulcer        1.7995          5.6          7.3
                                                                                         w MCC.
381................  Yes...............  No................     06  MED...............  Complicated peptic ulcer        1.1138          4.2          5.2
                                                                                         w CC.
382................  Yes...............  No................     06  MED...............  Complicated peptic ulcer        0.8208          3.1          3.7
                                                                                         w/o CC/MCC.
383................  No................  No................     06  MED...............  Uncomplicated peptic            1.1789          4.4          5.5
                                                                                         ulcer w MCC.
384................  No................  No................     06  MED...............  Uncomplicated peptic            0.7818          3.1          3.7
                                                                                         ulcer w/o MCC.
385................  No................  No................     06  MED...............  Inflammatory bowel              1.8541          6.5          8.8
                                                                                         disease w MCC.
386................  No................  No................     06  MED...............  Inflammatory bowel              1.0601          4.5          5.7
                                                                                         disease w CC.
387................  No................  No................     06  MED...............  Inflammatory bowel              0.7746          3.5          4.3
                                                                                         disease w/o CC/MCC.
388................  Yes...............  No................     06  MED...............  G.I. obstruction w MCC...       1.5392          5.5          7.3
389................  Yes...............  No................     06  MED...............  G.I. obstruction w CC....       0.9244          4.0          5.0
390................  Yes...............  No................     06  MED...............  G.I. obstruction w/o CC/        0.6333          3.0          3.6
                                                                                         MCC.
391................  No................  No................     06  MED...............  Esophagitis, gastroent &        1.0810          3.9          5.2
                                                                                         misc digest disorders w
                                                                                         MCC.
392................  No................  No................     06  MED...............  Esophagitis, gastroent &        0.6685          2.8          3.5
                                                                                         misc digest disorders w/
                                                                                         o MCC.
393................  No................  No................     06  MED...............  Other digestive system          1.5367          4.9          6.9
                                                                                         diagnoses w MCC.
394................  No................  No................     06  MED...............  Other digestive system          0.9489          3.8          4.8
                                                                                         diagnoses w CC.
395................  No................  No................     06  MED...............  Other digestive system          0.6745          2.6          3.3
                                                                                         diagnoses w/o CC/MCC.
405................  Yes...............  No................     07  SURG..............  Pancreas, liver & shunt         5.6481         12.4         17.0
                                                                                         procedures w MCC.
406................  Yes...............  No................     07  SURG..............  Pancreas, liver & shunt         2.7895          7.0          9.2
                                                                                         procedures w CC.
407................  Yes...............  No................     07  SURG..............  Pancreas, liver & shunt         1.8411          4.2          5.5
                                                                                         procedures w/o CC/MCC.
408................  No................  No................     07  SURG..............  Biliary tract proc except       4.2539         12.1         15.0
                                                                                         only cholecyst w or w/o
                                                                                         c.d.e. w MCC.
409................  No................  No................     07  SURG..............  Biliary tract proc except       2.5819          8.3          9.8
                                                                                         only cholecyst w or w/o
                                                                                         c.d.e. w CC.
410................  No................  No................     07  SURG..............  Biliary tract proc except       1.6374          5.4          6.5
                                                                                         only cholecyst w or w/o
                                                                                         c.d.e. w/o CC/MCC.
411................  No................  No................     07  SURG..............  Cholecystectomy w c.d.e.        3.7602         10.4         12.4
                                                                                         w MCC.
412................  No................  No................     07  SURG..............  Cholecystectomy w c.d.e.        2.3633          7.5          8.6
                                                                                         w CC.
413................  No................  No................     07  SURG..............  Cholecystectomy w c.d.e.        1.6896          5.0          5.9
                                                                                         w/o CC/MCC.
414................  Yes...............  No................     07  SURG..............  Cholecystectomy except by       3.5777          9.7         11.7
                                                                                         laparoscope w/o c.d.e. w
                                                                                         MCC.
415................  Yes...............  No................     07  SURG..............  Cholecystectomy except by       2.0372          6.5          7.6
                                                                                         laparoscope w/o c.d.e. w
                                                                                         CC.
416................  Yes...............  No................     07  SURG..............  Cholecystectomy except by       1.3290          4.1          4.8
                                                                                         laparoscope w/o c.d.e. w/
                                                                                         o CC/MCC.
417................  No................  No................     07  SURG..............  Laparoscopic                    2.4851          6.5          8.4
                                                                                         cholecystectomy w/o
                                                                                         c.d.e. w MCC.
418................  No................  No................     07  SURG..............  Laparoscopic                    1.6541          4.5          5.6
                                                                                         cholecystectomy w/o
                                                                                         c.d.e. w CC.

[[Page 23828]]

 
419................  No................  No................     07  SURG..............  Laparoscopic                    1.1296          2.5          3.2
                                                                                         cholecystectomy w/o
                                                                                         c.d.e. w/o CC/MCC.
420................  No................  No................     07  SURG..............  Hepatobiliary diagnostic        4.0976          9.9         13.7
                                                                                         procedures w MCC.
421................  No................  No................     07  SURG..............  Hepatobiliary diagnostic        1.8978          5.6          7.7
                                                                                         procedures w CC.
422................  No................  No................     07  SURG..............  Hepatobiliary diagnostic        1.2275          3.2          4.4
                                                                                         procedures w/o CC/MCC.
423................  No................  No................     07  SURG..............  Other hepatobiliary or          4.5535         11.8         15.9
                                                                                         pancreas O.R. procedures
                                                                                         w MCC.
424................  No................  No................     07  SURG..............  Other hepatobiliary or          2.5159          7.9         10.4
                                                                                         pancreas O.R. procedures
                                                                                         w CC.
425................  No................  No................     07  SURG..............  Other hepatobiliary or          1.3760          4.0          5.4
                                                                                         pancreas O.R. procedures
                                                                                         w/o CC/MCC.
432................  No................  No................     07  MED...............  Cirrhosis & alcoholic           1.6776          5.2          7.0
                                                                                         hepatitis w MCC.
433................  No................  No................     07  MED...............  Cirrhosis & alcoholic           0.9378          3.8          4.9
                                                                                         hepatitis w CC.
434................  No................  No................     07  MED...............  Cirrhosis & alcoholic           0.6551          2.9          3.7
                                                                                         hepatitis w/o CC/MCC.
435................  No................  No................     07  MED...............  Malignancy of                   1.7117          5.7          7.6
                                                                                         hepatobiliary system or
                                                                                         pancreas w MCC.
436................  No................  No................     07  MED...............  Malignancy of                   1.1892          4.5          5.8
                                                                                         hepatobiliary system or
                                                                                         pancreas w CC.
437................  No................  No................     07  MED...............  Malignancy of                   0.9506          3.2          4.3
                                                                                         hepatobiliary system or
                                                                                         pancreas w/o CC/MCC.
438................  No................  No................     07  MED...............  Disorders of pancreas           1.6992          5.5          7.5
                                                                                         except malignancy w MCC.
439................  No................  No................     07  MED...............  Disorders of pancreas           1.0223          4.2          5.3
                                                                                         except malignancy w CC.
440................  No................  No................     07  MED...............  Disorders of pancreas           0.6963          3.2          3.8
                                                                                         except malignancy w/o CC/
                                                                                         MCC.
441................  Yes...............  No................     07  MED...............  Disorders of liver except       1.6580          5.1          7.0
                                                                                         malig, cirr, alc hepa w
                                                                                         MCC.
442................  Yes...............  No................     07  MED...............  Disorders of liver except       0.9825          3.9          5.1
                                                                                         malig, cirr, alc hepa w
                                                                                         CC.
443................  Yes...............  No................     07  MED...............  Disorders of liver except       0.6945          3.0          3.8
                                                                                         malig, cirr, alc hepa w/
                                                                                         o CC/MCC.
444................  No................  No................     07  MED...............  Disorders of the biliary        1.5579          5.0          6.6
                                                                                         tract w MCC.
445................  No................  No................     07  MED...............  Disorders of the biliary        1.0375          3.8          4.7
                                                                                         tract w CC.
446................  No................  No................     07  MED...............  Disorders of the biliary        0.7225          2.6          3.3
                                                                                         tract w/o CC/MCC.
453................  No................  No................     08  SURG..............  Combined anterior/              9.8724         12.0         15.7
                                                                                         posterior spinal fusion
                                                                                         w MCC.
454................  No................  No................     08  SURG..............  Combined anterior/              7.0370          6.5          8.0
                                                                                         posterior spinal fusion
                                                                                         w CC.
455................  No................  No................     08  SURG..............  Combined anterior/              5.1744          3.7          4.4
                                                                                         posterior spinal fusion
                                                                                         w/o CC/MCC.
456................  No................  No................     08  SURG..............  Spinal fus exc cerv w           8.5225         11.6         14.7
                                                                                         spinal curv/malig/infec
                                                                                         or 9+ fus w MCC.
457................  No................  No................     08  SURG..............  Spinal fus exc cerv w           5.6672          6.2          7.5
                                                                                         spinal curv/malig/infec
                                                                                         or 9+ fus w CC.
458................  No................  No................     08  SURG..............  Spinal fus exc cerv w           4.7056          4.0          4.5
                                                                                         spinal curv/malig/infec
                                                                                         or 9+ fus w/o CC/MCC.
459................  Yes...............  No................     08  SURG..............  Spinal fusion except            5.9847          7.6          9.4
                                                                                         cervical w MCC.
460................  Yes...............  No................     08  SURG..............  Spinal fusion except            3.5746          3.6          4.2
                                                                                         cervical w/o MCC.
461................  No................  No................     08  SURG..............  Bilateral or multiple           4.5636          6.8          8.4
                                                                                         major joint procs of
                                                                                         lower extremity w MCC.
462................  No................  No................     08  SURG..............  Bilateral or multiple           3.1564          3.9          4.2
                                                                                         major joint procs of
                                                                                         lower extremity w/o MCC.
463................  Yes...............  No................     08  SURG..............  Wnd debrid & skn grft exc       4.6669         12.0         16.6
                                                                                         hand, for musculo-conn
                                                                                         tiss dis w MCC.
464................  Yes...............  No................     08  SURG..............  Wnd debrid & skn grft exc       2.6117          7.7         10.2
                                                                                         hand, for musculo-conn
                                                                                         tiss dis w CC.
465................  Yes...............  No................     08  SURG..............  Wnd debrid & skn grft exc       1.4955          4.4          5.9
                                                                                         hand, for musculo-conn
                                                                                         tiss dis w/o CC/MCC.
466................  Yes...............  No................     08  SURG..............  Revision of hip or knee         4.5564          7.4          9.2
                                                                                         replacement w MCC.

[[Page 23829]]

 
467................  Yes...............  No................     08  SURG..............  Revision of hip or knee         3.0720          4.8          5.5
                                                                                         replacement w CC.
468................  Yes...............  No................     08  SURG..............  Revision of hip or knee         2.4597          3.6          3.9
                                                                                         replacement w/o CC/MCC.
469................  Yes...............  No................     08  SURG..............  Major joint replacement         3.2979          6.9          8.2
                                                                                         or reattachment of lower
                                                                                         extremity w MCC.
470................  Yes...............  No................     08  SURG..............  Major joint replacement         2.0144          3.6          3.9
                                                                                         or reattachment of lower
                                                                                         extremity w/o MCC.
471................  No................  No................     08  SURG..............  Cervical spinal fusion w        4.4277          7.0          9.8
                                                                                         MCC.
472................  No................  No................     08  SURG..............  Cervical spinal fusion w        2.6200          2.8          4.1
                                                                                         CC.
473................  No................  No................     08  SURG..............  Cervical spinal fusion w/       1.9213          1.6          2.0
                                                                                         o CC/MCC.
474................  Yes...............  No................     08  SURG..............  Amputation for                  3.4435          9.5         12.6
                                                                                         musculoskeletal sys &
                                                                                         conn tissue dis w MCC.
475................  Yes...............  No................     08  SURG..............  Amputation for                  1.9768          6.5          8.4
                                                                                         musculoskeletal sys &
                                                                                         conn tissue dis w CC.
476................  Yes...............  No................     08  SURG..............  Amputation for                  1.1001          3.7          4.8
                                                                                         musculoskeletal sys &
                                                                                         conn tissue dis w/o CC/
                                                                                         MCC.
477................  Yes...............  Yes...............     08  SURG..............  Biopsies of                     3.2545          8.9         11.9
                                                                                         musculoskeletal system &
                                                                                         connective tissue w MCC.
478................  Yes...............  Yes...............     08  SURG..............  Biopsies of                     2.1266          4.6          6.6
                                                                                         musculoskeletal system &
                                                                                         connective tissue w CC.
479................  Yes...............  Yes...............     08  SURG..............  Biopsies of                     1.4779          1.9          2.8
                                                                                         musculoskeletal system &
                                                                                         connective tissue w/o CC/
                                                                                         MCC.
480................  Yes...............  Yes...............     08  SURG..............  Hip & femur procedures          2.9050          7.8          9.3
                                                                                         except major joint w MCC.
481................  Yes...............  Yes...............     08  SURG..............  Hip & femur procedures          1.8204          5.4          5.9
                                                                                         except major joint w CC.
482................  Yes...............  Yes...............     08  SURG..............  Hip & femur procedures          1.4976          4.5          4.8
                                                                                         except major joint w/o
                                                                                         CC/MCC.
483................  Yes...............  No................     08  SURG..............  Major joint & limb              2.2601          3.4          4.2
                                                                                         reattachment proc of
                                                                                         upper extremity w CC/MCC.
484................  Yes...............  No................     08  SURG..............  Major joint & limb              1.7535          2.1          2.4
                                                                                         reattachment proc of
                                                                                         upper extremity w/o CC/
                                                                                         MCC.
485................  No................  No................     08  SURG..............  Knee procedures w pdx of        3.3033          9.8         12.1
                                                                                         infection w MCC.
486................  No................  No................     08  SURG..............  Knee procedures w pdx of        2.1664          6.8          8.0
                                                                                         infection w CC.
487................  No................  No................     08  SURG..............  Knee procedures w pdx of        1.5507          4.9          5.7
                                                                                         infection w/o CC/MCC.
488................  Yes...............  No................     08  SURG..............  Knee procedures w/o pdx         1.6836          4.1          5.2
                                                                                         of infection w CC/MCC.
489................  Yes...............  No................     08  SURG..............  Knee procedures w/o pdx         1.1604          2.6          3.0
                                                                                         of infection w/o CC/MCC.
490................  No................  No................     08  SURG..............  Back & neck proc exc            1.7221          3.0          4.3
                                                                                         spinal fusion w CC/MCC
                                                                                         or disc device/neurostim.
491................  No................  No................     08  SURG..............  Back & neck proc exc            0.9413          1.8          2.2
                                                                                         spinal fusion w/o CC/MCC.
492................  Yes...............  Yes...............     08  SURG..............  Lower extrem & humer proc       2.7705          6.8          8.5
                                                                                         except hip,foot,femur w
                                                                                         MCC.
493................  Yes...............  Yes...............     08  SURG..............  Lower extrem & humer proc       1.7631          4.3          5.3
                                                                                         except hip,foot,femur w
                                                                                         CC.
494................  Yes...............  Yes...............     08  SURG..............  Lower extrem & humer proc       1.2385          2.8          3.4
                                                                                         except hip,foot,femur w/
                                                                                         o CC/MCC.
495................  Yes...............  No................     08  SURG..............  Local excision & removal        3.1782          8.1         11.0
                                                                                         int fix devices exc hip
                                                                                         & femur w MCC.
496................  Yes...............  No................     08  SURG..............  Local excision & removal        1.7775          4.6          6.0
                                                                                         int fix devices exc hip
                                                                                         & femur w CC.
497................  Yes...............  No................     08  SURG..............  Local excision & removal        1.1277          2.3          3.0
                                                                                         int fix devices exc hip
                                                                                         & femur w/o CC/MCC.
498................  No................  No................     08  SURG..............  Local excision & removal        2.0274          5.5          7.9
                                                                                         int fix devices of hip &
                                                                                         femur w CC/MCC.
499................  No................  No................     08  SURG..............  Local excision & removal        0.9097          2.3          3.0
                                                                                         int fix devices of hip &
                                                                                         femur w/o CC/MCC.
500................  Yes...............  Yes...............     08  SURG..............  Soft tissue procedures w        2.8423          7.8         10.8
                                                                                         MCC.
501................  Yes...............  Yes...............     08  SURG..............  Soft tissue procedures w        1.4718          4.5          6.0
                                                                                         CC.
502................  Yes...............  Yes...............     08  SURG..............  Soft tissue procedures w/       0.9585          2.3          2.9
                                                                                         o CC/MCC.
503................  No................  No................     08  SURG..............  Foot procedures w MCC....       2.3059          7.2          9.5

[[Page 23830]]

 
504................  No................  No................     08  SURG..............  Foot procedures w CC.....       1.4725          5.1          6.5
505................  No................  No................     08  SURG..............  Foot procedures w/o CC/         0.9882          2.6          3.4
                                                                                         MCC.
506................  No................  No................     08  SURG..............  Major thumb or joint            1.0286          2.5          3.4
                                                                                         procedures.
507................  No................  No................     08  SURG..............  Major shoulder or elbow         1.7188          3.7          5.1
                                                                                         joint procedures w CC/
                                                                                         MCC.
508................  No................  No................     08  SURG..............  Major shoulder or elbow         1.1156          1.7          2.1
                                                                                         joint procedures w/o CC/
                                                                                         MCC.
509................  No................  No................     08  SURG..............  Arthroscopy..............       1.1762          2.0          3.1
510................  Yes...............  No................     08  SURG..............  Shoulder,elbow or forearm       1.9973          4.9          6.4
                                                                                         proc, exc major joint
                                                                                         proc w MCC.
511................  Yes...............  No................     08  SURG..............  Shoulder,elbow or forearm       1.3434          3.2          4.0
                                                                                         proc, exc major joint
                                                                                         proc w CC.
512................  Yes...............  No................     08  SURG..............  Shoulder,elbow or forearm       0.9533          1.8          2.2
                                                                                         proc, exc major joint
                                                                                         proc w/o CC/MCC.
513................  No................  No................     08  SURG..............  Hand or wrist proc,             1.2813          3.6          5.0
                                                                                         except major thumb or
                                                                                         joint proc w CC/MCC.
514................  No................  No................     08  SURG..............  Hand or wrist proc,             0.8067          2.1          2.8
                                                                                         except major thumb or
                                                                                         joint proc w/o CC/MCC.
515................  Yes...............  Yes...............     08  SURG..............  Other musculoskelet sys &       3.0601          7.9         10.4
                                                                                         conn tiss O.R. proc w
                                                                                         MCC.
516................  Yes...............  Yes...............     08  SURG..............  Other musculoskelet sys &       1.8073          4.5          6.0
                                                                                         conn tiss O.R. proc w CC.
517................  Yes...............  Yes...............     08  SURG..............  Other musculoskelet sys &       1.3326          2.1          3.0
                                                                                         conn tiss O.R. proc w/o
                                                                                         CC/MCC.
533................  Yes...............  No................     08  MED...............  Fractures of femur w MCC.       1.4207          4.8          6.7
534................  Yes...............  No................     08  MED...............  Fractures of femur w/o          0.7318          3.3          4.0
                                                                                         MCC.
535................  Yes...............  No................     08  MED...............  Fractures of hip & pelvis       1.3327          4.8          6.2
                                                                                         w MCC.
536................  Yes...............  No................     08  MED...............  Fractures of hip & pelvis       0.6934          3.4          3.9
                                                                                         w/o MCC.
537................  No................  No................     08  MED...............  Sprains, strains, &             0.8871          3.6          4.5
                                                                                         dislocations of hip,
                                                                                         pelvis & thigh w CC/MCC.
538................  No................  No................     08  MED...............  Sprains, strains, &             0.5787          2.7          3.2
                                                                                         dislocations of hip,
                                                                                         pelvis & thigh w/o CC/
                                                                                         MCC.
539................  Yes...............  No................     08  MED...............  Osteomyelitis w MCC......       2.0097          7.5          9.7
540................  Yes...............  No................     08  MED...............  Osteomyelitis w CC.......       1.3457          5.7          7.1
541................  Yes...............  No................     08  MED...............  Osteomyelitis w/o CC/MCC.       0.9285          4.2          5.4
542................  Yes...............  No................     08  MED...............  Pathological fractures &        1.8953          6.7          8.8
                                                                                         musculoskelet & conn
                                                                                         tiss malig w MCC.
543................  Yes...............  No................     08  MED...............  Pathological fractures &        1.1263          4.8          5.9
                                                                                         musculoskelet & conn
                                                                                         tiss malig w CC.
544................  Yes...............  No................     08  MED...............  Pathological fractures &        0.7672          3.7          4.4
                                                                                         musculoskelet & conn
                                                                                         tiss malig w/o CC/MCC.
545................  Yes...............  No................     08  MED...............  Connective tissue               2.3477          6.5          9.1
                                                                                         disorders w MCC.
546................  Yes...............  No................     08  MED...............  Connective tissue               1.0951          4.4          5.5
                                                                                         disorders w CC.
547................  Yes...............  No................     08  MED...............  Connective tissue               0.7224          3.1          3.8
                                                                                         disorders w/o CC/MCC.
548................  No................  No................     08  MED...............  Septic arthritis w MCC...       1.8776          6.7          8.9
549................  No................  No................     08  MED...............  Septic arthritis w CC....       1.1590          5.1          6.4
550................  No................  No................     08  MED...............  Septic arthritis w/o CC/        0.8006          3.7          4.5
                                                                                         MCC.
551................  Yes...............  No................     08  MED...............  Medical back problems w         1.5261          5.4          7.1
                                                                                         MCC.
552................  Yes...............  No................     08  MED...............  Medical back problems w/o       0.7623          3.4          4.1
                                                                                         MCC.
553................  No................  No................     08  MED...............  Bone diseases &                 1.0978          4.7          6.0
                                                                                         arthropathies w MCC.
554................  No................  No................     08  MED...............  Bone diseases &                 0.6305          3.0          3.7
                                                                                         arthropathies w/o MCC.
555................  No................  No................     08  MED...............  Signs & symptoms of             1.0014          3.6          4.8
                                                                                         musculoskeletal system &
                                                                                         conn tissue w MCC.
556................  No................  No................     08  MED...............  Signs & symptoms of             0.5738          2.5          3.1
                                                                                         musculoskeletal system &
                                                                                         conn tissue w/o MCC.
557................  Yes...............  No................     08  MED...............  Tendonitis, myositis &          1.4264          5.2          6.6
                                                                                         bursitis w MCC.
558................  Yes...............  No................     08  MED...............  Tendonitis, myositis &          0.8009          3.5          4.3
                                                                                         bursitis w/o MCC.
559................  Yes...............  No................     08  MED...............  Aftercare,                      1.7085          5.3          7.6
                                                                                         musculoskeletal system &
                                                                                         connective tissue w MCC.

[[Page 23831]]

 
560................  Yes...............  No................     08  MED...............  Aftercare,                      0.9491          3.6          4.7
                                                                                         musculoskeletal system &
                                                                                         connective tissue w CC.
561................  Yes...............  No................     08  MED...............  Aftercare,                      0.5794          2.1          2.8
                                                                                         musculoskeletal system &
                                                                                         connective tissue w/o CC/
                                                                                         MCC.
562................  Yes...............  No................     08  MED...............  Fx, sprn, strn & disl           1.3933          4.9          6.4
                                                                                         except femur, hip,
                                                                                         pelvis & thigh w MCC.
563................  Yes...............  No................     08  MED...............  Fx, sprn, strn & disl           0.6749          3.1          3.7
                                                                                         except femur, hip,
                                                                                         pelvis & thigh w/o MCC.
564................  No................  No................     08  MED...............  Other musculoskeletal sys       1.4053          5.2          7.0
                                                                                         & connective tissue
                                                                                         diagnoses w MCC.
565................  No................  No................     08  MED...............  Other musculoskeletal sys       0.8848          3.9          5.0
                                                                                         & connective tissue
                                                                                         diagnoses w CC.
566................  No................  No................     08  MED...............  Other musculoskeletal sys       0.6673          3.0          3.7
                                                                                         & connective tissue
                                                                                         diagnoses w/o CC/MCC.
573................  Yes...............  No................     09  SURG..............  Skin graft &/or debrid          3.1703          9.6         13.1
                                                                                         for skn ulcer or
                                                                                         cellulitis w MCC.
574................  Yes...............  No................     09  SURG..............  Skin graft &/or debrid          1.9362          7.1          9.3
                                                                                         for skn ulcer or
                                                                                         cellulitis w CC.
575................  Yes...............  No................     09  SURG..............  Skin graft &/or debrid          1.1176          4.7          5.9
                                                                                         for skn ulcer or
                                                                                         cellulitis w/o CC/MCC.
576................  No................  No................     09  SURG..............  Skin graft &/or debrid          3.4522          8.4         13.0
                                                                                         exc for skin ulcer or
                                                                                         cellulitis w MCC.
577................  No................  No................     09  SURG..............  Skin graft &/or debrid          1.5788          4.2          6.1
                                                                                         exc for skin ulcer or
                                                                                         cellulitis w CC.
578................  No................  No................     09  SURG..............  Skin graft &/or debrid          0.9803          2.4          3.3
                                                                                         exc for skin ulcer or
                                                                                         cellulitis w/o CC/MCC.
579................  Yes...............  No................     09  SURG..............  Other skin, subcut tiss &       2.7821          7.8         10.7
                                                                                         breast proc w MCC.
580................  Yes...............  No................     09  SURG..............  Other skin, subcut tiss &       1.4093          3.7          5.5
                                                                                         breast proc w CC.
581................  Yes...............  No................     09  SURG..............  Other skin, subcut tiss &       0.8606          1.9          2.6
                                                                                         breast proc w/o CC/MCC.
582................  No................  No................     09  SURG..............  Mastectomy for malignancy       0.9682          2.1          2.8
                                                                                         w CC/MCC.
583................  No................  No................     09  SURG..............  Mastectomy for malignancy       0.7498          1.6          1.8
                                                                                         w/o CC/MCC.
584................  No................  No................     09  SURG..............  Breast biopsy, local            1.4344          4.0          6.0
                                                                                         excision & other breast
                                                                                         procedures w CC/MCC.
585................  No................  No................     09  SURG..............  Breast biopsy, local            0.7995          1.7          2.2
                                                                                         excision & other breast
                                                                                         procedures w/o CC/MCC.
592................  Yes...............  No................     09  MED...............  Skin ulcers w MCC........       1.7469          6.6          8.9
593................  Yes...............  No................     09  MED...............  Skin ulcers w CC.........       1.1021          5.2          6.4
594................  Yes...............  No................     09  MED...............  Skin ulcers w/o CC/MCC...       0.7871          4.1          5.1
595................  No................  No................     09  MED...............  Major skin disorders w          1.8159          6.2          8.3
                                                                                         MCC.
596................  No................  No................     09  MED...............  Major skin disorders w/o        0.8200          3.8          4.8
                                                                                         MCC.
597................  No................  No................     09  MED...............  Malignant breast                1.6001          5.9          8.2
                                                                                         disorders w MCC.
598................  No................  No................     09  MED...............  Malignant breast                1.0812          4.3          5.7
                                                                                         disorders w CC.
599................  No................  No................     09  MED...............  Malignant breast                0.7309          2.7          3.7
                                                                                         disorders w/o CC/MCC.
600................  No................  No................     09  MED...............  Non-malignant breast            0.9433          4.1          5.1
                                                                                         disorders w CC/MCC.
601................  No................  No................     09  MED...............  Non-malignant breast            0.6539          3.1          3.9
                                                                                         disorders w/o CC/MCC.
602................  Yes...............  No................     09  MED...............  Cellulitis w MCC.........       1.3980          5.5          7.0
603................  Yes...............  No................     09  MED...............  Cellulitis w/o MCC.......       0.7988          3.9          4.7
604................  No................  No................     09  MED...............  Trauma to the skin,             1.1875          4.3          5.7
                                                                                         subcut tiss & breast w
                                                                                         MCC.
605................  No................  No................     09  MED...............  Trauma to the skin,             0.6739          2.8          3.5
                                                                                         subcut tiss & breast w/o
                                                                                         MCC.
606................  No................  No................     09  MED...............  Minor skin disorders w          1.2415          4.4          6.3
                                                                                         MCC.
607................  No................  No................     09  MED...............  Minor skin disorders w/o        0.6434          2.9          3.8
                                                                                         MCC.
614................  No................  No................     10  SURG..............  Adrenal & pituitary             2.5046          5.1          7.0
                                                                                         procedures w CC/MCC.
615................  No................  No................     10  SURG..............  Adrenal & pituitary             1.3782          2.7          3.2
                                                                                         procedures w/o CC/MCC.
616................  Yes...............  No................     10  SURG..............  Amputat of lower limb for       4.6284         13.3         16.9
                                                                                         endocrine, nutrit, &
                                                                                         metabol dis w MCC.

[[Page 23832]]

 
617................  Yes...............  No................     10  SURG..............  Amputat of lower limb for       2.0940          7.0          8.8
                                                                                         endocrine, nutrit, &
                                                                                         metabol dis w CC.
618................  Yes...............  No................     10  SURG..............  Amputat of lower limb for       1.3234          5.1          6.4
                                                                                         endocrine, nutrit, &
                                                                                         metabol dis w/o CC/MCC.
619................  No................  No................     10  SURG..............  O.R. procedures for             3.3383          5.2          8.2
                                                                                         obesity w MCC.
620................  No................  No................     10  SURG..............  O.R. procedures for             1.8739          2.9          3.7
                                                                                         obesity w CC.
621................  No................  No................     10  SURG..............  O.R. procedures for             1.4269          1.9          2.2
                                                                                         obesity w/o CC/MCC.
622................  Yes...............  No................     10  SURG..............  Skin grafts & wound             3.1268          9.4         13.2
                                                                                         debrid for endoc, nutrit
                                                                                         & metab dis w MCC.
623................  Yes...............  No................     10  SURG..............  Skin grafts & wound             1.8728          6.7          8.6
                                                                                         debrid for endoc, nutrit
                                                                                         & metab dis w CC.
624................  Yes...............  No................     10  SURG..............  Skin grafts & wound             1.0877          4.8          6.0
                                                                                         debrid for endoc, nutrit
                                                                                         & metab dis w/o CC/MCC.
625................  No................  No................     10  SURG..............  Thyroid, parathyroid &          2.1260          4.7          7.1
                                                                                         thyroglossal procedures
                                                                                         w MCC.
626................  No................  No................     10  SURG..............  Thyroid, parathyroid &          1.1284          2.1          3.1
                                                                                         thyroglossal procedures
                                                                                         w CC.
627................  No................  No................     10  SURG..............  Thyroid, parathyroid &          0.7378          1.3          1.5
                                                                                         thyroglossal procedures
                                                                                         w/o CC/MCC.
628................  Yes...............  No................     10  SURG..............  Other endocrine, nutrit &       3.2732          7.5         11.2
                                                                                         metab O.R. proc w MCC.
629................  Yes...............  No................     10  SURG..............  Other endocrine, nutrit &       2.2931          6.9          8.7
                                                                                         metab O.R. proc w CC.
630................  Yes...............  No................     10  SURG..............  Other endocrine, nutrit &       1.5069          4.0          5.5
                                                                                         metab O.R. proc w/o CC/
                                                                                         MCC.
637................  Yes...............  No................     10  MED...............  Diabetes w MCC...........       1.3538          4.5          6.1
638................  Yes...............  No................     10  MED...............  Diabetes w CC............       0.8135          3.4          4.3
639................  Yes...............  No................     10  MED...............  Diabetes w/o CC/MCC......       0.5577          2.5          3.0
640................  Yes...............  No................     10  MED...............  Nutritional & misc              1.1105          3.9          5.4
                                                                                         metabolic disorders w
                                                                                         MCC.
641................  Yes...............  No................     10  MED...............  Nutritional & misc              0.6798          3.1          3.8
                                                                                         metabolic disorders w/o
                                                                                         MCC.
642................  No................  No................     10  MED...............  Inborn errors of                1.0169          3.7          5.2
                                                                                         metabolism.
643................  Yes...............  No................     10  MED...............  Endocrine disorders w MCC       1.6408          5.8          7.6
644................  Yes...............  No................     10  MED...............  Endocrine disorders w CC.       1.0437          4.4          5.5
645................  Yes...............  No................     10  MED...............  Endocrine disorders w/o         0.7164          3.1          3.9
                                                                                         CC/MCC.
652................  No................  No................     11  SURG..............  Kidney transplant........       2.9787          6.6          7.8
653................  Yes...............  No................     11  SURG..............  Major bladder procedures        5.8091         13.6         16.9
                                                                                         w MCC.
654................  Yes...............  No................     11  SURG..............  Major bladder procedures        2.9531          8.7          9.9
                                                                                         w CC.
655................  Yes...............  No................     11  SURG..............  Major bladder procedures        2.0241          5.7          6.5
                                                                                         w/o CC/MCC.
656................  No................  No................     11  SURG..............  Kidney & ureter                 3.2762          8.0         10.1
                                                                                         procedures for neoplasm
                                                                                         w MCC.
657................  No................  No................     11  SURG..............  Kidney & ureter                 1.8655          5.0          6.0
                                                                                         procedures for neoplasm
                                                                                         w CC.
658................  No................  No................     11  SURG..............  Kidney & ureter                 1.3790          3.3          3.7
                                                                                         procedures for neoplasm
                                                                                         w/o CC/MCC.
659................  Yes...............  No................     11  SURG..............  Kidney & ureter                 3.3225          8.0         11.2
                                                                                         procedures for non-
                                                                                         neoplasm w MCC.
660................  Yes...............  No................     11  SURG..............  Kidney & ureter                 1.8913          4.8          6.5
                                                                                         procedures for non-
                                                                                         neoplasm w CC.
661................  Yes...............  No................     11  SURG..............  Kidney & ureter                 1.2600          2.6          3.3
                                                                                         procedures for non-
                                                                                         neoplasm w/o CC/MCC.
662................  No................  No................     11  SURG..............  Minor bladder procedures        2.7078          7.4         10.3
                                                                                         w MCC.
663................  No................  No................     11  SURG..............  Minor bladder procedures        1.4443          3.7          5.3
                                                                                         w CC.
664................  No................  No................     11  SURG..............  Minor bladder procedures        0.9940          1.6          2.1
                                                                                         w/o CC/MCC.
665................  No................  No................     11  SURG..............  Prostatectomy w MCC......       2.5635          8.2         11.1
666................  No................  No................     11  SURG..............  Prostatectomy w CC.......       1.5553          4.3          6.4
667................  No................  No................     11  SURG..............  Prostatectomy w/o CC/MCC.       0.8259          2.1          2.9
668................  No................  No................     11  SURG..............  Transurethral procedures        2.2348          6.2          8.5
                                                                                         w MCC.
669................  No................  No................     11  SURG..............  Transurethral procedures        1.2049          3.1          4.4
                                                                                         w CC.
670................  No................  No................     11  SURG..............  Transurethral procedures        0.7672          1.9          2.5
                                                                                         w/o CC/MCC.
671................  No................  No................     11  SURG..............  Urethral procedures w CC/       1.4136          4.1          5.9
                                                                                         MCC.
672................  No................  No................     11  SURG..............  Urethral procedures w/o         0.7962          1.9          2.5
                                                                                         CC/MCC.

[[Page 23833]]

 
673................  No................  No................     11  SURG..............  Other kidney & urinary          2.7645          5.8          9.7
                                                                                         tract procedures w MCC.
674................  No................  No................     11  SURG..............  Other kidney & urinary          2.1527          4.6          7.2
                                                                                         tract procedures w CC.
675................  No................  No................     11  SURG..............  Other kidney & urinary          1.3137          1.5          2.1
                                                                                         tract procedures w/o CC/
                                                                                         MCC.
682................  Yes...............  No................     11  MED...............  Renal failure w MCC......       1.6374          5.2          7.2
683................  Yes...............  No................     11  MED...............  Renal failure w CC.......       1.1270          4.5          5.7
684................  Yes...............  No................     11  MED...............  Renal failure w/o CC/MCC.       0.7278          3.2          3.9
685................  No................  No................     11  MED...............  Admit for renal dialysis.       0.8578          2.5          3.5
686................  No................  No................     11  MED...............  Kidney & urinary tract          1.6240          5.6          7.6
                                                                                         neoplasms w MCC.
687................  No................  No................     11  MED...............  Kidney & urinary tract          1.0719          4.1          5.4
                                                                                         neoplasms w CC.
688................  No................  No................     11  MED...............  Kidney & urinary tract          0.6816          2.5          3.3
                                                                                         neoplasms w/o CC/MCC.
689................  Yes...............  No................     11  MED...............  Kidney & urinary tract          1.2271          4.9          6.2
                                                                                         infections w MCC.
690................  Yes...............  No................     11  MED...............  Kidney & urinary tract          0.7559          3.5          4.2
                                                                                         infections w/o MCC.
691................  No................  No................     11  MED...............  Urinary stones w esw            1.4503          2.9          4.0
                                                                                         lithotripsy w CC/MCC.
692................  No................  No................     11  MED...............  Urinary stones w esw            1.1528          1.9          2.4
                                                                                         lithotripsy w/o CC/MCC.
693................  No................  No................     11  MED...............  Urinary stones w/o esw          1.1915          3.6          4.8
                                                                                         lithotripsy w MCC.
694................  No................  No................     11  MED...............  Urinary stones w/o esw          0.6573          2.0          2.6
                                                                                         lithotripsy w/o MCC.
695................  No................  No................     11  MED...............  Kidney & urinary tract          1.1723          4.2          5.5
                                                                                         signs & symptoms w MCC.
696................  No................  No................     11  MED...............  Kidney & urinary tract          0.6308          2.6          3.3
                                                                                         signs & symptoms w/o MCC.
697................  No................  No................     11  MED...............  Urethral stricture.......       0.6938          2.4          3.1
698................  Yes...............  No................     11  MED...............  Other kidney & urinary          1.4719          5.0          6.7
                                                                                         tract diagnoses w MCC.
699................  Yes...............  No................     11  MED...............  Other kidney & urinary          0.9700          3.7          4.8
                                                                                         tract diagnoses w CC.
700................  Yes...............  No................     11  MED...............  Other kidney & urinary          0.6813          2.8          3.6
                                                                                         tract diagnoses w/o CC/
                                                                                         MCC.
707................  No................  No................     12  SURG..............  Major male pelvic               1.6265          3.4          4.4
                                                                                         procedures w CC/MCC.
708................  No................  No................     12  SURG..............  Major male pelvic               1.1839          1.8          2.1
                                                                                         procedures w/o CC/MCC.
709................  No................  No................     12  SURG..............  Penis procedures w CC/MCC       1.8803          3.8          6.5
710................  No................  No................     12  SURG..............  Penis procedures w/o CC/        1.2586          1.4          1.8
                                                                                         MCC.
711................  No................  No................     12  SURG..............  Testes procedures w CC/         2.0318          5.5          8.2
                                                                                         MCC.
712................  No................  No................     12  SURG..............  Testes procedures w/o CC/       0.8077          2.2          3.0
                                                                                         MCC.
713................  No................  No................     12  SURG..............  Transurethral                   1.1188          2.9          4.2
                                                                                         prostatectomy w CC/MCC.
714................  No................  No................     12  SURG..............  Transurethral                   0.6333          1.7          1.9
                                                                                         prostatectomy w/o CC/MCC.
715................  No................  No................     12  SURG..............  Other male reproductive         1.7120          3.9          6.3
                                                                                         system O.R. proc for
                                                                                         malignancy w CC/MCC.
716................  No................  No................     12  SURG..............  Other male reproductive         0.9713          1.2          1.4
                                                                                         system O.R. proc for
                                                                                         malignancy w/o CC/MCC.
717................  No................  No................     12  SURG..............  Other male reproductive         1.8091          5.1          7.2
                                                                                         system O.R. proc exc
                                                                                         malignancy w CC/MCC.
718................  No................  No................     12  SURG..............  Other male reproductive         0.7849          2.2          2.8
                                                                                         system O.R. proc exc
                                                                                         malignancy w/o CC/MCC.
722................  No................  No................     12  MED...............  Malignancy, male                1.5588          5.7          7.6
                                                                                         reproductive system w
                                                                                         MCC.
723................  No................  No................     12  MED...............  Malignancy, male                0.9901          4.1          5.3
                                                                                         reproductive system w CC.
724................  No................  No................     12  MED...............  Malignancy, male                0.6006          2.4          3.2
                                                                                         reproductive system w/o
                                                                                         CC/MCC.
725................  No................  No................     12  MED...............  Benign prostatic                1.0462          4.2          5.5
                                                                                         hypertrophy w MCC.

[[Page 23834]]

 
726................  No................  No................     12  MED...............  Benign prostatic                0.6675          2.7          3.5
                                                                                         hypertrophy w/o MCC.
727................  No................  No................     12  MED...............  Inflammation of the male        1.3016          5.0          6.4
                                                                                         reproductive system w
                                                                                         MCC.
728................  No................  No................     12  MED...............  Inflammation of the male        0.6911          3.3          4.0
                                                                                         reproductive system w/o
                                                                                         MCC.
729................  No................  No................     12  MED...............  Other male reproductive         1.0993          4.0          5.6
                                                                                         system diagnoses w CC/
                                                                                         MCC.
730................  No................  No................     12  MED...............  Other male reproductive         0.5963          2.4          3.1
                                                                                         system diagnoses w/o CC/
                                                                                         MCC.
734................  No................  No................     13  SURG..............  Pelvic evisceration, rad        2.3505          6.0          8.0
                                                                                         hysterectomy & rad
                                                                                         vulvectomy w CC/MCC.
735................  No................  No................     13  SURG..............  Pelvic evisceration, rad        1.1311          2.9          3.4
                                                                                         hysterectomy & rad
                                                                                         vulvectomy w/o CC/MCC.
736................  No................  No................     13  SURG..............  Uterine & adnexa proc for       4.1736         11.2         13.8
                                                                                         ovarian or adnexal
                                                                                         malignancy w MCC.
737................  No................  No................     13  SURG..............  Uterine & adnexa proc for       1.9577          6.0          7.2
                                                                                         ovarian or adnexal
                                                                                         malignancy w CC.
738................  No................  No................     13  SURG..............  Uterine & adnexa proc for       1.1577          3.5          3.9
                                                                                         ovarian or adnexal
                                                                                         malignancy w/o CC/MCC.
739................  No................  No................     13  SURG..............  Uterine, adnexa proc for        3.0131          7.8         10.2
                                                                                         non-ovarian/adnexal
                                                                                         malig w MCC.
740................  No................  No................     13  SURG..............  Uterine, adnexa proc for        1.4661          4.3          5.2
                                                                                         non-ovarian/adnexal
                                                                                         malig w CC.
741................  No................  No................     13  SURG..............  Uterine, adnexa proc for        1.0021          2.7          3.0
                                                                                         non-ovarian/adnexal
                                                                                         malig w/o CC/MCC.
742................  No................  No................     13  SURG..............  Uterine & adnexa proc for       1.3433          3.5          4.5
                                                                                         non-malignancy w CC/MCC.
743................  No................  No................     13  SURG..............  Uterine & adnexa proc for       0.8469          2.0          2.3
                                                                                         non-malignancy w/o CC/
                                                                                         MCC.
744................  No................  No................     13  SURG..............  D&C, conization,                1.3918          4.1          5.8
                                                                                         laparoscopy & tubal
                                                                                         interruption w CC/MCC.
745................  No................  No................     13  SURG..............  D&C, conization,                0.7460          2.1          2.6
                                                                                         laparoscopy & tubal
                                                                                         interruption w/o CC/MCC.
746................  No................  No................     13  SURG..............  Vagina, cervix & vulva          1.2662          3.0          4.2
                                                                                         procedures w CC/MCC.
747................  No................  No................     13  SURG..............  Vagina, cervix & vulva          0.8403          1.6          1.9
                                                                                         procedures w/o CC/MCC.
748................  No................  No................     13  SURG..............  Female reproductive             0.8193          1.5          1.7
                                                                                         system reconstructive
                                                                                         procedures.
749................  No................  No................     13  SURG..............  Other female reproductive       2.4919          6.7          9.3
                                                                                         system O.R. procedures w
                                                                                         CC/MCC.
750................  No................  No................     13  SURG..............  Other female reproductive       0.9660          2.5          3.1
                                                                                         system O.R. procedures w/
                                                                                         o CC/MCC.
754................  No................  No................     13  MED...............  Malignancy, female              1.7520          6.2          8.3
                                                                                         reproductive system w
                                                                                         MCC.
755................  No................  No................     13  MED...............  Malignancy, female              1.0769          4.3          5.7
                                                                                         reproductive system w CC.
756................  No................  No................     13  MED...............  Malignancy, female              0.6327          2.5          3.1
                                                                                         reproductive system w/o
                                                                                         CC/MCC.
757................  No................  No................     13  MED...............  Infections, female              1.5775          6.5          8.1
                                                                                         reproductive system w
                                                                                         MCC.
758................  No................  No................     13  MED...............  Infections, female              1.0621          4.9          6.1
                                                                                         reproductive system w CC.
759................  No................  No................     13  MED...............  Infections, female              0.7646          3.6          4.5
                                                                                         reproductive system w/o
                                                                                         CC/MCC.
760................  No................  No................     13  MED...............  Menstrual & other female        0.7917          3.0          4.0
                                                                                         reproductive system
                                                                                         disorders w CC/MCC.
761................  No................  No................     13  MED...............  Menstrual & other female        0.5008          1.9          2.4
                                                                                         reproductive system
                                                                                         disorders w/o CC/MCC.
765................  No................  No................     14  SURG..............  Cesarean section w CC/MCC       1.0606          4.0          5.0
766................  No................  No................     14  SURG..............  Cesarean section w/o CC/        0.7486          3.0          3.2
                                                                                         MCC.
767................  No................  No................     14  SURG..............  Vaginal delivery w              0.9741          2.6          3.4
                                                                                         sterilization &/or D&C.
768................  No................  No................     14  SURG..............  Vaginal delivery w O.R.         1.7321          0.0          0.0
                                                                                         proc except steril &/or
                                                                                         D&C.

[[Page 23835]]

 
769................  No................  No................     14  SURG..............  Postpartum & post               1.2935          3.2          4.6
                                                                                         abortion diagnoses w
                                                                                         O.R. procedure.
770................  No................  No................     14  SURG..............  Abortion w D&C,                 0.6677          1.6          2.2
                                                                                         aspiration curettage or
                                                                                         hysterotomy.
774................  No................  No................     14  MED...............  Vaginal delivery w              0.6571          2.6          3.2
                                                                                         complicating diagnoses.
775................  No................  No................     14  MED...............  Vaginal delivery w/o            0.4830          2.0          2.2
                                                                                         complicating diagnoses.
776................  No................  No................     14  MED...............  Postpartum & post               0.6192          2.5          3.3
                                                                                         abortion diagnoses w/o
                                                                                         O.R. procedure.
777................  No................  No................     14  MED...............  Ectopic pregnancy........       0.7721          1.9          2.2
778................  No................  No................     14  MED...............  Threatened abortion......       0.4373          2.0          3.0
779................  No................  No................     14  MED...............  Abortion w/o D&C.........       0.4871          1.6          2.1
780................  No................  No................     14  MED...............  False labor..............       0.1962          1.3          1.5
781................  No................  No................     14  MED...............  Other antepartum                0.6154          2.6          3.8
                                                                                         diagnoses w medical
                                                                                         complications.
782................  No................  No................     14  MED...............  Other antepartum                0.3926          1.7          2.5
                                                                                         diagnoses w/o medical
                                                                                         complications.
789................  No................  No................     15  MED...............  Neonates, died or               1.4227          0.0          0.0
                                                                                         transferred to another
                                                                                         acute care facility.
790................  No................  No................     15  MED...............  Extreme immaturity or           4.6916          0.0          0.0
                                                                                         respiratory distress
                                                                                         syndrome, neonate.
791................  No................  No................     15  MED...............  Prematurity w major             3.2042          0.0          0.0
                                                                                         problems.
792................  No................  No................     15  MED...............  Prematurity w/o major           1.9334          0.0          0.0
                                                                                         problems.
793................  No................  No................     15  MED...............  Full term neonate w major       3.2914          0.0          0.0
                                                                                         problems.
794................  No................  No................     15  MED...............  Neonate w other                 1.1650          0.0          0.0
                                                                                         significant problems.
795................  No................  No................     15  MED...............  Normal newborn...........       0.1577          0.0          0.0
799................  No................  No................     16  SURG..............  Splenectomy w MCC........       4.7602         10.8         14.1
800................  No................  No................     16  SURG..............  Splenectomy w CC.........       2.5819          6.2          7.9
801................  No................  No................     16  SURG..............  Splenectomy w/o CC/MCC...       1.6484          3.8          4.9
802................  No................  No................     16  SURG..............  Other O.R. proc of the          3.3539          8.9         12.2
                                                                                         blood & blood forming
                                                                                         organs w MCC.
803................  No................  No................     16  SURG..............  Other O.R. proc of the          1.7689          4.7          6.7
                                                                                         blood & blood forming
                                                                                         organs w CC.
804................  No................  No................     16  SURG..............  Other O.R. proc of the          1.0613          2.5          3.4
                                                                                         blood & blood forming
                                                                                         organs w/o CC/MCC.
808................  No................  No................     16  MED...............  Major hematol/immun diag        1.9850          6.3          8.2
                                                                                         exc sickle cell crisis &
                                                                                         coagul w MCC.
809................  No................  No................     16  MED...............  Major hematol/immun diag        1.1737          4.2          5.3
                                                                                         exc sickle cell crisis &
                                                                                         coagul w CC.
810................  No................  No................     16  MED...............  Major hematol/immun diag        0.8957          3.2          4.0
                                                                                         exc sickle cell crisis &
                                                                                         coagul w/o CC/MCC.
811................  No................  No................     16  MED...............  Red blood cell disorders        1.2742          4.0          5.7
                                                                                         w MCC.
812................  No................  No................     16  MED...............  Red blood cell disorders        0.7629          2.8          3.7
                                                                                         w/o MCC.
813................  No................  No................     16  MED...............  Coagulation disorders....       1.3556          3.7          5.1
814................  No................  No................     16  MED...............  Reticuloendothelial &           1.4932          5.0          6.7
                                                                                         immunity disorders w MCC.
815................  No................  No................     16  MED...............  Reticuloendothelial &           0.9973          3.8          5.0
                                                                                         immunity disorders w CC.
816................  No................  No................     16  MED...............  Reticuloendothelial &           0.6989          2.8          3.5
                                                                                         immunity disorders w/o
                                                                                         CC/MCC.
820................  No................  No................     17  SURG..............  Lymphoma & leukemia w           5.6401         13.3         17.7
                                                                                         major O.R. procedure w
                                                                                         MCC.
821................  No................  No................     17  SURG..............  Lymphoma & leukemia w           2.2489          5.5          7.9
                                                                                         major O.R. procedure w
                                                                                         CC.
822................  No................  No................     17  SURG..............  Lymphoma & leukemia w           1.2399          2.6          3.5
                                                                                         major O.R. procedure w/o
                                                                                         CC/MCC.
823................  No................  No................     17  SURG..............  Lymphoma & non-acute            4.0990         12.1         15.4
                                                                                         leukemia w other O.R.
                                                                                         proc w MCC.
824................  No................  No................     17  SURG..............  Lymphoma & non-acute            2.1791          6.6          8.7
                                                                                         leukemia w other O.R.
                                                                                         proc w CC.
825................  No................  No................     17  SURG..............  Lymphoma & non-acute            1.2059          3.0          4.3
                                                                                         leukemia w other O.R.
                                                                                         proc w/o CC/MCC.
826................  No................  No................     17  SURG..............  Myeloprolif disord or           4.6385         11.1         15.0
                                                                                         poorly diff neopl w maj
                                                                                         O.R. proc w MCC.
827................  No................  No................     17  SURG..............  Myeloprolif disord or           2.2759          5.9          8.0
                                                                                         poorly diff neopl w maj
                                                                                         O.R. proc w CC.

[[Page 23836]]

 
828................  No................  No................     17  SURG..............  Myeloprolif disord or           1.3050          3.0          3.8
                                                                                         poorly diff neopl w maj
                                                                                         O.R. proc w/o CC/MCC.
829................  No................  No................     17  SURG..............  Myeloprolif disord or           2.8972          7.0         10.7
                                                                                         poorly diff neopl w
                                                                                         other O.R. proc w CC/MCC.
830................  No................  No................     17  SURG..............  Myeloprolif disord or           1.0802          2.5          3.7
                                                                                         poorly diff neopl w
                                                                                         other O.R. proc w/o CC/
                                                                                         MCC.
834................  No................  No................     17  MED...............  Acute leukemia w/o major        4.5854          9.5         15.5
                                                                                         O.R. procedure w MCC.
835................  No................  No................     17  MED...............  Acute leukemia w/o major        2.5840          6.2         10.4
                                                                                         O.R. procedure w CC.
836................  No................  No................     17  MED...............  Acute leukemia w/o major        1.2085          3.4          5.2
                                                                                         O.R. procedure w/o CC/
                                                                                         MCC.
837................  No................  No................     17  MED...............  Chemo w acute leukemia as       6.4047         17.6         23.1
                                                                                         sdx or w high dose chemo
                                                                                         agent w MCC.
838................  No................  No................     17  MED...............  Chemo w acute leukemia as       2.9669          7.9         12.3
                                                                                         sdx w CC or high dose
                                                                                         chemo agent.
839................  No................  No................     17  MED...............  Chemo w acute leukemia as       1.4181          5.0          6.4
                                                                                         sdx w/o CC/MCC.
840................  Yes...............  No................     17  MED...............  Lymphoma & non-acute            2.6031          7.7         10.4
                                                                                         leukemia w MCC.
841................  Yes...............  No................     17  MED...............  Lymphoma & non-acute            1.5529          5.2          6.9
                                                                                         leukemia w CC.
842................  Yes...............  No................     17  MED...............  Lymphoma & non-acute            1.0261          3.4          4.6
                                                                                         leukemia w/o CC/MCC.
843................  No................  No................     17  MED...............  Other myeloprolif dis or        1.8203          6.1          8.5
                                                                                         poorly diff neopl diag w
                                                                                         MCC.
844................  No................  No................     17  MED...............  Other myeloprolif dis or        1.2030          4.6          6.1
                                                                                         poorly diff neopl diag w
                                                                                         CC.
845................  No................  No................     17  MED...............  Other myeloprolif dis or        0.8143          3.3          4.3
                                                                                         poorly diff neopl diag w/
                                                                                         o CC/MCC.
846................  No................  No................     17  MED...............  Chemotherapy w/o acute          2.1299          5.8          8.4
                                                                                         leukemia as secondary
                                                                                         diagnosis w MCC.
847................  No................  No................     17  MED...............  Chemotherapy w/o acute          0.9436          2.7          3.4
                                                                                         leukemia as secondary
                                                                                         diagnosis w CC.
848................  No................  No................     17  MED...............  Chemotherapy w/o acute          0.7995          2.5          3.1
                                                                                         leukemia as secondary
                                                                                         diagnosis w/o CC/MCC.
849................  No................  No................     17  MED...............  Radiotherapy.............       1.2021          4.4          6.0
853................  Yes...............  No................     18  SURG..............  Infectious & parasitic          5.4286         12.7         16.7
                                                                                         diseases w O.R.
                                                                                         procedure w MCC.
854................  Yes...............  No................     18  SURG..............  Infectious & parasitic          2.9171          9.1         11.1
                                                                                         diseases w O.R.
                                                                                         procedure w CC.
855................  Yes...............  No................     18  SURG..............  Infectious & parasitic          1.8093          5.6          7.0
                                                                                         diseases w O.R.
                                                                                         procedure w/o CC/MCC.
856................  Yes...............  No................     18  SURG..............  Postoperative or post-          4.7315         11.5         15.4
                                                                                         traumatic infections w
                                                                                         O.R. proc w MCC.
857................  Yes...............  No................     18  SURG..............  Postoperative or post-          2.0472          6.6          8.5
                                                                                         traumatic infections w
                                                                                         O.R. proc w CC.
858................  Yes...............  No................     18  SURG..............  Postoperative or post-          1.3563          4.5          5.7
                                                                                         traumatic infections w
                                                                                         O.R. proc w/o CC/MCC.
862................  Yes...............  No................     18  MED...............  Postoperative & post-           1.9123          6.1          8.2
                                                                                         traumatic infections w
                                                                                         MCC.
863................  Yes...............  No................     18  MED...............  Postoperative & post-           0.9575          4.2          5.2
                                                                                         traumatic infections w/o
                                                                                         MCC.
864................  No................  No................     18  MED...............  Fever of unknown origin..       0.8224          3.2          4.1
865................  No................  No................     18  MED...............  Viral illness w MCC......       1.4950          4.7          6.7
866................  No................  No................     18  MED...............  Viral illness w/o MCC....       0.6673          2.8          3.5
867................  Yes...............  No................     18  MED...............  Other infectious &              2.3423          7.0          9.6
                                                                                         parasitic diseases
                                                                                         diagnoses w MCC.
868................  Yes...............  No................     18  MED...............  Other infectious &              1.0761          4.5          5.8
                                                                                         parasitic diseases
                                                                                         diagnoses w CC.
869................  Yes...............  No................     18  MED...............  Other infectious &              0.7628          3.5          4.3
                                                                                         parasitic diseases
                                                                                         diagnoses w/o CC/MCC.
870................  Yes...............  No................     18  MED...............  Septicemia or severe            5.7422         12.9         15.5
                                                                                         sepsis w MV 96+ hours.
871................  Yes...............  No................     18  MED...............  Septicemia or severe            1.8211          5.5          7.5
                                                                                         sepsis w/o MV 96+ hours
                                                                                         w MCC.

[[Page 23837]]

 
872................  Yes...............  No................     18  MED...............  Septicemia or severe            1.1188          4.7          5.7
                                                                                         sepsis w/o MV 96+ hours
                                                                                         w/o MCC.
876................  No................  No................     19  SURG..............  O.R. procedure w                2.4279          7.8         11.9
                                                                                         principal diagnoses of
                                                                                         mental illness.
880................  No................  No................     19  MED...............  Acute adjustment reaction       0.5867          2.4          3.2
                                                                                         & psychosocial
                                                                                         dysfunction.
881................  No................  No................     19  MED...............  Depressive neuroses......       0.5784          3.1          4.2
882................  No................  No................     19  MED...............  Neuroses except                 0.6086          3.1          4.4
                                                                                         depressive.
883................  No................  No................     19  MED...............  Disorders of personality        1.0102          4.4          7.4
                                                                                         & impulse control.
884................  Yes...............  No................     19  MED...............  Organic disturbances &          0.8923          4.1          5.5
                                                                                         mental retardation.
885................  No................  No................     19  MED...............  Psychoses................       0.8380          5.5          7.6
886................  No................  No................     19  MED...............  Behavioral &                    0.7479          4.0          6.1
                                                                                         developmental disorders.
887................  No................  No................     19  MED...............  Other mental disorder           0.7275          3.0          4.6
                                                                                         diagnoses.
894................  No................  No................     20  MED...............  Alcohol/drug abuse or           0.3842          2.1          3.0
                                                                                         dependence, left ama.
895................  No................  No................     20  MED...............  Alcohol/drug abuse or           0.8727          8.1         10.5
                                                                                         dependence w
                                                                                         rehabilitation therapy.
896................  Yes...............  No................     20  MED...............  Alcohol/drug abuse or           1.3787          4.8          6.6
                                                                                         dependence w/o
                                                                                         rehabilitation therapy w
                                                                                         MCC.
897................  Yes...............  No................     20  MED...............  Alcohol/drug abuse or           0.6152          3.3          4.1
                                                                                         dependence w/o
                                                                                         rehabilitation therapy w/
                                                                                         o MCC.
901................  No................  No................     21  SURG..............  Wound debridements for          3.8708          9.9         15.1
                                                                                         injuries w MCC.
902................  No................  No................     21  SURG..............  Wound debridements for          1.6889          5.5          7.7
                                                                                         injuries w CC.
903................  No................  No................     21  SURG..............  Wound debridements for          0.9976          3.4          4.6
                                                                                         injuries w/o CC/MCC.
904................  No................  No................     21  SURG..............  Skin grafts for injuries        2.9204          7.0         11.2
                                                                                         w CC/MCC.
905................  No................  No................     21  SURG..............  Skin grafts for injuries        1.1156          3.4          4.7
                                                                                         w/o CC/MCC.
906................  No................  No................     21  SURG..............  Hand procedures for             0.9941          2.1          3.1
                                                                                         injuries.
907................  Yes...............  No................     21  SURG..............  Other O.R. procedures for       3.6871          8.0         11.6
                                                                                         injuries w MCC.
908................  Yes...............  No................     21  SURG..............  Other O.R. procedures for       1.9162          4.9          6.8
                                                                                         injuries w CC.
909................  Yes...............  No................     21  SURG..............  Other O.R. procedures for       1.1372          2.7          3.6
                                                                                         injuries w/o CC/MCC.
913................  No................  No................     21  MED...............  Traumatic injury w MCC...       1.2246          4.2          5.7
914................  No................  No................     21  MED...............  Traumatic injury w/o MCC.       0.6625          2.7          3.4
915................  No................  No................     21  MED...............  Allergic reactions w MCC.       1.2354          3.3          4.7
916................  No................  No................     21  MED...............  Allergic reactions w/o          0.4409          1.7          2.1
                                                                                         MCC.
917................  Yes...............  No................     21  MED...............  Poisoning & toxic effects       1.4143          3.7          5.2
                                                                                         of drugs w MCC.
918................  Yes...............  No................     21  MED...............  Poisoning & toxic effects       0.5809          2.1          2.7
                                                                                         of drugs w/o MCC.
919................  No................  No................     21  MED...............  Complications of                1.5200          4.5          6.4
                                                                                         treatment w MCC.
920................  No................  No................     21  MED...............  Complications of                0.9220          3.3          4.4
                                                                                         treatment w CC.
921................  No................  No................     21  MED...............  Complications of                0.6097          2.3          3.0
                                                                                         treatment w/o CC/MCC.
922................  No................  No................     21  MED...............  Other injury, poisoning &       1.3580          4.1          6.0
                                                                                         toxic effect diag w MCC.
923................  No................  No................     21  MED...............  Other injury, poisoning &       0.6142          2.4          3.2
                                                                                         toxic effect diag w/o
                                                                                         MCC.
927................  No................  No................     22  SURG..............  Extensive burns or full        14.0060         23.4         31.1
                                                                                         thickness burns w MV 96+
                                                                                         hrs w skin graft.
928................  No................  No................     22  SURG..............  Full thickness burn w           5.0621         11.7         16.0
                                                                                         skin graft or inhal inj
                                                                                         w CC/MCC.
929................  No................  No................     22  SURG..............  Full thickness burn w           2.1574          5.3          7.7
                                                                                         skin graft or inhal inj
                                                                                         w/o CC/MCC.
933................  No................  No................     22  MED...............  Extensive burns or full         2.1246          2.3          4.3
                                                                                         thickness burns w MV 96+
                                                                                         hrs w/o skin graft.
934................  No................  No................     22  MED...............  Full thickness burn w/o         1.2949          4.4          6.2
                                                                                         skin grft or inhal inj.
935................  No................  No................     22  MED...............  Non-extensive burns......       1.2209          3.6          5.4
939................  No................  No................     23  SURG..............  O.R. proc w diagnoses of        2.6570          6.6         10.1
                                                                                         other contact w health
                                                                                         services w MCC.

[[Page 23838]]

 
940................  No................  No................     23  SURG..............  O.R. proc w diagnoses of        1.6379          3.6          5.4
                                                                                         other contact w health
                                                                                         services w CC.
941................  No................  No................     23  SURG..............  O.R. proc w diagnoses of        1.0782          2.1          2.7
                                                                                         other contact w health
                                                                                         services w/o CC/MCC.
945................  Yes...............  No................     23  MED...............  Rehabilitation w CC/MCC..       1.2869          8.6         10.5
946................  Yes...............  No................     23  MED...............  Rehabilitation w/o CC/MCC       1.0861          6.9          7.9
947................  Yes...............  No................     23  MED...............  Signs & symptoms w MCC...       1.0525          3.8          5.0
948................  Yes...............  No................     23  MED...............  Signs & symptoms w/o MCC.       0.6473          2.8          3.5
949................  No................  No................     23  MED...............  Aftercare w CC/MCC.......       0.7925          2.6          4.1
950................  No................  No................     23  MED...............  Aftercare w/o CC/MCC.....       0.5548          2.4          3.5
951................  No................  No................     23  MED...............  Other factors influencing       0.7442          2.2          4.7
                                                                                         health status.
955................  No................  No................     24  SURG..............  Craniotomy for multiple         5.0969          8.6         12.3
                                                                                         significant trauma.
956................  Yes...............  No................     24  SURG..............  Limb reattachment, hip &        3.5263          7.6          9.3
                                                                                         femur proc for multiple
                                                                                         significant trauma.
957................  No................  No................     24  SURG..............  Other O.R. procedures for       6.0787         10.2         14.9
                                                                                         multiple significant
                                                                                         trauma w MCC.
958................  No................  No................     24  SURG..............  Other O.R. procedures for       3.6129          8.0         10.4
                                                                                         multiple significant
                                                                                         trauma w CC.
959................  No................  No................     24  SURG..............  Other O.R. procedures for       2.3808          4.9          6.3
                                                                                         multiple significant
                                                                                         trauma w/o CC/MCC.
963................  No................  No................     24  MED...............  Other multiple                  2.8713          6.7          9.5
                                                                                         significant trauma w MCC.
964................  No................  No................     24  MED...............  Other multiple                  1.6024          4.9          6.2
                                                                                         significant trauma w CC.
965................  No................  No................     24  MED...............  Other multiple                  0.9832          3.4          4.1
                                                                                         significant trauma w/o
                                                                                         CC/MCC.
969................  No................  No................     25  SURG..............  HIV w extensive O.R.            5.3749         12.9         18.8
                                                                                         procedure w MCC.
970................  No................  No................     25  SURG..............  HIV w extensive O.R.            2.4892          6.5          9.8
                                                                                         procedure w/o MCC.
974................  No................  No................     25  MED...............  HIV w major related             2.5595          7.3         10.4
                                                                                         condition w MCC.
975................  No................  No................     25  MED...............  HIV w major related             1.3571          5.3          7.0
                                                                                         condition w CC.
976................  No................  No................     25  MED...............  HIV w major related             0.8910          3.8          4.9
                                                                                         condition w/o CC/MCC.
977................  No................  No................     25  MED...............  HIV w or w/o other              1.0965          3.9          5.3
                                                                                         related condition.
981................  Yes...............  No................  .....  SURG..............  Extensive O.R. procedure        5.0175         11.7         15.1
                                                                                         unrelated to principal
                                                                                         diagnosis w MCC.
982................  Yes...............  No................  .....  SURG..............  Extensive O.R. procedure        3.0780          7.5          9.7
                                                                                         unrelated to principal
                                                                                         diagnosis w CC.
983................  Yes...............  No................  .....  SURG..............  Extensive O.R. procedure        1.9959          3.9          5.4
                                                                                         unrelated to principal
                                                                                         diagnosis w/o CC/MCC.
984................  No................  No................  .....  SURG..............  Prostatic O.R. procedure        3.3256         11.8         14.6
                                                                                         unrelated to principal
                                                                                         diagnosis w MCC.
985................  No................  No................  .....  SURG..............  Prostatic O.R. procedure        2.2113          7.3          9.7
                                                                                         unrelated to principal
                                                                                         diagnosis w CC.
986................  No................  No................  .....  SURG..............  Prostatic O.R. procedure        1.2767          3.5          5.3
                                                                                         unrelated to principal
                                                                                         diagnosis w/o CC/MCC.
987................  Yes...............  No................  .....  SURG..............  Non-extensive O.R. proc         3.4336          9.8         13.0
                                                                                         unrelated to principal
                                                                                         diagnosis w MCC.
988................  Yes...............  No................  .....  SURG..............  Non-extensive O.R. proc         1.8752          5.8          7.8
                                                                                         unrelated to principal
                                                                                         diagnosis w CC.
989................  Yes...............  No................  .....  SURG..............  Non-extensive O.R. proc         1.1032          2.9          4.1
                                                                                         unrelated to principal
                                                                                         diagnosis w/o CC/MCC.
998................  No................  No................  .....  **................  Principal diagnosis             0.0000          0.0          0.0
                                                                                         invalid as discharge
                                                                                         diagnosis.
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 obtain a meaningful computation of these statistics.


[[Page 23839]]


                                         Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
    Diagnosis code               Description                   CC           MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
046.11................  Variant Creutzfeldt-Jakob      CC...............       01  056, 057
                         disease.
046.19................  Other and unspecified          CC...............       01  056, 057
                         Creutzfeldt-Jakob disease.
046.71................  Gerstmann-Str[auml]ussler-     CC...............       01  056, 057
                         Scheinker syndrome.
                                                                               25  974, 975, 976
046.72................  Fatal familial insomnia......  CC...............       01  056, 057
                                                                               25  974, 975, 976
046.79................  Other and unspecified prion    CC...............       01  056, 057
                         disease of central nervous
                         system.
                                                                               25  974, 975, 976
051.01................  Cowpox.......................  N................       18  865, 866
051.02................  Vaccinia not from vaccination  N................       18  865, 866
059.00................  Orthopoxvirus infection,       N................       18  865, 866
                         unspecified.
059.01................  Monkeypox....................  CC...............       18  865, 866
059.09................  Other orthopoxvirus            N................       18  865, 866
                         infections.
059.10................  Parapoxvirus infection,        N................       18  865, 866
                         unspecified.
059.11................  Bovine stomatitis............  N................       18  865, 866
059.12................  Sealpox......................  N................       18  865, 866
059.19................  Other parapoxvirus infections  N................       18  865, 866
059.21................  Tanapox......................  CC...............       18  865, 866
059.22................  Yaba monkey tumor virus......  N................       18  865, 866
059.29................  Yatapoxvirus infection,        N................       18  865, 866
                         unspecified.
059.8.................  Other poxvirus infections....  N................       18  865, 866
059.9.................  Poxvirus infections,           N................       18  865, 866
                         unspecified.
078.12................  Plantar wart.................  N................       09  606, 607
136.21................  Specific infection due to      N................       18  867, 868, 869
                         acanthamoeba.
136.29................  Other specific infections by   CC...............       18  867, 868, 869
                         free-living amebae.
199.2.................  Malignant neoplasm associated  CC...............       17  843, 844, 845
                         with transplant organ.
203.02................  Multiple myeloma, in relapse.  CC...............       17  820, 821, 822, 823, 824, 825,
                                                                                    840, 841, 842
203.12................  Plasma cell leukemia, in       CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
203.82................  Other immunoproliferative      CC...............       17  820, 821, 822, 823, 824, 825,
                         neoplasms, in relapse.                                     840, 841, 842
204.02................  Acute lymphoid leukemia, in    CC...............       17  820, 821, 822, 834, 835, 836,
                         relapse.                                                   837 \1\, 838 \1\, 839 \1\
204.12................  Chronic lymphoid leukemia, in  CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
204.22................  Subacute lymphoid leukemia,    CC...............       17  820, 821, 822, 823, 824, 825,
                         in relapse.                                                840, 841, 842
204.82................  Other lymphoid leukemia, in    CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
204.92................  Unspecified lymphoid           CC...............       17  820, 821, 822, 823, 824, 825,
                         leukemia, in relapse.                                      840, 841, 842
205.02................  Acute myeloid leukemia, in     CC...............       17  820, 821, 822, 834, 835, 836,
                         relapse.                                                   837 \1\, 838 \1\, 839 \1\
205.12................  Chronic myeloid leukemia, in   CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
205.22................  Subacute myeloid leukemia, in  CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
205.32................  Myeloid sarcoma, in relapse..  CC...............       17  820, 821, 822, 823, 824, 825,
                                                                                    840, 841, 842
205.82................  Other myeloid leukemia, in     CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
205.92................  Unspecified myeloid leukemia,  CC...............       17  820, 821, 822, 823, 824, 825,
                         in relapse.                                                840, 841, 842

[[Page 23840]]

 
206.02................  Acute monocytic leukemia, in   CC...............       17  820, 821, 822, 834, 835, 836,
                         relapse.                                                   837 \1\, 838 \1\, 839 \1\
206.12................  Chronic monocytic leukemia,    CC...............       17  820, 821, 822, 823, 824, 825,
                         in relapse.                                                840, 841, 842
206.22................  Subacute monocytic leukemia,   CC...............       17  820, 821, 822, 823, 824, 825,
                         in relapse.                                                840, 841, 842
206.82................  Other monocytic leukemia, in   CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
206.92................  Unspecified monocytic          CC...............       17  820, 821, 822, 823, 824, 825,
                         leukemia, in relapse.                                      840, 841, 842
207.02................  Acute erythremia and           CC...............       17  820, 821, 822, 834, 835, 836,
                         erythroleukemia, in relapse.                               837 \1\, 838 \1\, 839 \1\
207.12................  Chronic erythremia, in         CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
207.22................  Megakaryocytic leukemia, in    CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
207.82................  Other specified leukemia, in   CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
208.02................  Acute leukemia of unspecified  CC...............       17  820, 821, 822, 834, 835, 836,
                         cell type, in relapse.                                     837 \1\, 838 \1\, 839 \1\
208.12................  Chronic leukemia of            CC...............       17  820, 821, 822, 823, 824, 825,
                         unspecified cell type, in                                  840, 841, 842
                         relapse.
208.22................  Subacute leukemia of           CC...............       17  820, 821, 822, 823, 824, 825,
                         unspecified cell type, in                                  840, 841, 842
                         relapse.
208.82................  Other leukemia of unspecified  CC...............       17  820, 821, 822, 823, 824, 825,
                         cell type, in relapse.                                     840, 841, 842
208.92................  Unspecified leukemia, in       CC...............       17  820, 821, 822, 823, 824, 825,
                         relapse.                                                   840, 841, 842
209.00................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the small intestine,
                         unspecified portion.
209.01................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the duodenum.
209.02................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the jejunum.
209.03................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the ileum.
209.10................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the large intestine,
                         unspecified portion.
209.11................  Malignant carcinoid tumor of   CC...............       06  338, 339, 340, 374, 375, 376
                         the appendix.
209.12................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the cecum.
209.13................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the ascending colon.
209.14................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the transverse colon.
209.15................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the descending colon.
209.16................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the sigmoid colon.
209.17................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the rectum.
209.20................  Malignant carcinoid tumor of   CC...............       17  843, 844, 845
                         unknown primary site.
209.21................  Malignant carcinoid tumor of   CC...............       04  180, 181, 182
                         the bronchus and lung.
209.22................  Malignant carcinoid tumor of   CC...............       17  843, 844, 845
                         the thymus.
209.23................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         the stomach.
209.24................  Malignant carcinoid tumor of   CC...............       11  656, 657, 658, 686, 687, 688
                         the kidney.
209.25................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         foregut, not otherwise
                         specified.
209.26................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         midgut, not otherwise
                         specified.
209.27................  Malignant carcinoid tumor of   CC...............       06  374, 375, 376
                         hindgut, not otherwise
                         specified.
209.29................  Malignant carcinoid tumor of   CC...............       17  843, 844, 845
                         other sites.
209.30................  Malignant poorly               CC...............       17  843, 844, 845
                         differentiated
                         neuroendocrine carcinoma,
                         any site.
209.40................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         small intestine, unspecified
                         portion.
209.41................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         duodenum.

[[Page 23841]]

 
209.42................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         jejunum.
209.43................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         ileum.
209.50................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         large intestine, unspecified
                         portion.
209.51................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         appendix.
209.52................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         cecum.
209.53................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         ascending colon.
209.54................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         transverse colon.
209.55................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         descending colon.
209.56................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         sigmoid colon.
209.57................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         rectum.
209.60................  Benign carcinoid tumor of      N................       17  843, 844, 845
                         unknown primary site.
209.61................  Benign carcinoid tumor of the  N................       04  180, 181, 182
                         bronchus and lung.
209.62................  Benign carcinoid tumor of the  N................       16  814, 815, 816
                         thymus.
209.63................  Benign carcinoid tumor of the  N................       06  393, 394, 395
                         stomach.
209.64................  Benign carcinoid tumor of the  N................       11  656, 657, 658, 686, 687, 688
                         kidney.
209.65................  Benign carcinoid tumor of      N................       06  393, 394, 395
                         foregut, not otherwise
                         specified.
209.66................  Benign carcinoid tumor of      N................       06  393, 394, 395
                         midgut, not otherwise
                         specified.
209.67................  Benign carcinoid tumor of      N................       06  393, 394, 395
                         hindgut, not otherwise
                         specified.
209.69................  Benign carcinoid tumor of      N................       17  843, 844, 845
                         other sites.
238.77................  Post-transplant                CC...............       21  919, 920, 921
                         lymphoproliferative disorder
                         (PTLD).
249.00................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         without mention of                                        637, 638, 639
                         complication, not stated as
                         uncontrolled, or unspecified.
249.01................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         without mention of                                        637, 638, 639
                         complication, uncontrolled.
249.10................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with ketoacidosis, not                                    637, 638, 639
                         stated as uncontrolled, or
                         unspecified.
249.11................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with ketoacidosis,                                        637, 638, 639,
                         uncontrolled.
249.20................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with hyperosmolarity, not                                 637, 638, 639
                         stated as uncontrolled, or
                         unspecified.
249.21................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with hyperosmolarity,                                     637, 638, 639
                         uncontrolled.
249.30................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with other coma, not stated                               637, 638, 639
                         as uncontrolled, or
                         unspecified.
249.31................  Secondary diabetes mellitus    MCC..............   PRE 10  008, 010
                         with other coma,                                          637, 638, 639
                         uncontrolled.
249.40................  Secondary diabetes mellitus    N................   PRE 11  008, 010
                         with renal manifestations,                                698, 699, 700
                         not stated as uncontrolled,
                         or unspecified.
249.41................  Secondary diabetes mellitus    N................   PRE 11  008, 010
                         with renal manifestations,                                698, 699, 700
                         uncontrolled.
249.50................  Secondary diabetes mellitus    N................   PRE 02  008, 010
                         with ophthalmic                                           124, 125
                         manifestations, not stated
                         as uncontrolled, or
                         unspecified.
249.51................  Secondary diabetes mellitus    N................   PRE 02  008, 010
                         with ophthalmic                                           124, 125
                         manifestations, uncontrolled.
249.60................  Secondary diabetes mellitus    N................   PRE 01  008, 010
                         with neurological                                         073, 074
                         manifestations, not stated
                         as uncontrolled, or
                         unspecified.
249.61................  Secondary diabetes mellitus    N................   PRE 01  008, 010
                         with neurological                                         073, 074
                         manifestations, uncontrolled.
249.70................  Secondary diabetes mellitus    N................   PRE 05  008, 010
                         with peripheral circulatory                               299, 300, 301
                         disorders, not stated as
                         uncontrolled, or unspecified.
249.71................  Secondary diabetes mellitus    N................   PRE 05  008, 010
                         with peripheral circulatory                               299, 300, 301
                         disorders, uncontrolled.
249.80................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         with other specified                                      637, 638, 639
                         manifestations, not stated
                         as uncontrolled, or
                         unspecified.
249.81................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         with other specified                                      637, 638, 639
                         manifestations, uncontrolled.
249.90................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         with unspecified                                          637, 638, 639
                         complication, not stated as
                         uncontrolled, or unspecified.
249.91................  Secondary diabetes mellitus    N................   PRE 10  008, 010
                         with unspecified                                          637, 638, 639
                         complication, uncontrolled.
259.50................  Androgen insensitivity,        N................       10  643, 644, 645
                         unspecified.
259.51................  Androgen insensitivity         N................       10  643, 644, 645
                         syndrome.
259.52................  Partial androgen               N................       10  643, 644, 645
                         insensitivity.
275.5.................  Hungry bone syndrome.........  N................       10  640, 641
279.50................  Graft-versus-host disease,     CC...............       16  808, 809, 810
                         unspecified.
279.51................  Acute graft-versus-host        CC...............       16  808, 809, 810
                         disease.
279.52................  Chronic graft-versus-host      CC...............       16  808, 809, 810
                         disease.
279.53................  Acute on chronic graft-versus- CC...............       16  808, 809, 810
                         host disease.
289.84................  Heparin-induced                N................       15  791 \2\, 793 \2\
                         thrombocytopenia (HIT).
                                                                               16  813

[[Page 23842]]

 
                                                                               25  977
337.00................  Idiopathic peripheral          N................       01  073, 074
                         autonomic neuropathy,
                         unspecified.
337.01................  Carotid sinus syndrome.......  N................       01  073, 074
337.09................  Other idiopathic peripheral    N................       01  073, 074
                         autonomic neuropathy.
339.00................  Cluster headache syndrome,     N................       01  102, 103
                         unspecified.
339.01................  Episodic cluster headache....  N................       01  102, 103
339.02................  Chronic cluster headache.....  N................       01  102, 103
339.03................  Episodic paroxysmal            N................       01  102, 103
                         hemicrania.
339.04................  Chronic paroxysmal hemicrania  N................       01  102, 103
339.05................  Short lasting unilateral       N................       01  102, 103
                         neuralgiform headache with
                         conjunctival injection and
                         tearing.
339.09................  Other trigeminal autonomic     N................       01  102, 103
                         cephalgias.
339.10................  Tension type headache,         N................       01  102, 103
                         unspecified.
339.11................  Episodic tension type          N................       01  102, 103
                         headache.
339.12................  Chronic tension type headache  N................       01  102, 103
339.20................  Post-traumatic headache,       N................       01  102, 103
                         unspecified.
339.21................  Acute post-traumatic headache  N................       01  102, 103
339.22................  Chronic post-traumatic         N................       01  102, 103
                         headache.
339.3.................  Drug induced headache, not     N................       01  102, 103
                         elsewhere classified.
339.41................  Hemicrania continua..........  N................       01  102, 103
339.42................  New daily persistent headache  N................       01  102, 103
339.43................  Primary thunderclap headache.  N................       01  102, 103
339.44................  Other complicated headache     N................       01  102, 103
                         syndrome.
339.81................  Hypnic headache..............  N................       01  102, 103
339.82................  Headache associated with       N................       01  102, 103
                         sexual activity.
339.83................  Primary cough headache.......  N................       01  102, 103
339.84................  Primary exertional headache..  N................       01  102, 103
339.85................  Primary stabbing headache....  N................       01  102, 103
339.89................  Other headache syndromes.....  N................       01  102, 103
346.02................  Migraine with aura, without    N................       01  102, 103
                         mention of intractable
                         migraine with status
                         migrainosus.
346.03................  Migraine with aura, with       N................       01  102, 103
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.12................  Migraine without aura,         N................       01  102, 103
                         without mention of
                         intractable migraine with
                         status migrainosus.
346.13................  Migraine without aura, with    N................       01  102, 103
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.22................  Variants of migraine, not      N................       01  102, 103
                         elsewhere classified,
                         without mention of
                         intractable migraine with
                         status migrainosus.
346.23................  Variants of migraine, not      N................       01  102, 103
                         elsewhere classified, with
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.30................  Hemiplegic migraine, without   N................       01  102, 103
                         mention of intractable
                         migraine without mention of
                         status migrainosus.
346.31................  Hemiplegic migraine, with      N................       01  102, 103
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.32................  Hemiplegic migraine, without   N................       01  102, 103
                         mention of intractable
                         migraine with status
                         migrainosus.
346.33................  Hemiplegic migraine, with      N................       01  102, 103
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.40................  Menstrual migraine, without    N................       01  102, 103
                         mention of intractable
                         migraine without mention of
                         status migrainosus.
346.41................  Menstrual migraine, with       N................       01  102, 103
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.42................  Menstrual migraine, without    N................       01  102, 103
                         mention of intractable
                         migraine with status
                         migrainosus.
346.43................  Menstrual migraine, with       N................       01  102, 103
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.50................  Persistent migraine aura       N................       01  102, 103
                         without cerebral infarction,
                         without mention of
                         intractable migraine without
                         mention of status
                         migrainosus.
346.51................  Persistent migraine aura       N................       01  102, 103
                         without cerebral infarction,
                         with intractable migraine,
                         so stated, without mention
                         of status migrainosus.
346.52................  Persistent migraine aura       N................       01  102, 103
                         without cerebral infarction,
                         without mention of
                         intractable migraine with
                         status migrainosus.
346.53................  Persistent migraine aura       N................       01  102, 103
                         without cerebral infarction,
                         with intractable migraine,
                         so stated, with status
                         migrainosus.
346.60................  Persistent migraine aura with  CC...............       01  102, 103
                         cerebral infarction, without
                         mention of intractable
                         migraine without mention of
                         status migrainosus.
346.61................  Persistent migraine aura with  CC...............       01  102, 103
                         cerebral infarction, with
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.62................  Persistent migraine aura with  CC...............       01  102, 103
                         cerebral infarction, without
                         mention of intractable
                         migraine with status
                         migrainosus.
346.63................  Persistent migraine aura with  CC...............       01  102, 103
                         cerebral infarction, with
                         intractable migraine, so
                         stated, with status
                         migrainosus.
346.70................  Chronic migraine without       N................       01  102, 103
                         aura, without mention of
                         intractable migraine without
                         mention of status
                         migrainosus.
346.71................  Chronic migraine without       N................       01  102, 103
                         aura, with intractable
                         migraine, so stated, without
                         mention of status
                         migrainosus.
346.72................  Chronic migraine without       N................       01  102, 103
                         aura, without mention of
                         intractable migraine with
                         status migrainosus.
346.73................  Chronic migraine without       N................       01  102, 103
                         aura, with intractable
                         migraine, so stated, with
                         status migrainosus.

[[Page 23843]]

 
346.82................  Other forms of migraine,       N................       01  102, 103
                         without mention of
                         intractable migraine with
                         status migrainosus.
346.83................  Other forms of migraine, with  N................       01  102, 103
                         intractable migraine, so
                         stated, with status
                         migrainosus.
362.20................  Retinopathy of prematurity,    N................       02  124, 125
                         unspecified.
362.22................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 0.
362.23................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 1.
362.24................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 2.
362.25................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 3.
362.26................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 4.
362.27................  Retinopathy of prematurity,    N................       02  124, 125
                         stage 5.
364.82................  Plateau iris syndrome........  N................       02  124, 125
372.34................  Pingueculitis................  N................       02  124, 125
414.3.................  Coronary atherosclerosis due   N................       05  302, 303
                         to lipid rich plaque.
511.81................  Malignant pleural effusion...  CC...............       04  180, 181, 182
511.89................  Other specified forms of       CC...............       04  186, 187, 188
                         effusion, except tuberculous.
                                                                               15  791 \2\, 793 \2\
569.44................  Dysplasia of anus............  N................       06  393, 394, 395
571.42................  Autoimmune hepatitis.........  N................       07  441, 442, 443
599.70................  Hematuria, unspecified.......  N................       11  695, 696
                                                                               15  791 \2\, 793 \2\
599.71................  Gross hematuria..............  N................       11  695, 696
                                                                               15  791 \2\, 793 \2\
599.72................  Microscopic hematuria........  N................       11  695, 696
                                                                               15  791 \2\, 793 \2\
611.81................  Ptosis of breast.............  N................       09  600, 601
611.82................  Hypoplasia of breast.........  N................       09  600, 601
611.83................  Capsular contracture of        N................       09  600, 601
                         breast implant.
611.89................  Other specified disorders of   N................       09  600, 601
                         breast.
612.0.................  Deformity of reconstructed     N................       09  600, 601
                         breast.
612.1.................  Disproportion of               N................       09  600, 601
                         reconstructed breast.
625.70................  Vulvodynia, unspecified......  N................       13  742, 743, 760, 761
625.71................  Vulvar vestibulitis..........  N................       13  742, 743, 757, 758, 759
625.79................  Other vulvodynia.............  N................       13  742, 743, 760, 761
649.70................  Cervical shortening,           CC...............       14  998
                         unspecified as to episode of
                         care or not applicable.
649.71................  Cervical shortening,           CC...............       14  765, 766, 767, 768, 774, 775
                         delivered, with or without
                         mention of antepartum
                         condition.
649.73................  Cervical shortening,           CC...............       14  781, 782
                         antepartum condition or
                         complication.
678.00................  Fetal hematologic conditions,  N................       14  998
                         unspecified as to episode of
                         care or not applicable.
678.01................  Fetal hematologic conditions,  N................       14  765, 766, 767, 768, 774, 775
                         delivered, with or without
                         mention of antepartum
                         condition.
678.03................  Fetal hematologic conditions,  N................       14  781, 782
                         antepartum condition or
                         complication.
678.10................  Fetal conjoined twins,         N................       14  998
                         unspecified as to episode of
                         care or not applicable.
678.11................  Fetal conjoined twins,         N................       14  765, 766, 767, 768, 774, 775
                         delivered, with or without
                         mention of antepartum
                         condition.
678.13................  Fetal conjoined twins,         N................       14  781, 782
                         antepartum condition or
                         complication.
679.00................  Maternal complications from    N................       14  765, 766, 767, 768, 774, 775
                         in utero procedure,
                         unspecified as to episode of
                         care or not applicable.
679.01................  Maternal complications from    N................       14  765, 766, 767, 768, 774
                         in utero procedure,
                         delivered, with or without
                         mention of antepartum
                         condition.
679.02................  Maternal complications from    N................       14  765, 766, 767, 768, 774
                         in utero procedure,
                         delivered, with mention of
                         postpartum complication.
679.03................  Maternal complications from    N................       14  781, 782
                         in utero procedure,
                         antepartum condition or
                         complication.
679.04................  Maternal complications from    N................       14  769, 776
                         in utero procedure,
                         postpartum condition or
                         complication.
679.10................  Fetal complications from in    N................       14  998
                         utero procedures,
                         unspecified as to episode of
                         care or not applicable.
679.11................  Fetal complications from in    N................       14  765, 766, 767, 768, 774, 775
                         utero procedures, delivered,
                         with or without mention of
                         antepartum condition.
679.12................  Fetal complications from in    N................       14  765, 766, 767, 768, 774, 775
                         utero procedures, delivered,
                         with mention of postpartum
                         complication.
679.13................  Fetal complications from in    N................       14  781, 782
                         utero procedures, antepartum
                         condition or complication.
679.14................  Fetal complications from in    N................       14  769, 776
                         utero procedures, postpartum
                         condition or complication.
695.10................  Erythema multiforme,           N................       09  595, 596
                         unspecified.
695.11................  Erythema multiforme minor....  N................       09  595, 596
695.12................  Erythema multiforme major....  CC...............       09  595, 596
695.13................  Stevens-Johnson syndrome.....  CC...............       09  595, 596
695.14................  Stevens-Johnson syndrome-      CC...............       09  595, 596
                         toxic epidermal necrolysis
                         overlap syndrome.
695.15................  Toxic epidermal necrolysis...  CC...............       09  595, 596
695.19................  Other erythema multiforme....  N................       09  595, 596
695.50................  Exfoliation due to             N................       09  606, 607
                         erythematous condition
                         involving less than 10
                         percent of body surface.

[[Page 23844]]

 
695.51................  Exfoliation due to             N................       09  606, 607
                         erythematous condition
                         involving 10-19 percent of
                         body surface.
695.52................  Exfoliation due to             N................       09  606, 607
                         erythematous condition
                         involving 20-29 percent of
                         body surface.
695.53................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 30-39 percent of
                         body surface.
695.54................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 40-49 percent of
                         body surface.
695.55................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 50-59 percent of
                         body surface.
695.56................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 60-69 percent of
                         body surface.
695.57................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 70-79 percent of
                         body surface.
695.58................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 80-89 percent of
                         body surface.
695.59................  Exfoliation due to             CC...............       09  606, 607
                         erythematous condition
                         involving 90 percent or more
                         of body surface.
707.20................  Pressure ulcer, unspecified    N................       09  573, 574, 575, 592, 593, 594
                         stage.
707.21................  Pressure ulcer, stage I......  N................       09  573, 574, 575, 592, 593, 594
707.22................  Pressure ulcer, stage II.....  N................       09  573, 574, 575, 592, 593, 594
707.23................  Pressure ulcer, stage III....  MCC \3\..........       09  573, 574, 575, 592, 593, 594
707.24................  Pressure ulcer, stage IV.....  MCC \3\..........       09  573, 574, 575, 592, 593, 594
729.90................  Disorders of soft tissue,      N................       08  555, 556
                         unspecified.
729.91................  Post-traumatic seroma........  N................       08  555, 556
729.92................  Nontraumatic hematoma of soft  N................       08  555, 556
                         tissue.
729.99................  Other disorders of soft        N................       08  555, 556
                         tissue.
760.61................  Newborn affected by            N................       15  794
                         amniocentesis.
760.62................  Newborn affected by other in   N................       15  794
                         utero procedure.
760.63................  Newborn affected by other      N................       15  794
                         surgical operations on
                         mother during pregnancy.
760.64................  Newborn affected by previous   N................       15  794
                         surgical procedure on mother
                         not associated with
                         pregnancy.
777.50................  Necrotizing enterocolitis in   MCC..............       15  791 \4\, 793 \4\
                         newborn, unspecified.
777.51................  Stage I necrotizing            MCC..............       15  791 \4\, 793 \4\
                         enterocolitis in newborn.
777.52................  Stage II necrotizing           MCC..............       15  791 \4\, 793 \4\
                         enterocolitis in newborn.
777.53................  Stage III necrotizing          MCC..............       15  791 \4\, 793 \4\
                         enterocolitis in newborn.
780.72................  Functional quadriplegia......  MCC..............       01  052, 053
788.91................  Functional urinary             N................       11  695, 696
                         incontinence.
788.99................  Other symptoms involving       N................       11  695, 696
                         urinary system.
795.07................  Satisfactory cervical smear    N................       13  742, 743, 760, 761
                         but lacking transformation
                         zone.
795.10................  Abnormal glandular             N................       13  742, 743, 760, 761
                         Papanicolaou smear of vagina.
795.11................  Papanicolaou smear of vagina   N................       13  742, 743, 760, 761
                         with atypical squamous cells
                         of undetermined significance
                         (ASC-US).
795.12................  Papanicolaou smear of vagina   N................       13  742, 743, 760, 761
                         with atypical squamous cells
                         cannot exclude high grade
                         squamous intraepithelial
                         lesion (ASC-H).
795.13................  Papanicolaou smear of vagina   N................       13  742, 743, 760, 761
                         with low grade squamous
                         intraepithelial lesion
                         (LGSIL).
795.14................  Papanicolaou smear of vagina   N................       13  742, 743, 760, 761
                         with high grade squamous
                         intraepithelial lesion
                         (HGSIL).
795.15................  Vaginal high risk human        N................       13  742, 743, 760, 761
                         papillomavirus (HPV) DNA
                         test positive.
795.16................  Papanicolaou smear of vagina   N................       13  742, 743, 760, 761
                         with cytologic evidence of
                         malignancy.
795.18................  Unsatisfactory vaginal         N................       13  742, 743, 760, 761
                         cytology smear.
795.19................  Other abnormal Papanicolaou    N................       13  742, 743, 760, 761
                         smear of vagina and vaginal
                         HPV.
796.70................  Abnormal glandular             N................       06  393, 394, 395
                         Papanicolaou smear of anus.
796.71................  Papanicolaou smear of anus     N................       06  393, 394, 395
                         with atypical squamous cells
                         of undetermined significance
                         (ASC-US).
796.72................  Papanicolaou smear of anus     N................       06  393, 394, 395
                         with atypical squamous cells
                         cannot exclude high grade
                         squamous intraepithelial
                         lesion (ASC-H).
796.73................  Papanicolaou smear of anus     N................       06  393, 394, 395
                         with low grade squamous
                         intraepithelial lesion
                         (LGSIL).
796.74................  Papanicolaou smear of anus     N................       06  393, 394, 395
                         with high grade squamous
                         intraepithelial lesion
                         (HGSIL).
796.75................  Anal high risk human           N................       06  393, 394, 395
                         papillomavirus (HPV) DNA
                         test positive.
796.76................  Papanicolaou smear of anus     N................       06  393, 394, 395
                         with cytologic evidence of
                         malignancy.
796.77................  Satisfactory anal smear but    N................       06  393, 394, 395
                         lacking transformation zone.
796.78................  Unsatisfactory anal cytology   N................       06  393, 394, 395
                         smear.
796.79................  Other abnormal Papanicolaou    N................       06  393, 394, 395
                         smear of anus and anal HPV.
997.31................  Ventilator associated          CC...............       04  205, 206
                         pneumonia.
                                                                               15  791 \2\, 793 \2\
997.39................  Other respiratory              CC...............       04  205, 206
                         complications.
                                                                               15  791 \2\, 793 \2\
998.30................  Disruption of wound,           CC...............       21  919, 920, 921
                         unspecified.

[[Page 23845]]

 
998.33................  Disruption of traumatic wound  CC...............       21  919, 920, 921
                         repair.
999.81................  Extravasation of vesicant      CC...............       05  314, 315, 316
                         chemotherapy.
                                                                               15  791 \2\, 793 \2\
999.82................  Extravasation of other         CC...............       05  314, 315, 316
                         vesicant agent.
                                                                               15  791 \2\, 793 \2\
999.88................  Other infusion reaction......  N................       05  314, 315, 316
                                                                               15  791 \2\, 793 \2\
999.89................  Other transfusion reaction...  N................       15  791 \2\, 793 \2\
                                                                               16  811, 812
V07.51................  Prophylactic use of selective  N................       23  951
                         estrogen receptor modulators
                         (SERMs).
V07.52................  Prophylactic use of aromatase  N................       23  951
                         inhibitors.
V07.59................  Prophylactic use of other      N................       23  951
                         agents affecting estrogen
                         receptors and estrogen
                         levels.
V13.51................  Personal history of            N................       23  951
                         pathologic fracture.
V13.52................  Personal history of stress     N................       23  951
                         fracture.
V13.59................  Personal history of other      N................       23  951
                         musculoskeletal disorders.
V15.21................  Personal history of            N................       23  951
                         undergoing in utero
                         procedure during pregnancy.
V15.22................  Personal history of            N................       23  951
                         undergoing in utero
                         procedure while a fetus.
V15.29................  Personal history of surgery    N................       23  951
                         to other organs.
V15.51................  Personal history of traumatic  N................       23  951
                         fracture.
V15.59................  Personal history of other      N................       23  951
                         injury.
V23.85................  Pregnancy resulting from       N................       14  998
                         assisted reproductive
                         technology.
V23.86................  Pregnancy with history of in   N................       14  998
                         utero procedure during
                         previous pregnancy.
V28.81................  Encounter for fetal anatomic   N................       23  951
                         survey.
V28.82................  Encounter for screening for    N................       23  951
                         risk of pre-term labor.
V28.89................  Other specified antenatal      N................       23  951
                         screening.
V45.11................  Renal dialysis status........  N................       23  951
V45.12................  Noncompliance with renal       N................       23  951
                         dialysis.
V45.87................  Transplanted organ removal     N................       23  951
                         status.
V46.3.................  Wheelchair dependence........  N................       23  951
V51.0.................  Encounter for breast           N................       09  606, 607
                         reconstruction following
                         mastectomy.
V51.8.................  Other aftercare involving the  N................       09  606, 607
                         use of plastic surgery.
V87.01................  Contact with and (suspected)   N................       23  951
                         exposure to arsenic.
V87.09................  Contact with and (suspected)   N................       23  951
                         exposure to other hazardous
                         metals.
V87.11................  Contact with and (suspected)   N................       23  951
                         exposure to aromatic amines.
V87.12................  Contact with and (suspected)   N................       23  951
                         exposure to benzene.
V87.19................  Contact with and (suspected)   N................       23  951
                         exposure to other hazardous
                         aromatic compounds.
V87.2.................  Contact with and (suspected)   N................       23  951
                         exposure to other
                         potentially hazardous
                         chemicals.
V87.31................  Contact with and (suspected)   N................       23  951
                         exposure to mold.
V87.39................  Contact with and (suspected)   N................       23  951
                         exposure to other
                         potentially hazardous
                         substances.
V87.41................  Personal history of            N................       23  949, 950
                         antineoplastic chemotherapy.
V87.42................  Personal history of            N................       23  949, 950
                         monoclonal drug therapy.
V87.49................  Personal history of other      N................       23  949, 950
                         drug therapy.
V88.01................  Acquired absence of both       N................       13  742, 743, 760, 761
                         cervix and uterus.
V88.02................  Acquired absence of uterus     N................       13  742, 743, 760, 761
                         with remaining cervical
                         stump.
V88.03................  Acquired absence of cervix     N................       13  742, 743, 760, 761
                         with remaining uterus.
V89.01................  Suspected problem with         N................       23  951
                         amniotic cavity and membrane
                         not found.
V89.02................  Suspected placental problem    N................       23  951
                         not found.
V89.03................  Suspected fetal anomaly not    N................       23  951
                         found.
V89.04................  Suspected problem with fetal   N................       23  951
                         growth not found.
V89.05................  Suspected cervical shortening  N................       23  951
                         not found.
V89.09................  Other suspected maternal and   N................       23  951
                         fetal condition not found.
----------------------------------------------------------------------------------------------------------------
\1\ Secondary diagnosis of acute leukemia
\2\ Secondary diagnosis of major problem.
\3\ The pressure ulcer site specific codes (707.00-707.09) will be non-CCs. The pressure ulcer stage III and IV
  codes will be classified as MCCs.
\4\ Principal or secondary diagnosis of major problem.


                                         Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
    Procedure code               Description                  O.R.          MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
00.49.................  SuperSaturated oxygen therapy  N.
00.58.................  Insertion of intra-aneurysm    N.
                         sac pressure monitoring
                         device (intraoperative).
00.59.................  Intravascular pressure         N.
                         measurement of coronary
                         arteries.
00.67.................  Intravascular pressure         N.
                         measurement of intrathoracic
                         arteries.
00.68.................  Intravascular pressure         N.
                         measurement of peripheral
                         arteries.
00.69.................  Intravascular pressure         N.
                         measurement, other specified
                         and unspecified vessels.

[[Page 23846]]

 
17.11.................  Laparoscopic repair of direct  Y................       06  350, 351, 352
                         inguinal hernia with graft
                         or prosthesis.
17.12.................  Laparoscopic repair of         Y................       06  350, 351, 352
                         indirect inguinal hernia
                         with graft or prosthesis.
17.13.................  Laparoscopic repair of         Y................       06  350, 351, 352
                         inguinal hernia with graft
                         or prosthesis, not otherwise
                         specified.
17.21.................  Laparoscopic bilateral repair  Y................       06  350, 351, 352
                         of direct inguinal hernia
                         with graft or prosthesis.
17.22.................  Laparoscopic bilateral repair  Y................       06  350, 351, 352
                         of indirect inguinal hernia
                         with graft or prosthesis.
17.23.................  Laparoscopic bilateral repair  Y................       06  350, 351, 352
                         of inguinal hernia, one
                         direct and one indirect,
                         with graft or prosthesis.
17.24.................  Laparoscopic bilateral repair  Y................       06  350, 351, 352
                         of inguinal hernia with
                         graft or prosthesis, not
                         otherwise specified.
17.31.................  Laparoscopic multiple          Y................       06  329, 330, 331
                         segmental resection of large
                         intestine.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.32.................  Laparoscopic cecectomy.......  Y................       05  264
                                                                               06  329, 330, 331
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.33.................  Laparoscopic right             Y................       05  264
                         hemicolectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.34.................  Laparoscopic resection of      Y................       05  264
                         transverse colon.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.35.................  Laparoscopic left              Y................       05  264
                         hemicolectomy.
                                                                               06  329, 330, 331
                                                                               10  628, 629, 630
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.36.................  Laparoscopic sigmoidectomy...  Y................       06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
17.39.................  Other laparoscopic partial     Y................       05  264
                         excision of large intestine.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
37.36.................  Excision or destruction of     N.
                         left atrial appendage (LAA).
37.55.................  Removal of internal            Y................      PRE  001, 002
                         biventricular heart
                         replacement system.
                                                                               05  237, 238
38.23.................  Intravascular spectroscopy...  N.
45.81.................  Laparoscopic total intra-      Y................       05  264
                         abdominal colectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.82.................  Open total intra-abdominal     Y................       05  264
                         colectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.83.................  Other and unspecified total    Y................       05  264
                         intra-abdominal colectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.40.................  Pull-through resection of      Y................       06  332, 333, 334
                         rectum, not otherwise
                         specified.

[[Page 23847]]

 
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.42.................  Laparoscopic pull-through      Y................       06  332, 333, 334
                         resection of rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.43.................  Open pull-through resection    Y................       06  332, 333, 334
                         of rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.50.................  Abdominoperineal resection of  Y................       06  332, 333, 334
                         the rectum, not otherwise
                         specified.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.51.................  Laparoscopic abdominoperineal  Y................       06  332, 333, 334
                         resection of the rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.52.................  Open abdominoperineal          Y................       06  332, 333, 334
                         resection of the rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.59.................  Other abdominoperineal         Y................       06  332, 333, 334
                         resection of the rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.42.................  Laparoscopic repair of         Y................       06  353, 354, 355
                         umbilical hernia with graft
                         or prosthesis.
53.43.................  Other laparoscopic umbilical   Y................       06  353, 354, 355
                         herniorrhaphy.
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.62.................  Laparoscopic incisional        Y................       06  353, 354, 355
                         hernia repair with graft or
                         prosthesis.
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.63.................  Other laparoscopic repair of   Y................       06  353, 354, 355
                         other hernia of anterior
                         abdominal wall with graft or
                         prosthesis.
53.71.................  Laparoscopic repair of         Y................       04  163, 164, 165
                         diaphragmatic hernia,
                         abdominal approach.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.72.................  Other and open repair of       Y................       04  163, 164, 165
                         diaphragmatic hernia,
                         abdominal approach.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.75.................  Repair of diaphragmatic        Y................       04  163, 164, 165
                         hernia, abdominal approach,
                         not otherwise specified.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.83.................  Laparoscopic repair of         Y................       04  163, 164, 165
                         diaphragmatic hernia, with
                         thoracic approach.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.84.................  Other and open repair of       Y................       04  163, 164, 165
                         diaphragmatic hernia, with
                         thoracic approach.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
80.53.................  Repair of the anulus fibrosus  Y................       01  028, 029, 030
                         with graft or prosthesis.
                                                                               08  490, 491
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
80.54.................  Other and unspecified repair   Y................       01  028, 029, 030
                         of the anulus fibrosus.
                                                                               08  490, 491
                                                                               17  820, 821, 822, 826, 827, 828

[[Page 23848]]

 
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
----------------------------------------------------------------------------------------------------------------


                                       Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
    Diagnosis code               Description                   CC           MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
046.1.................  Jakob-Creutzfeldt disease....  CC...............       01  056, 057
051.0.................  Cowpox.......................  N................       18  865, 866
136.2.................  Specific infections by free-   MCC..............       18  867, 868, 869
                         living amebae.
259.5.................  Androgen insensitivity         N................       10  643, 644, 645
                         syndrome.
337.0.................  Idiopathic peripheral          CC...............       01  073, 074
                         autonomic neuropathy.
511.8.................  Other specified forms of       MCC..............       04  186, 187, 188
                         pleural effusion, except
                         tuberculous.
                                                                               15  791 \1\, 793 \1\
599.7.................  Hematuria....................  N................       11  695, 696
                                                                               15  791 \1\, 793 \1\
611.8.................  Other specified disorders of   N................       09  600, 601
                         breast.
695.1.................  Erythema multiforme..........  CC...............       09  595, 596
729.9.................  Other and unspecified          N................       08  555, 556
                         disorders of soft tissue.
760.6.................  Surgical operation on mother.  N................       15  794
777.5.................  Necrotizing enterocolitis in   MCC..............       15  791 \2\, 793 \2\
                         fetus or newborn.
788.9.................  Other symptoms involving       N................       11  695, 696
                         urinary system.
795.1.................  Nonspecific abnormal           N................       04  180, 181, 182
                         Papanicolaou smear of other
                         site.
997.3.................  Respiratory complications....  CC...............       04  205, 206
                                                                               15  791 \1\, 793 \1\
999.8.................  Other transfusion reaction...  CC...............       15  791 \1\, 793 \1\
                                                                               16  811, 812
V13.5.................  Personal history of other      N................       23  951
                         musculoskeletal disorders.
V15.2.................  Personal history of surgery    N................       23  951
                         to other major organs.
V15.5.................  Personal history of injury...  N................       23  951
V28.8.................  Encounter for other specified  N................       23  951
                         antenatal screening.
V45.1.................  Renal dialysis status........  N................       23  951
V51...................  Aftercare involving the use    N................       09  606, 607
                         of plastic surgery.
----------------------------------------------------------------------------------------------------------------
\1\ Principal or secondary diagnosis of major problem.
\2\ Principal or secondary diagnosis of major problem.


                                       Table 6D.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
    Procedure code               Description                  O.R.          MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
                                                                          .......  .............................
45.8..................  Total intra-abdominal          Y................       05  264
                         colectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
48.5..................  Abdominoperineal resection of  Y................       06  332, 333, 334
                         rectum.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.7..................  Repair of diaphragmatic        Y................       04  163, 164, 165
                         hernia, abdominal approach.
                                                                               06  326, 327, 328
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
----------------------------------------------------------------------------------------------------------------


                                    Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
    Diagnosis code               Description                   CC           MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
203.00................  Multiple myeloma, without      CC...............       17  820, 821, 822, 823, 824, 825,
                         mention of having achieved                                 840, 841, 842
                         remission.

[[Page 23849]]

 
203.10................  Plasma cell leukemia, without  CC...............       17  820, 821, 822, 823, 824, 825,
                         mention of having achieved                                 840, 841, 842
                         remission.
203.80................  Other immunoproliferative      CC...............       17  820, 821, 822, 823, 824, 825,
                         neoplasms, without mention                                 840, 841, 842
                         of having achieved remission.
204.00................  Acute lymphoid leukemia,       CC...............       17  820, 821, 822, 834, 835, 836,
                         without mention of having                                  837 \1\, 838 \1\, 839 \1\
                         achieved remission.
204.10................  Chronic lymphoid leukemia,     CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
204.20................  Subacute lymphoid leukemia,    CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
204.80................  Other lymphoid leukemia,       CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
204.90................  Unspecified lymphoid           CC...............       17  820, 821, 822, 823, 824, 825,
                         leukemia, without mention of                               840, 841, 842
                         having achieved remission.
205.00................  Acute myeloid leukemia,        CC...............       17  820, 821, 822, 834, 835, 836,
                         without mention of having                                  837 \1\, 838 \1\, 839 \1\
                         achieved remission.
205.10................  Chronic myeloid leukemia,      CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
205.20................  Subacute myeloid leukemia,     CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
205.30................  Myeloid sarcoma, without       CC...............       17  820, 821, 822, 823, 824, 825,
                         mention of having achieved                                 840, 841, 842
                         remission.
205.80................  Other myeloid leukemia,        CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
205.90................  Unspecified myeloid leukemia,  CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
206.00................  Acute monocytic leukemia,      CC...............       17  820, 821, 822, 834, 835, 836,
                         without mention of having                                  837 \1\, 838 \1\, 839 \1\
                         achieved remission.
206.10................  Chronic monocytic leukemia,    CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
206.20................  Subacute monocytic leukemia,   CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
206.80................  Other monocytic leukemia,      CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
206.90................  Unspecified monocytic          CC...............       17  820, 821, 822, 823, 824, 825,
                         leukemia, without mention of                               840, 841, 842
                         having achieved remission.
207.00................  Acute erythremia and           CC...............       17  820, 821, 822, 834, 835, 836,
                         erythroleukemia, without                                   837 \1\, 838 \1\, 839 \1\
                         mention of having achieved
                         remission.
207.10................  Chronic erythremia, without    CC...............       17  820, 821, 822, 823, 824, 825,
                         mention of having achieved                                 840, 841, 842
                         remission.
207.20................  Megakaryocytic leukemia,       CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.
207.80................  Other specified leukemia,      CC...............       17  820, 821, 822, 823, 824, 825,
                         without mention of having                                  840, 841, 842
                         achieved remission.

[[Page 23850]]

 
208.00................  Acute leukemia of unspecified  CC...............       17  820, 821, 822, 834, 835, 836,
                         cell type, without mention                                 837 \1\, 838 \1\, 839 \1\
                         of having achieved remission.
208.10................  Chronic leukemia of            CC...............       17  820, 821, 822, 823, 824, 825,
                         unspecified cell type,                                     840, 841, 842
                         without mention of having
                         achieved remission.
208.20................  Subacute leukemia of           CC...............       17  820, 821, 822, 823, 824, 825,
                         unspecified cell type,                                     840, 841, 842
                         without mention of having
                         achieved remission.
208.80................  Other leukemia of unspecified  CC...............       17  820, 821, 822, 823, 824, 825,
                         cell type, without mention                                 840, 841, 842
                         of having achieved remission.
208.90................  Unspecified leukemia, without  CC...............       17  820, 821, 822, 823, 824, 825,
                         mention of having achieved                                 840, 841, 842
                         remission.
346.00................  Migraine with aura, without    N................       01  102, 103
                         mention of intractable
                         migraine without mention of
                         status migrainosus.
346.01................  Migraine with aura, with       N................       01  102, 103
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.10................  Migraine without aura,         N................       01  102, 103
                         without mention of
                         intractable migraine without
                         mention of status
                         migrainosus.
346.11................  Migraine without aura, with    N................       01  102, 103
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.20................  Variants of migraine, not      N................       01  102, 103
                         elsewhere classified,
                         without mention of
                         intractable migraine without
                         mention of status
                         migrainosus.
346.21................  Variants of migraine, not      N................       01  102, 103
                         elsewhere classified, with
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
346.80................  Other forms of migraine,       N................       01  102, 103
                         without mention of
                         intractable migraine without
                         mention of status
                         migrainosus.
346.81................  Other forms of migraine, with  N................       01  102, 103
                         intractable migraine, so
                         stated, without mention of
                         status migrainosus.
386.00................  M[eacute]ni[egrave]re's        N................       03  149
                         disease, unspecified.
386.01................  Active                         N................       03  149
                         M[eacute]ni[egrave]re's
                         disease, cochleovestibular.
386.02................  Active                         N................       03  149
                         M[eacute]ni[egrave]re's
                         disease, cochlear.
386.03................  Active                         N................       03  149
                         M[eacute]ni[egrave]re's
                         disease, vestibular.
386.04................  Inactive                       N................       03  149
                         M[eacute]ni[egrave]re's
                         disease.
707.00................  Pressure ulcer, unspecified    N \2\............       09  573, 574, 575, 592, 593, 594
                         site.
707.01................  Pressure ulcer, elbow........  N \2\............       09  573, 574, 575, 592, 593, 594
707.02................  Pressure ulcer, upper back...  N \2\............       09  573, 574, 575, 592, 593, 594
707.03................  Pressure ulcer, lower back...  N \2\............       09  573, 574, 575, 592, 593, 594
707.04................  Pressure ulcer, hip..........  N \2\............       09  573, 574, 575, 592, 593, 594
707.05................  Pressure ulcer, buttock......  N \2\............       09  573, 574, 575, 592, 593, 594
707.06................  Pressure ulcer, ankle........  N \2\............       09  573, 574, 575, 592, 593, 594
707.07................  Pressure ulcer, heel.........  N \2\............       09  573, 574, 575, 592, 593, 594
707.09................  Pressure ulcer, other site...  N \2\............       09  573, 574, 575, 592, 593, 594
776.9.................  Unspecified hematological      N................       15  794
                         disorder specific to newborn.
795.08................  Unsatisfactory cervical        N................       13  742, 743, 760, 761
                         cytology smear.
998.31................  Disruption of internal         CC...............       21  919, 920, 921
                         operation (surgical) wound.
V28.3.................  Encounter for routine          N................       23  951
                         screening for malformation
                         using ultrasonics.
V45.71................  Acquired absence of breast     N................       23  951
                         and nipple.
----------------------------------------------------------------------------------------------------------------
\1\ Secondary diagnosis of acute leukemia.
\2\ The pressure ulcer site specific codes (707.00-707.09) will be non-CCs. The pressure ulcer stage III and IV
  codes will be classified as MCCs.


[[Page 23851]]


                                    Table 6F.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
    Procedure code               Description                  O.R.          MDC                MS-DRG
----------------------------------------------------------------------------------------------------------------
37.52.................  Implantation of internal       Y................      PRE  001 \1\, 002 \1\
                         biventricular heart
                         replacement system.
37.53.................  Replacement or repair of       Y................       05  215
                         thoracic unit of (total)
                         replacement heart system.
37.54.................  Replacement or repair of       Y................       05  215
                         other implantable component
                         of (total) replacement heart
                         system.
45.71.................  Open and other multiple        Y................       06  329, 330, 331
                         segmental resection of large
                         intestine.
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.72.................  Open and other cecectomy.....  Y................       05  264
                                                                               06  329, 330, 331
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.73.................  Open and other right           Y................       05  264
                         hemicolectomy.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.74.................  Open and other resection of    Y................       05  264
                         transverse colon.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.75.................  Open and other left            Y................       05  264
                         hemicolectomy.
                                                                               06  329, 330, 331
                                                                               10  628, 629, 630
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.76.................  Open and other sigmoidectomy.  Y................       06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
45.79.................  Other and unspecified partial  Y................       05  264
                         excision of large intestine.
                                                                               06  329, 330, 331
                                                                               17  820, 821, 822, 826, 827, 828
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.01.................  Other and open repair of       Y................       06  350, 351, 352
                         direct inguinal hernia.
53.02.................  Other and open repair of       Y................       06  350, 351, 352
                         indirect inguinal hernia.
53.03.................  Other and open repair of       Y................       06  350, 351, 352
                         direct inguinal hernia with
                         graft or prosthesis.
53.04.................  Other and open repair of       Y................       06  350, 351, 352
                         indirect inguinal hernia
                         with graft or prosthesis.
53.11.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of direct inguinal
                         hernia.
53.12.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of indirect inguinal
                         hernia.
53.13.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of inguinal hernia,
                         one direct and one indirect.
53.14.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of direct inguinal
                         hernia with graft or
                         prosthesis.
53.15.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of indirect inguinal
                         hernia with graft or
                         prosthesis.
53.16.................  Other and open bilateral       Y................       06  350, 351, 352
                         repair of inguinal hernia,
                         one direct and one indirect,
                         with graft or prosthesis.
53.41.................  Other and open repair of       Y................       06  353, 354, 355
                         umbilical hernia with graft
                         or prosthesis.
53.49.................  Other open umbilical           Y................       06  353, 354, 355
                         herniorrhaphy.
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.61.................  Other open incisional hernia   Y................       06  353, 354, 355
                         repair with graft or
                         prosthesis.
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
53.69.................  Other and open repair of       Y................       06  353, 354, 355
                         other hernia of anterior
                         abdominal wall with graft or
                         prosthesis.
81.65.................  Percutaneous vertebroplasty..  Y................       08  515, 516, 517
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
81.66.................  Percutaneous vertebral         Y................       08  515, 516, 517
                         augmentation.
                                                                               21  907, 908, 909
                                                                               24  957, 958, 959
----------------------------------------------------------------------------------------------------------------
\1\ Note MS-DRG change.


[[Page 23852]]


     Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007 Grouper V25.0 MS-DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Number of    Arithmetic      10th         25th         50th         75th         90th
                            MS-DRG                              discharges    mean LOS    percentile   percentile   percentile   percentile   percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................          655      40.2107           12           17           31           51           83
2............................................................          287      24.7456            9           12           17           28           48
3............................................................       23,205      39.6406           16           22           32           48           68
4............................................................       21,267      28.8412           11           17           24           35           49
5............................................................          635      21.1717            7           10           15           26           42
6............................................................          229      10.2576            6            7            9           12           17
7............................................................          356      19.6517            8           10           15           22           38
8............................................................          483      11.9337            6            7            9           13           20
9............................................................        1,346      21.9725            8           16           20           25           35
10...........................................................          163      10.7791            6            7            8           11           19
11...........................................................        1,264      16.7302            6            9           13           20           30
12...........................................................        1,907      10.6754            4            6            9           13           18
13...........................................................        1,268       6.9267            3            4            6            8           11
20...........................................................          885      18.3525            6           10           17           24           32
21...........................................................          530      15.4472            8           11           14           19           25
22...........................................................          212       9.3726            2            6            9           12           15
23...........................................................        3,730      12.6794            2            5           10           17           25
24...........................................................        2,092       9.0263            1            4            8           12           18
25...........................................................        8,697      13.0331            4            6           10           17           25
26...........................................................       11,781       8.2206            2            4            7           11           15
27...........................................................       13,695       4.5403            1            2            4            6            9
28...........................................................        1,666      14.3055            4            7           11           18           27
29...........................................................        3,070       7.1091            1            3            6            9           14
30...........................................................        3,398       3.7310            1            1            3            5            7
31...........................................................        1,024      13.1377            3            6           10           18           27
32...........................................................        2,780       5.9781            1            2            4            8           14
33...........................................................        3,623       3.0395            1            1            2            4            6
34...........................................................          765       7.2261            1            2            5            9           15
35...........................................................        2,239       3.2823            1            1            2            4            8
36...........................................................        6,947       1.5949            1            1            1            2            3
37...........................................................        4,841       8.5478            2            3            7           11           17
38...........................................................       14,146       3.7666            1            1            2            5            9
39...........................................................       51,927       1.8278            1            1            1            2            3
40...........................................................        4,766      13.3479            3            6           10           17           25
41...........................................................        7,573       7.2006            1            3            6            9           14
42...........................................................        4,859       3.6300            1            1            2            5            8
52...........................................................        1,163       6.7395            2            3            5            8           14
53...........................................................          587       4.0102            1            2            3            5            7
54...........................................................        5,240       6.9504            2            3            5            9           14
55...........................................................       16,289       5.0708            1            2            4            6           10
56...........................................................        8,250       7.7668            2            3            6            9           14
57...........................................................       47,224       4.9743            2            3            4            6            9
58...........................................................          736       7.5978            2            4            6            9           15
59...........................................................        2,752       5.1432            2            3            4            6            9
60...........................................................        4,068       3.9668            2            2            4            5            7
61...........................................................        1,586       8.9426            2            4            7           11           17
62...........................................................        2,464       6.2683            3            4            5            8           11
63...........................................................        1,323       4.5110            2            3            4            6            8
64...........................................................       55,734       7.4669            2            3            6           10           15
65...........................................................      105,000       5.2179            2            3            4            6            9
66...........................................................       89,325       3.7141            1            2            3            5            7
67...........................................................        1,397       5.8232            2            3            5            7           11
68...........................................................       11,402       3.4467            1            2            3            4            6
69...........................................................      101,817       2.9920            1            2            2            4            5
70...........................................................        7,341       7.8574            2            4            6           10           15
71...........................................................        9,526       5.5568            2            3            4            7           10
72...........................................................        5,739       3.5389            1            2            3            4            7
73...........................................................        9,223       6.2394            2            3            5            8           12
74...........................................................       31,500       4.3070            1            2            3            5            8
75...........................................................        1,238       7.3021            2            4            6            9           14
76...........................................................          873       4.1340            2            2            4            5            7
77...........................................................        1,211       6.6821            2            3            5            9           12
78...........................................................        1,405       4.4157            2            2            4            6            8
79...........................................................          931       3.3845            1            2            3            4            6
80...........................................................        1,861       5.1016            1            2            4            6           10
81...........................................................        7,124       3.5267            1            2            3            4            6
82...........................................................        1,757       6.4087            1            1            4            9           15
83...........................................................        2,049       4.9551            1            2            4            7           10
84...........................................................        2,769       3.1268            1            1            2            4            6
85...........................................................        5,879       7.6399            2            3            6           10           15

[[Page 23853]]

 
86...........................................................       11,469       5.0021            1            3            4            6            9
87...........................................................       12,958       3.2740            1            2            3            4            6
88...........................................................          711       5.8748            1            3            4            7           12
89...........................................................        2,733       3.7603            1            2            3            5            7
90...........................................................        3,089       2.5494            1            1            2            3            5
91...........................................................        7,605       6.3657            2            3            5            8           13
92...........................................................       16,265       4.4647            1            2            4            6            8
93...........................................................       16,121       3.2188            1            2            3            4            6
94...........................................................        1,473      11.8547            4            6           10           15           22
95...........................................................        1,030       8.6359            3            5            7           11           15
96...........................................................          757       6.1744            2            4            6            8           11
97...........................................................        1,192      12.6023            4            7           11           16           23
98...........................................................        1,005       8.3522            3            5            7           10           15
99...........................................................          641       5.8752            2            3            5            8           11
100..........................................................       16,989       6.3526            2            3            5            8           12
101..........................................................       56,991       3.6950            1            2            3            5            7
102..........................................................        1,080       4.5306            1            2            3            6            9
103..........................................................       13,735       3.1270            1            2            2            4            6
113..........................................................          525       5.5981            1            2            4            8           12
114..........................................................          555       2.6090            1            1            2            3            5
115..........................................................        1,046       4.3222            1            2            4            5            7
116..........................................................          546       4.0678            1            1            2            5            8
117..........................................................          996       2.1596            1            1            1            2            3
121..........................................................          542       5.4576            2            3            4            7           10
122..........................................................          617       4.0454            2            2            3            5            7
123..........................................................        2,785       2.8747            1            2            2            4            5
124..........................................................          749       5.2697            1            2            4            7           10
125..........................................................        4,661       3.5134            1            2            3            4            7
129..........................................................        1,353       5.1803            1            2            4            6           11
130..........................................................        1,073       2.9385            1            1            2            4            6
131..........................................................          929       5.7492            1            2            4            8           12
132..........................................................          886       2.6501            1            1            2            3            5
133..........................................................        1,981       5.3296            1            2            4            7           11
134..........................................................        3,362       2.2329            1            1            1            3            4
135..........................................................          352       5.8295            1            2            4            8           12
136..........................................................          472       2.3305            1            1            1            3            5
137..........................................................          773       5.4062            1            2            4            7           11
138..........................................................          886       2.5237            1            1            2            3            5
139..........................................................        1,490       1.8456            1            1            1            2            3
146..........................................................          674       9.4466            2            4            7           12           19
147..........................................................        1,364       6.1320            1            2            4            8           12
148..........................................................          847       3.8040            1            1            3            5            8
149..........................................................       38,817       2.7185            1            1            2            3            5
150..........................................................          949       5.1981            1            2            4            6           10
151..........................................................        6,810       2.8921            1            1            2            4            5
152..........................................................        1,726       4.4571            1            2            3            5            8
153..........................................................       11,433       3.2168            1            2            3            4            6
154..........................................................        1,899       6.3381            2            3            5            8           12
155..........................................................        4,471       4.4187            1            2            4            6            8
156..........................................................        4,819       3.1731            1            2            3            4            6
157..........................................................        1,044       6.6542            1            3            5            8           14
158..........................................................        3,219       4.5281            1            2            3            6            9
159..........................................................        2,355       3.0522            1            1            2            4            6
163..........................................................       13,614      14.9476            5            8           13           19           27
164..........................................................       17,887       8.0977            3            5            7           10           15
165..........................................................       13,805       5.1442            2            3            5            6            9
166..........................................................       20,549      12.9161            4            7           10           16           24
167..........................................................       20,520       7.9756            2            4            7           10           15
168..........................................................        5,467       5.2532            1            2            4            7           10
175..........................................................       12,682       7.2650            3            4            6            9           12
176..........................................................       41,338       5.3283            2            3            5            7            9
177..........................................................       63,750       9.1032            3            5            7           12           17
178..........................................................       70,831       7.3794            3            4            6            9           13
179..........................................................       26,087       5.5654            2            3            5            7           10
180..........................................................       22,324       7.9001            2            4            6           10           15
181..........................................................       30,220       5.9078            2            3            5            8           11
182..........................................................        5,446       4.1761            1            2            3            5            8
183..........................................................        1,856       7.2338            2            4            6            9           13
184..........................................................        4,320       4.5829            2            3            4            6            8
185..........................................................        2,506       3.4066            1            2            3            4            6

[[Page 23854]]

 
186..........................................................        9,239       7.4006            2            4            6            9           14
187..........................................................       10,028       5.3216            2            3            4            7           10
188..........................................................        5,014       3.9928            1            2            3            5            8
189..........................................................      113,067       6.1459            2            3            5            8           11
190..........................................................       58,781       6.2972            2            3            5            8           12
191..........................................................      118,162       5.0156            2            3            4            6            9
192..........................................................      184,764       3.9705            1            2            3            5            7
193..........................................................       87,315       6.7517            2            4            6            8           12
194..........................................................      253,950       5.2660            2            3            4            7            9
195..........................................................      133,231       4.0792            2            2            4            5            7
196..........................................................        5,388       7.3537            3            4            6            9           14
197..........................................................        6,796       5.3899            2            3            4            7           10
198..........................................................        4,616       4.0804            1            2            3            5            7
199..........................................................        3,208       8.3030            2            4            7           11           16
200..........................................................        8,382       5.0894            1            2            4            7           10
201..........................................................        3,467       4.0580            1            2            3            5            8
202..........................................................       29,252       4.3530            1            2            4            5            8
203..........................................................       36,870       3.3859            1            2            3            4            6
204..........................................................       25,669       2.8746            1            1            2            4            5
205..........................................................        5,848       5.5050            1            2            4            7           10
206..........................................................       21,532       3.4393            1            2            3            4            6
207..........................................................       39,505      15.0709            6            9           13           18           25
208..........................................................       76,444       7.2241            1            3            6           10           14
215..........................................................          141      14.1844            1            3            9           17           31
216..........................................................        8,616      18.3713            8           11           16           23           31
217..........................................................        7,236      12.3046            6            8           11           15           20
218..........................................................        2,554       9.0568            5            6            8           11           14
219..........................................................       10,525      13.9944            6            8           11           17           26
220..........................................................       13,928       8.5619            5            6            7           10           14
221..........................................................        7,032       6.4428            4            5            6            7           10
222..........................................................        2,771      13.0949            5            7           11           17           23
223..........................................................        5,080       6.2701            1            3            5            8           12
224..........................................................        1,911      11.3673            4            6            9           14           21
225..........................................................        5,076       5.6420            2            3            5            7           10
226..........................................................        7,064       9.3342            1            3            7           12           19
227..........................................................       42,807       2.8263            1            1            1            3            7
228..........................................................        2,974      14.7078            6            8           13           18           26
229..........................................................        3,596       9.1096            4            6            8           11           15
230..........................................................        1,566       6.4757            3            4            6            8           11
231..........................................................        1,446      13.3811            6            8           11           17           24
232..........................................................        1,515       9.1868            5            7            8           11           14
233..........................................................       16,254      14.1787            7            9           12           17           24
234..........................................................       34,309       8.9262            5            6            8           11           13
235..........................................................        9,629      11.2185            5            7            9           14           20
236..........................................................       30,065       6.6177            4            5            6            8           10
237..........................................................       22,384      10.8073            2            5            9           14           21
238..........................................................       42,226       4.6444            1            2            3            6            9
239..........................................................       13,307      15.3499            5            8           12           19           29
240..........................................................       11,658      10.3695            3            5            8           13           19
241..........................................................        2,680       6.7634            3            4            6            8           12
242..........................................................       17,519       8.7738            3            4            7           11           17
243..........................................................       36,074       5.0924            1            2            4            7           10
244..........................................................       62,706       2.9268            1            1            2            4            6
245..........................................................        5,887       3.3061            1            1            2            4            7
246..........................................................       28,818       5.3370            1            2            4            7           12
247..........................................................      188,884       2.1674            1            1            1            3            4
248..........................................................       13,847       5.9831            1            2            4            8           12
249..........................................................       69,978       2.4966            1            1            2            3            5
250..........................................................        6,762       7.7798            1            3            6           10           16
251..........................................................       41,707       2.8343            1            1            2            4            6
252..........................................................       45,567       8.5378            1            3            6           11           18
253..........................................................       44,910       6.0144            1            2            5            8           13
254..........................................................       53,360       2.7299            1            1            2            3            6
255..........................................................        2,521       9.6942            2            4            8           12           18
256..........................................................        3,425       7.4762            2            4            6            9           13
257..........................................................          705       4.8482            1            2            4            7           10
258..........................................................          686       7.3761            2            3            6            9           14
259..........................................................        7,302       2.8020            1            1            2            4            6
260..........................................................        1,549      11.2214            3            5            8           14           22
261..........................................................        3,522       4.2127            1            1            3            6            9

[[Page 23855]]

 
262..........................................................        3,531       2.5902            1            1            2            3            6
263..........................................................          652       5.4126            1            1            3            7           13
264..........................................................       28,273       8.8998            1            3            6           11           19
280..........................................................       63,593       7.3381            2            4            6            9           13
281..........................................................       53,704       4.8075            2            3            4            6            9
282..........................................................       54,305       3.2480            1            2            3            4            6
283..........................................................       14,888       5.4547            1            1            3            7           13
284..........................................................        4,139       3.2341            1            1            2            4            7
285..........................................................        2,803       2.2112            1            1            1            3            5
286..........................................................       23,695       6.9333            2            3            5            9           14
287..........................................................      158,158       3.1457            1            1            2            4            6
288..........................................................        2,953      11.7541            4            6            9           14           22
289..........................................................        1,357       8.6610            3            5            7           11           15
290..........................................................          473       6.4947            2            4            5            8           11
291..........................................................      187,597       6.4926            2            3            5            8           12
292..........................................................      204,514       4.9936            2            3            4            6            9
293..........................................................      196,441       3.6816            1            2            3            5            6
294..........................................................        1,415       5.5611            2            3            5            7            9
295..........................................................        1,343       4.3291            2            3            4            6            7
296..........................................................        1,917       3.0303            1            1            1            3            7
297..........................................................          791       1.8217            1            1            1            2            3
298..........................................................          602       1.3040            1            1            1            1            2
299..........................................................       17,750       6.6518            2            3            5            8           12
300..........................................................       44,551       5.0493            2            3            4            6            9
301..........................................................       36,994       3.6992            1            2            3            5            7
302..........................................................        7,587       4.3756            1            2            3            5            8
303..........................................................       70,544       2.5315            1            1            2            3            5
304..........................................................        2,086       5.1942            1            2            4            7           10
305..........................................................       35,079       2.8628            1            1            2            4            5
306..........................................................        1,515       6.2964            1            3            4            8           12
307..........................................................        6,344       3.4455            1            2            3            4            6
308..........................................................       35,699       5.5438            1            2            4            7           11
309..........................................................       79,311       3.9373            1            2            3            5            7
310..........................................................      158,556       2.7530            1            1            2            4            5
311..........................................................       21,034       2.3089            1            1            2            3            4
312..........................................................      165,835       3.1053            1            2            2            4            6
313..........................................................      211,391       2.1067            1            1            2            3            4
314..........................................................       61,613       7.0205            2            3            5            9           14
315..........................................................       29,960       4.6041            1            2            4            6            9
316..........................................................       17,966       2.9978            1            1            2            4            6
326..........................................................       11,226      17.1201            6            9           14           21           32
327..........................................................       10,457      10.0519            3            5            8           13           18
328..........................................................        8,865       4.3610            1            2            3            6            9
329..........................................................       48,110      15.9561            6            9           13           20           29
330..........................................................       63,624       9.7138            4            6            8           12           17
331..........................................................       28,171       5.8793            3            4            5            7            9
332..........................................................        1,823      14.3489            6            8           12           18           25
333..........................................................        5,922       8.8349            4            6            8           10           15
334..........................................................        3,719       5.5052            2            4            5            7            9
335..........................................................        7,182      14.0778            5            8           12           18           25
336..........................................................       12,448       9.0917            3            5            8           11           16
337..........................................................        8,570       5.5883            1            3            5            8           10
338..........................................................        1,501      10.7082            4            6            9           13           19
339..........................................................        3,163       7.0452            3            4            6            9           12
340..........................................................        3,558       4.1521            2            2            4            5            7
341..........................................................          878       7.1287            2            3            5            9           14
342..........................................................        2,544       4.1395            1            2            3            5            8
343..........................................................        6,975       2.1792            1            1            2            3            4
344..........................................................          936      11.7575            4            6            9           15           22
345..........................................................        2,914       7.2447            3            4            6            9           12
346..........................................................        2,759       4.9467            2            3            5            6            8
347..........................................................        1,625       8.8166            2            4            7           11           17
348..........................................................        4,164       5.7366            2            3            5            7           11
349..........................................................        5,155       3.0795            1            1            2            4            6
350..........................................................        1,756       7.9897            2            3            6           10           16
351..........................................................        4,287       4.5573            1            2            4            6            9
352..........................................................        8,183       2.4793            1            1            2            3            5
353..........................................................        3,165       8.4051            2            4            7           11           16
354..........................................................        8,420       5.0816            2            3            4            6            9
355..........................................................       15,316       2.8995            1            1            2            4            5

[[Page 23856]]

 
356..........................................................        8,335      12.9146            3            6           10           16           25
357..........................................................        7,801       8.1406            2            4            6           10           16
358..........................................................        2,477       4.4719            1            2            4            6            9
368..........................................................        3,566       6.5979            2            3            5            8           13
369..........................................................        5,248       4.7487            2            3            4            6            9
370..........................................................        3,554       3.3995            1            2            3            4            6
371..........................................................       24,371       8.7488            3            4            7           11           17
372..........................................................       27,061       6.8532            3            4            6            8           12
373..........................................................       15,249       4.9382            2            3            4            6            8
374..........................................................        9,039       8.5759            2            4            7           11           16
375..........................................................       18,945       6.0287            2            3            5            8           12
376..........................................................        4,279       4.1837            1            2            3            5            8
377..........................................................       51,556       6.3806            2            3            5            8           12
378..........................................................      110,340       4.4472            2            3            4            5            8
379..........................................................       92,136       3.4088            1            2            3            4            6
380..........................................................        3,020       7.2738            2            3            6            9           14
381..........................................................        5,293       5.1734            2            3            4            6            9
382..........................................................        4,492       3.6814            1            2            3            5            7
383..........................................................        1,223       5.5200            2            3            4            7           10
384..........................................................        8,080       3.7490            1            2            3            5            7
385..........................................................        1,996       8.8191            3            4            6           11           18
386..........................................................        7,126       5.6996            2            3            5            7           10
387..........................................................        5,033       4.2935            1            2            4            5            8
388..........................................................       18,540       7.3159            2            3            6            9           14
389..........................................................       45,795       5.0160            2            3            4            6            9
390..........................................................       46,426       3.5522            1            2            3            4            6
391..........................................................       44,299       5.2367            1            2            4            6           10
392..........................................................      282,071       3.4889            1            2            3            4            6
393..........................................................       23,253       6.8917            2            3            5            8           14
394..........................................................       45,853       4.8196            1            2            4            6            9
395..........................................................       24,740       3.3344            1            2            3            4            6
405..........................................................        3,963      17.0056            5            8           13           21           34
406..........................................................        5,300       9.1566            2            5            7           11           18
407..........................................................        2,115       5.4851            1            3            5            7           10
408..........................................................        1,548      14.9961            6            8           12           18           28
409..........................................................        1,737       9.8290            4            6            8           12           18
410..........................................................          598       6.5033            2            4            6            8           11
411..........................................................          956      12.4069            5            7           10           15           22
412..........................................................          955       8.5696            4            6            8           11           14
413..........................................................          756       5.9272            2            4            5            7           10
414..........................................................        5,241      11.7296            5            7           10           14           21
415..........................................................        6,127       7.6236            3            5            7            9           13
416..........................................................        5,328       4.8281            2            3            4            6            8
417..........................................................       16,444       8.3803            3            4            7           10           16
418..........................................................       27,075       5.6341            2            3            5            7           10
419..........................................................       35,887       3.1911            1            1            3            4            6
420..........................................................          766      13.6606            3            6           10           17           26
421..........................................................        1,054       7.6879            2            3            6           10           16
422..........................................................          327       4.3609            1            2            4            6            8
423..........................................................        1,542      15.8599            4            7           12           20           32
424..........................................................          894      10.4172            3            5            8           14           20
425..........................................................          125       5.3760            1            2            4            7           10
432..........................................................       15,140       6.9542            2            3            5            9           14
433..........................................................        9,672       4.8719            1            2            4            6            9
434..........................................................          877       3.6933            1            2            3            5            6
435..........................................................       12,111       7.5614            2            3            6           10           15
436..........................................................       13,158       5.8396            2            3            5            8           11
437..........................................................        3,887       4.2529            1            2            3            6            8
438..........................................................       14,063       7.5128            2            3            5            9           15
439..........................................................       24,364       5.3275            2            3            4            7           10
440..........................................................       25,670       3.8103            1            2            3            5            7
441..........................................................       13,335       7.0467            2            3            5            9           14
442..........................................................       14,144       5.1103            2            2            4            6            9
443..........................................................        6,544       3.7796            1            2            3            5            7
444..........................................................       12,898       6.6243            2            3            5            8           13
445..........................................................       16,794       4.7264            1            2            4            6            9
446..........................................................       15,932       3.2658            1            2            3            4            6
453..........................................................          948      15.6561            5            7           12           19           29
454..........................................................        1,771       8.0237            3            4            6           10           14
455..........................................................        1,969       4.4307            1            3            4            5            7

[[Page 23857]]

 
456..........................................................          946      14.7061            5            7           11           19           28
457..........................................................        2,413       7.4836            3            4            6            9           13
458..........................................................        1,609       4.5438            2            3            4            6            7
459..........................................................        3,508       9.4478            4            5            7           11           17
460..........................................................       51,883       4.2180            2            3            4            5            7
461..........................................................        1,018       8.4342            3            5            6            9           14
462..........................................................       13,194       4.2178            3            3            4            5            6
463..........................................................        5,054      16.5693            5            7           12           20           33
464..........................................................        5,839      10.2197            3            5            8           12           20
465..........................................................        2,398       5.8661            1            3            5            7           11
466..........................................................        4,072       9.1717            3            5            7           11           16
467..........................................................       14,331       5.4882            3            3            4            6            9
468..........................................................       21,133       3.9306            2            3            3            4            6
469..........................................................       30,532       8.2006            3            5            7           10           14
470..........................................................      405,204       3.9281            3            3            3            4            6
471..........................................................        2,283       9.7946            2            4            7           13           20
472..........................................................        6,954       4.0913            1            1            3            5            9
473..........................................................       22,875       1.9623            1            1            1            2            4
474..........................................................        2,918      12.6453            4            6           10           15           24
475..........................................................        3,277       8.3946            3            4            7           11           15
476..........................................................        1,589       4.7885            1            2            4            6            9
477..........................................................        2,582      11.8548            3            6            9           15           22
478..........................................................        8,562       6.6119            1            3            6            9           13
479..........................................................       11,424       2.8188            1            1            1            4            7
480..........................................................       26,724       9.2958            4            5            8           11           16
481..........................................................       72,123       5.9291            3            4            5            7            9
482..........................................................       48,111       4.8427            3            4            4            6            7
483..........................................................        7,100       4.2093            2            2            3            5            8
484..........................................................       17,842       2.4311            1            2            2            3            4
485..........................................................        1,183      12.1116            4            6           10           15           22
486..........................................................        2,186       8.0425            3            5            7           10           14
487..........................................................        1,312       5.6715            3            3            5            7            9
488..........................................................        2,495       5.2236            2            3            4            6           10
489..........................................................        5,763       3.0465            1            2            3            4            5
490..........................................................       22,971       4.3437            1            1            3            5            9
491..........................................................       52,406       2.2104            1            1            2            3            4
492..........................................................        5,217       8.5338            3            5            7           11           15
493..........................................................       16,900       5.2509            2            3            4            6            9
494..........................................................       29,166       3.3992            1            2            3            4            6
495..........................................................        1,970      10.9609            3            5            8           14           21
496..........................................................        5,555       5.9802            2            3            5            7           11
497..........................................................        6,632       3.0054            1            1            2            4            6
498..........................................................        1,163       7.8865            2            3            6           10           16
499..........................................................        1,110       2.9757            1            1            2            4            6
500..........................................................        1,503      10.8283            3            5            8           14           21
501..........................................................        3,873       5.9700            2            3            5            8           12
502..........................................................        6,452       2.9416            1            1            2            4            6
503..........................................................          833       9.4586            3            5            7           11           17
504..........................................................        2,162       6.4510            2            3            6            8           12
505..........................................................        3,004       3.3832            1            2            3            4            6
506..........................................................          810       3.4074            1            1            2            4            7
507..........................................................          836       5.1459            1            2            4            6           10
508..........................................................        2,481       2.0512            1            1            1            2            3
509..........................................................          627       3.1100            1            1            2            3            7
510..........................................................          973       6.4070            2            3            5            8           12
511..........................................................        3,926       3.9758            1            2            3            5            7
512..........................................................       10,961       2.1581            1            1            2            3            4
513..........................................................        1,052       5.0266            1            2            4            6           10
514..........................................................        1,006       2.8191            1            1            2            3            6
515..........................................................        3,818      10.4445            3            5            8           13           20
516..........................................................       11,280       5.9870            1            3            5            8           11
517..........................................................       17,523       3.0079            1            1            2            4            7
533..........................................................          822       6.6861            2            3            5            8           12
534..........................................................        3,392       4.0292            1            2            3            5            7
535..........................................................        6,990       6.2365            2            3            5            8           12
536..........................................................       33,661       3.9328            2            3            3            5            7
537..........................................................          665       4.4722            2            3            4            5            8
538..........................................................        1,056       3.2197            1            2            3            4            6
539..........................................................        3,417       9.7085            3            5            8           12           17
540..........................................................        4,016       7.1257            3            4            6            8           13

[[Page 23858]]

 
541..........................................................        1,618       5.3745            2            3            4            7            9
542..........................................................        5,709       8.7758            3            4            7           11           17
543..........................................................       17,012       5.9463            2            3            5            7           11
544..........................................................       10,798       4.4077            2            3            4            5            8
545..........................................................        4,079       9.0924            2            4            6           11           19
546..........................................................        5,577       5.5338            2            3            4            7           10
547..........................................................        4,533       3.8083            1            2            3            5            7
548..........................................................          580       8.9379            3            4            7           11           17
549..........................................................        1,110       6.3874            2            3            5            8           12
550..........................................................          858       4.4545            2            2            4            6            8
551..........................................................       10,066       7.1058            2            3            6            9           14
552..........................................................       85,179       4.1225            1            2            3            5            7
553..........................................................        3,076       5.9620            2            3            5            7           11
554..........................................................       19,173       3.6913            1            2            3            5            7
555..........................................................        2,013       4.8405            1            2            4            6            9
556..........................................................       18,639       3.1089            1            2            3            4            6
557..........................................................        3,646       6.6100            2            3            5            8           12
558..........................................................       15,089       4.2586            2            2            4            5            7
559..........................................................        1,815       7.5444            2            3            6            9           15
560..........................................................        4,319       4.7217            1            2            4            6            9
561..........................................................        7,107       2.7680            1            1            2            3            5
562..........................................................        5,458       6.3674            2            3            5            8           12
563..........................................................       36,267       3.7016            1            2            3            4            6
564..........................................................        1,661       6.9934            2            3            5            9           13
565..........................................................        3,311       4.9795            2            3            4            6            9
566..........................................................        2,624       3.6825            1            2            3            5            7
573..........................................................        5,477      13.0933            4            6            9           16           26
574..........................................................       11,123       9.3248            3            5            7           11           17
575..........................................................        5,462       5.8521            2            3            5            7           11
576..........................................................          547      12.9506            2            4            9           17           28
577..........................................................        2,228       6.1104            1            2            4            8           13
578..........................................................        3,054       3.3062            1            1            2            4            7
579..........................................................        3,511      10.6830            3            5            8           14           21
580..........................................................       10,711       5.5084            1            2            4            7           12
581..........................................................       12,142       2.6146            1            1            2            3            6
582..........................................................        5,337       2.8943            1            1            2            3            5
583..........................................................        8,748       1.8056            1            1            1            2            3
584..........................................................          668       5.9850            1            2            4            8           13
585..........................................................        1,469       2.2321            1            1            1            2            4
592..........................................................        4,178       8.8712            3            4            7           10           16
593..........................................................       12,304       6.4415            2            3            5            8           11
594..........................................................        2,751       5.0593            2            3            4            6            9
595..........................................................        1,112       8.3327            2            4            6           10           16
596..........................................................        5,308       4.7600            1            2            4            6            8
597..........................................................          458       8.2009            2            3            6           10           16
598..........................................................        1,400       5.7243            2            3            4            7           11
599..........................................................          306       3.7320            1            1            3            4            6
600..........................................................          682       5.0513            2            3            4            7            9
601..........................................................          884       3.8541            1            2            3            5            7
602..........................................................       22,088       7.0278            2            4            6            9           13
603..........................................................      130,121       4.7073            2            3            4            6            8
604..........................................................        2,660       5.6590            1            3            4            7           11
605..........................................................       22,097       3.4622            1            2            3            4            6
606..........................................................        1,350       6.3422            1            3            4            7           12
607..........................................................        7,168       3.7913            1            2            3            5            7
614..........................................................        1,457       7.0336            2            3            5            8           14
615..........................................................        1,546       3.1572            1            2            3            4            5
616..........................................................        1,091      16.9432            6            9           13           20           31
617..........................................................        6,718       8.7904            3            5            7           11           15
618..........................................................          258       6.3605            2            3            6            8           11
619..........................................................          696       8.2011            2            3            5            9           18
620..........................................................        2,186       3.6780            1            2            3            4            7
621..........................................................        7,848       2.1617            1            1            2            3            4
622..........................................................        1,112      13.1574            3            6            9           16           24
623..........................................................        3,077       8.5707            3            4            7           10           15
624..........................................................          383       6.0261            2            3            5            7           10
625..........................................................        1,274       7.0879            1            2            5            9           15
626..........................................................        2,538       3.1233            1            1            2            3            7
627..........................................................       14,026       1.5172            1            1            1            2            2
628..........................................................        3,366      11.1851            2            4            8           14           23

[[Page 23859]]

 
629..........................................................        4,160       8.7418            3            5            7           11           16
630..........................................................          534       5.5281            1            2            4            7           11
637..........................................................       17,104       6.0581            2            3            5            7           12
638..........................................................       42,581       4.2659            1            2            3            5            8
639..........................................................       38,312       3.0382            1            2            2            4            5
640..........................................................       60,806       5.4332            1            2            4            7           11
641..........................................................      201,324       3.8256            1            2            3            5            7
642..........................................................        1,492       5.1810            1            2            4            6            9
643..........................................................        5,176       7.6103            2            4            6            9           14
644..........................................................       11,788       5.4597            2            3            4            7           10
645..........................................................        8,179       3.8912            1            2            3            5            7
652..........................................................       10,067       7.7888            4            5            6            9           13
653..........................................................        1,697      16.8981            7            9           13           21           31
654..........................................................        3,452       9.8624            5            7            8           11           16
655..........................................................        1,633       6.5150            3            5            7            8           10
656..........................................................        3,918      10.1146            4            5            8           12           19
657..........................................................        7,422       5.9603            3            4            5            7           10
658..........................................................        8,271       3.7356            2            2            3            5            6
659..........................................................        4,658      11.2003            3            5            8           14           22
660..........................................................        7,594       6.5146            2            3            5            8           13
661..........................................................        4,260       3.2758            1            2            3            4            6
662..........................................................          949      10.2740            2            4            8           14           20
663..........................................................        2,054       5.2639            1            2            4            7           11
664..........................................................        4,390       2.1223            1            1            1            2            4
665..........................................................          654      11.0627            3            5            9           14           21
666..........................................................        2,092       6.3595            1            2            4            9           14
667..........................................................        3,616       2.8695            1            1            2            3            6
668..........................................................        3,833       8.5265            2            4            7           11           16
669..........................................................       12,746       4.4236            1            2            3            6            9
670..........................................................       11,687       2.5131            1            1            2            3            5
671..........................................................          808       5.9468            1            2            4            8           12
672..........................................................          943       2.5302            1            1            2            3            5
673..........................................................       12,542       9.7323            1            3            7           13           21
674..........................................................       11,715       7.1905            1            2            5            9           15
675..........................................................        7,824       2.0675            1            1            1            2            4
682..........................................................       82,091       7.1569            2            3            5            9           14
683..........................................................      132,320       5.6544            2            3            5            7           10
684..........................................................       44,932       3.8913            1            2            3            5            7
685..........................................................        2,331       3.4822            1            1            2            4            7
686..........................................................        1,597       7.5717            2            3            6            9           15
687..........................................................        3,261       5.3502            1            3            4            7           10
688..........................................................        1,073       3.2591            1            1            2            4            6
689..........................................................       55,995       6.2004            2            3            5            8           11
690..........................................................      198,101       4.2356            2            2            4            5            7
691..........................................................          821       3.9586            1            2            3            5            8
692..........................................................          491       2.3992            1            1            2            3            5
693..........................................................        2,429       4.8345            1            2            4            6           10
694..........................................................       18,000       2.5778            1            1            2            3            5
695..........................................................          975       5.5251            1            3            4            7           11
696..........................................................       10,518       3.2901            1            2            3            4            6
697..........................................................          592       3.1115            1            1            2            4            6
698..........................................................       23,320       6.6546            2            3            5            8           13
699..........................................................       24,207       4.8302            1            2            4            6            9
700..........................................................       12,279       3.5497            1            2            3            4            7
707..........................................................        5,979       4.4131            1            2            3            5            8
708..........................................................       18,063       2.1475            1            1            2            3            4
709..........................................................          762       6.5341            1            2            4            8           15
710..........................................................        1,831       1.7739            1            1            1            2            3
711..........................................................          790       8.1684            1            3            6           10           16
712..........................................................          705       3.0496            1            1            2            4            7
713..........................................................       10,252       4.1916            1            2            3            5            9
714..........................................................       28,797       1.9430            1            1            2            2            3
715..........................................................          531       6.2806            1            2            4            8           13
716..........................................................        1,273       1.4289            1            1            1            1            2
717..........................................................          703       7.2319            2            3            5            9           14
718..........................................................          589       2.7640            1            1            2            3            5
722..........................................................          745       7.5852            2            3            6           10           14
723..........................................................        1,949       5.2678            1            3            4            7           10
724..........................................................          578       3.1522            1            1            2            4            6
725..........................................................          755       5.5007            2            3            4            7           10

[[Page 23860]]

 
726..........................................................        3,716       3.4739            1            2            3            4            6
727..........................................................        1,294       6.3995            2            3            5            8           12
728..........................................................        6,158       4.0404            1            2            3            5            7
729..........................................................          591       5.5736            1            2            4            7           10
730..........................................................          471       3.0786            1            1            2            4            6
734..........................................................        1,362       7.9941            3            4            6            9           15
735..........................................................        1,130       3.3602            1            2            3            4            5
736..........................................................          854      13.7752            5            7           11           17           25
737..........................................................        3,293       7.1786            3            4            6            8           13
738..........................................................          863       3.8714            2            3            3            5            6
739..........................................................        1,013      10.1955            3            5            8           12           20
740..........................................................        4,326       5.2305            2            3            4            6            9
741..........................................................        6,014       2.9940            1            2            3            4            5
742..........................................................       10,950       4.5175            2            2            3            5            8
743..........................................................       32,325       2.2608            1            2            2            3            3
744..........................................................        1,520       5.8355            1            2            4            7           12
745..........................................................        1,694       2.5738            1            1            2            3            5
746..........................................................        2,634       4.2134            1            2            3            5            8
747..........................................................       10,409       1.8856            1            1            2            2            3
748..........................................................       19,857       1.7358            1            1            1            2            3
749..........................................................          982       9.3401            2            4            7           12           19
750..........................................................          435       3.1103            1            1            2            4            6
754..........................................................          978       8.3395            2            4            7           11           16
755..........................................................        2,933       5.6870            2            3            4            7           11
756..........................................................          677       3.1359            1            1            2            4            6
757..........................................................        1,393       8.1436            3            4            6           10           16
758..........................................................        1,605       6.0536            2            3            5            7           11
759..........................................................        1,239       4.4722            2            2            4            5            8
760..........................................................        1,700       3.9594            1            2            3            5            8
761..........................................................        1,749       2.4351            1            1            2            3            5
765..........................................................        2,754       5.0359            2            3            4            5            7
766..........................................................        2,686       3.1601            2            2            3            4            4
767..........................................................          132       3.3712            2            2            2            3            5
768..........................................................            6       3.5000            1            2            3            6            6
769..........................................................           98       4.6224            1            2            3            6           11
770..........................................................          202       2.2277            1            1            1            2            5
774..........................................................        1,506       3.1886            2            2            2            3            5
775..........................................................        5,768       2.2394            1            2            2            3            3
776..........................................................          511       3.3112            1            2            2            4            7
777..........................................................          206       2.2136            1            1            2            3            4
778..........................................................          474       3.0127            1            1            2            3            5
779..........................................................          110       2.1182            1            1            1            2            3
780..........................................................           40       1.4500            1            1            1            1            3
781..........................................................        3,017       3.7630            1            1            2            4            7
782..........................................................          171       2.4971            1            1            1            2            4
790..........................................................            1      25.0000          125          125          125          125          125
799..........................................................          566      14.0583            5            7           11           18           26
800..........................................................          705       7.8610            3            4            6            9           15
801..........................................................          557       4.9336            2            2            4            6            9
802..........................................................          765      12.2706            3            5            9           15           25
803..........................................................        1,070       6.6738            1            3            5            8           14
804..........................................................          987       3.4215            1            1            3            4            6
808..........................................................        6,088       8.2467            3            4            6           10           16
809..........................................................       12,869       5.3247            2            3            4            7           10
810..........................................................        2,786       4.0337            1            2            3            5            7
811..........................................................       21,404       5.6912            1            2            4            7           11
812..........................................................       89,951       3.7401            1            2            3            5            7
813..........................................................       14,232       5.1669            1            2            4            6           10
814..........................................................        1,554       6.7368            2            3            5            8           13
815..........................................................        3,297       4.9706            1            2            4            6            9
816..........................................................        2,147       3.5198            1            2            3            4            7
820..........................................................        1,299      17.7229            5            8           14           23           34
821..........................................................        2,474       7.8646            1            3            6           10           16
822..........................................................        1,893       3.5288            1            1            3            4            7
823..........................................................        2,178      15.4385            5            8           12           20           29
824..........................................................        2,974       8.7492            2            4            7           11           17
825..........................................................        1,748       4.3084            1            1            3            6            9
826..........................................................          524      15.0401            4            7           11           19           29
827..........................................................        1,254       7.9793            2            4            6           10           16
828..........................................................          799       3.7722            1            2            3            5            7

[[Page 23861]]

 
829..........................................................        1,171      10.6576            2            4            7           13           22
830..........................................................          521       3.7179            1            1            2            4            8
834..........................................................        4,028      15.4615            2            4           10           23           36
835..........................................................        2,703      10.4351            2            3            6           12           28
836..........................................................        1,622       5.1843            1            2            3            6           10
837..........................................................        1,043      23.1419            5           10           23           31           42
838..........................................................        1,320      12.2629            3            4            6           21           29
839..........................................................        1,467       6.4104            3            4            5            6           10
840..........................................................        9,659      10.4408            3            5            8           13           21
841..........................................................       10,035       6.9221            2            3            5            9           13
842..........................................................        5,310       4.5563            1            2            4            6            9
843..........................................................        1,350       8.5222            2            4            6           10           17
844..........................................................        2,412       6.0987            2            3            5            8           12
845..........................................................          804       4.3022            1            2            3            6            8
846..........................................................        2,113       8.4179            2            3            5           10           18
847..........................................................       23,862       3.3508            1            2            3            4            6
848..........................................................        1,723       3.1294            1            1            3            4            5
849..........................................................        1,477       5.9709            2            3            5            6           12
853..........................................................       34,852      16.6669            5            8           13           21           30
854..........................................................        6,643      11.1072            4            6            9           14           20
855..........................................................          459       7.0261            2            4            6            9           13
856..........................................................        5,892      15.3839            4            7           12           19           30
857..........................................................        9,614       8.4628            3            4            7           10           16
858..........................................................        3,246       5.6741            2            3            5            7           10
862..........................................................        7,929       8.1778            2            4            6           10           16
863..........................................................       21,420       5.1976            2            3            4            7            9
864..........................................................       18,946       4.0639            1            2            3            5            7
865..........................................................        1,705       6.7009            2            3            4            8           14
866..........................................................        8,182       3.5351            1            2            3            4            7
867..........................................................        5,062       9.6254            2            4            7           12           19
868..........................................................        2,641       5.7819            2            3            4            7           11
869..........................................................        1,103       4.3128            2            2            4            5            7
870..........................................................       21,199      15.4758            6            9           13           19           27
871..........................................................      216,384       7.4839            2            3            6           10           14
872..........................................................       90,892       5.7138            2            3            5            7           10
876..........................................................          857      11.9498            2            5            9           14           24
880..........................................................        9,282       3.1518            1            1            2            4            6
881..........................................................        4,623       4.1888            1            2            3            5            8
882..........................................................        1,556       4.4274            1            2            3            6            9
883..........................................................          757       7.3725            1            2            4            8           15
884..........................................................       19,006       5.4936            2            3            4            6           10
885..........................................................       80,806       7.6211            2            3            6            9           14
886..........................................................          404       6.0767            1            2            4            7           12
887..........................................................          393       4.6209            1            2            3            5            8
894..........................................................        4,369       2.9528            1            1            2            3            4
895..........................................................        6,958      10.4997            3            4            6            7            9
896..........................................................        5,490       6.6087            2            3            5            8           13
897..........................................................       36,053       4.0582            1            2            3            5            6
901..........................................................          924      15.0693            3            6           10           18           30
902..........................................................        2,031       7.7371            2            3            6            9           16
903..........................................................        1,500       4.5680            1            2            4            6            9
904..........................................................        1,047      11.2178            2            4            7           13           23
905..........................................................          811       4.6523            1            2            4            6            8
906..........................................................          712       3.1657            1            1            2            4            6
907..........................................................        8,462      11.6494            2            5            8           14           23
908..........................................................        8,319       6.7682            2            3            5            8           13
909..........................................................        5,447       3.6367            1            1            3            5            7
913..........................................................          804       5.6629            1            3            4            7           12
914..........................................................        6,609       3.4330            1            2            3            4            6
915..........................................................        1,078       4.7356            1            2            3            6            9
916..........................................................        5,508       2.1044            1            1            2            3            4
917..........................................................       15,775       5.1645            1            2            4            6           11
918..........................................................       35,653       2.7260            1            1            2            3            5
919..........................................................       11,089       6.3723            2            3            5            8           13
920..........................................................       13,970       4.3608            1            2            3            5            8
921..........................................................        9,423       2.9687            1            1            2            4            6
922..........................................................        1,047       5.9933            1            2            4            7           12
923..........................................................        3,952       3.2338            1            1            2            4            6
927..........................................................          211      31.1374            7           15           26           41           60
928..........................................................          818      15.9694            4            7           12           21           31

[[Page 23862]]

 
929..........................................................          438       7.6872            1            3            6           10           16
933..........................................................          139       4.3453            1            1            1            4            8
934..........................................................          659       6.1988            1            3            5            8           12
935..........................................................        2,201       5.4330            1            2            4            7           11
939..........................................................          671      10.0611            2            4            7           13           20
940..........................................................        1,320       5.4220            1            2            4            7           12
941..........................................................        1,707       2.7299            1            1            2            3            5
945..........................................................        6,244      10.4947            4            6            8           12           15
946..........................................................        3,055       7.8628            3            5            6            7            8
947..........................................................        9,715       5.0101            1            2            4            6           10
948..........................................................       47,722       3.4806            1            2            3            4            6
949..........................................................          632       4.1092            1            1            2            4            6
950..........................................................          387       3.4858            1            1            2            4            5
951..........................................................          940       4.6436            1            1            2            3            6
955..........................................................          443      12.2822            2            5           10           16           26
956..........................................................        3,975       9.2896            4            5            7           11           17
957..........................................................        1,311      14.8795            2            7           12           19           28
958..........................................................        1,146      10.4031            3            6            8           13           19
959..........................................................          286       6.2413            2            3            5            8           11
963..........................................................        1,586       9.5214            2            4            8           13           19
964..........................................................        2,573       6.2274            2            3            5            8           11
965..........................................................        1,071       4.1391            1            2            3            5            7
969..........................................................          639      18.8279            4            8           14           22           36
970..........................................................          136       9.8309            2            3            7           12           17
974..........................................................        5,920      10.3723            2            4            8           13           21
975..........................................................        4,674       7.0148            2            3            5            9           13
976..........................................................        2,617       4.9308            2            2            4            6            8
977..........................................................        4,565       5.2931            1            2            4            6           10
981..........................................................       25,479      15.1488            5            8           12           19           28
982..........................................................       18,329       9.7455            3            5            8           12           18
983..........................................................        6,112       5.3613            1            2            4            7           11
984..........................................................          671      14.6811            5            8           13           18           25
985..........................................................          903       9.6512            2            5            8           13           18
986..........................................................          731       5.3338            1            2            3            7           12
987..........................................................        8,240      13.0089            4            6           10           16           24
988..........................................................       11,583       7.8090            2            3            6           10           15
989..........................................................        5,796       4.1046            1            1            3            6            9
                                                              --------------
                                                                11,387,276
--------------------------------------------------------------------------------------------------------------------------------------------------------



     Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007 Grouper V26.0 MS-DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Number of    Arithmetic      10th         25th         50th         75th         90th
                            MS-DRG                              discharges    mean LOS    percentile   percentile   percentile   percentile   percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................          655      40.2107           12           17           31           51           83
2............................................................          287      24.7456            9           12           17           28           48
3............................................................       23,205      39.6406           16           22           32           48           68
4............................................................       21,267      28.8412           11           17           24           35           49
5............................................................          635      21.1717            7           10           15           26           42
6............................................................          229      10.2576            6            7            9           12           17
7............................................................          356      19.6517            8           10           15           22           38
8............................................................          483      11.9337            6            7            9           13           20
9............................................................        1,346      21.9725            8           16           20           25           35
10...........................................................          163      10.7791            6            7            8           11           19
11...........................................................        1,264      16.7302            6            9           13           20           30
12...........................................................        1,907      10.6754            4            6            9           13           18
13...........................................................        1,268       6.9267            3            4            6            8           11
20...........................................................          885      18.3525            6           10           17           24           32
21...........................................................          530      15.4472            8           11           14           19           25
22...........................................................          212       9.3726            2            6            9           12           15
23...........................................................        3,730      12.6794            2            5           10           17           25
24...........................................................        2,092       9.0263            1            4            8           12           18
25...........................................................        8,697      13.0331            4            6           10           17           25
26...........................................................       11,781       8.2206            2            4            7           11           15

[[Page 23863]]

 
27...........................................................       13,695       4.5403            1            2            4            6            9
28...........................................................        1,666      14.3055            4            7           11           18           27
29...........................................................        3,070       7.1091            1            3            6            9           14
30...........................................................        3,398       3.7310            1            1            3            5            7
31...........................................................        1,024      13.1377            3            6           10           18           27
32...........................................................        2,780       5.9781            1            2            4            8           14
33...........................................................        3,623       3.0395            1            1            2            4            6
34...........................................................          765       7.2261            1            2            5            9           15
35...........................................................        2,239       3.2823            1            1            2            4            8
36...........................................................        6,947       1.5949            1            1            1            2            3
37...........................................................        4,841       8.5478            2            3            7           11           17
38...........................................................       14,146       3.7666            1            1            2            5            9
39...........................................................       51,927       1.8278            1            1            1            2            3
40...........................................................        4,765      13.3490            3            6           10           17           25
41...........................................................        7,573       7.2006            1            3            6            9           14
42...........................................................        4,859       3.6300            1            1            2            5            8
52...........................................................        1,163       6.7395            2            3            5            8           14
53...........................................................          587       4.0102            1            2            3            5            7
54...........................................................        5,240       6.9504            2            3            5            9           14
55...........................................................       16,289       5.0708            1            2            4            6           10
56...........................................................        8,250       7.7668            2            3            6            9           14
57...........................................................       47,224       4.9743            2            3            4            6            9
58...........................................................          736       7.5978            2            4            6            9           15
59...........................................................        2,752       5.1432            2            3            4            6            9
60...........................................................        4,068       3.9668            2            2            4            5            7
61...........................................................        1,586       8.9426            2            4            7           11           17
62...........................................................        2,464       6.2683            3            4            5            8           11
63...........................................................        1,323       4.5110            2            3            4            6            8
64...........................................................       55,734       7.4669            2            3            6           10           15
65...........................................................      105,000       5.2179            2            3            4            6            9
66...........................................................       89,325       3.7141            1            2            3            5            7
67...........................................................        1,397       5.8232            2            3            5            7           11
68...........................................................       11,402       3.4467            1            2            3            4            6
69...........................................................      101,817       2.9920            1            2            2            4            5
70...........................................................        7,341       7.8574            2            4            6           10           15
71...........................................................        9,526       5.5568            2            3            4            7           10
72...........................................................        5,739       3.5389            1            2            3            4            7
73...........................................................        9,223       6.2394            2            3            5            8           12
74...........................................................       31,500       4.3070            1            2            3            5            8
75...........................................................        1,238       7.3021            2            4            6            9           14
76...........................................................          873       4.1340            2            2            4            5            7
77...........................................................        1,211       6.6821            2            3            5            9           12
78...........................................................        1,405       4.4157            2            2            4            6            8
79...........................................................          931       3.3845            1            2            3            4            6
80...........................................................        1,861       5.1016            1            2            4            6           10
81...........................................................        7,124       3.5267            1            2            3            4            6
82...........................................................        1,757       6.4087            1            1            4            9           15
83...........................................................        2,049       4.9551            1            2            4            7           10
84...........................................................        2,769       3.1268            1            1            2            4            6
85...........................................................        5,879       7.6399            2            3            6           10           15
86...........................................................       11,468       5.0024            1            3            4            6            9
87...........................................................       12,958       3.2740            1            2            3            4            6
88...........................................................          711       5.8748            1            3            4            7           12
89...........................................................        2,733       3.7603            1            2            3            5            7
90...........................................................        3,089       2.5494            1            1            2            3            5
91...........................................................        7,605       6.3657            2            3            5            8           13
92...........................................................       16,265       4.4647            1            2            4            6            8
93...........................................................       16,121       3.2188            1            2            3            4            6
94...........................................................        1,473      11.8547            4            6           10           15           22
95...........................................................        1,030       8.6359            3            5            7           11           15
96...........................................................          757       6.1744            2            4            6            8           11
97...........................................................        1,192      12.6023            4            7           11           16           23
98...........................................................        1,005       8.3522            3            5            7           10           15
99...........................................................          641       5.8752            2            3            5            8           11
100..........................................................       16,989       6.3526            2            3            5            8           12
101..........................................................       56,991       3.6950            1            2            3            5            7
102..........................................................        1,080       4.5306            1            2            3            6            9
103..........................................................       13,735       3.1270            1            2            2            4            6
113..........................................................          525       5.5981            1            2            4            8           12
114..........................................................          555       2.6090            1            1            2            3            5

[[Page 23864]]

 
115..........................................................        1,046       4.3222            1            2            4            5            7
116..........................................................          546       4.0678            1            1            2            5            8
117..........................................................          996       2.1596            1            1            1            2            3
121..........................................................          542       5.4576            2            3            4            7           10
122..........................................................          617       4.0454            2            2            3            5            7
123..........................................................        2,785       2.8747            1            2            2            4            5
124..........................................................          749       5.2697            1            2            4            7           10
125..........................................................        4,661       3.5134            1            2            3            4            7
129..........................................................        1,353       5.1803            1            2            4            6           11
130..........................................................        1,073       2.9385            1            1            2            4            6
131..........................................................          929       5.7492            1            2            4            8           12
132..........................................................          886       2.6501            1            1            2            3            5
133..........................................................        1,981       5.3296            1            2            4            7           11
134..........................................................        3,362       2.2329            1            1            1            3            4
135..........................................................          352       5.8295            1            2            4            8           12
136..........................................................          472       2.3305            1            1            1            3            5
137..........................................................          773       5.4062            1            2            4            7           11
138..........................................................          886       2.5237            1            1            2            3            5
139..........................................................        1,490       1.8456            1            1            1            2            3
146..........................................................          674       9.4466            2            4            7           12           19
147..........................................................        1,364       6.1320            1            2            4            8           12
148..........................................................          847       3.8040            1            1            3            5            8
149..........................................................       38,817       2.7185            1            1            2            3            5
150..........................................................          949       5.1981            1            2            4            6           10
151..........................................................        6,810       2.8921            1            1            2            4            5
152..........................................................        1,726       4.4571            1            2            3            5            8
153..........................................................       11,433       3.2168            1            2            3            4            6
154..........................................................        1,899       6.3381            2            3            5            8           12
155..........................................................        4,471       4.4187            1            2            4            6            8
156..........................................................        4,819       3.1731            1            2            3            4            6
157..........................................................        1,044       6.6542            1            3            5            8           14
158..........................................................        3,219       4.5281            1            2            3            6            9
159..........................................................        2,355       3.0522            1            1            2            4            6
163..........................................................       13,614      14.9476            5            8           13           19           27
164..........................................................       17,887       8.0977            3            5            7           10           15
165..........................................................       13,805       5.1442            2            3            5            6            9
166..........................................................       20,549      12.9161            4            7           10           16           24
167..........................................................       20,520       7.9756            2            4            7           10           15
168..........................................................        5,467       5.2532            1            2            4            7           10
175..........................................................       12,682       7.2650            3            4            6            9           12
176..........................................................       41,338       5.3283            2            3            5            7            9
177..........................................................       63,750       9.1032            3            5            7           12           17
178..........................................................       70,831       7.3794            3            4            6            9           13
179..........................................................       26,087       5.5654            2            3            5            7           10
180..........................................................       22,324       7.9001            2            4            6           10           15
181..........................................................       30,220       5.9078            2            3            5            8           11
182..........................................................        5,446       4.1761            1            2            3            5            8
183..........................................................        1,856       7.2338            2            4            6            9           13
184..........................................................        4,320       4.5829            2            3            4            6            8
185..........................................................        2,506       3.4066            1            2            3            4            6
186..........................................................        9,239       7.4006            2            4            6            9           14
187..........................................................       10,028       5.3216            2            3            4            7           10
188..........................................................        5,014       3.9928            1            2            3            5            8
189..........................................................      113,067       6.1459            2            3            5            8           11
190..........................................................       58,781       6.2972            2            3            5            8           12
191..........................................................      118,162       5.0156            2            3            4            6            9
192..........................................................      184,764       3.9705            1            2            3            5            7
193..........................................................       87,315       6.7517            2            4            6            8           12
194..........................................................      253,950       5.2660            2            3            4            7            9
195..........................................................      133,231       4.0792            2            2            4            5            7
196..........................................................        5,388       7.3537            3            4            6            9           14
197..........................................................        6,796       5.3899            2            3            4            7           10
198..........................................................        4,616       4.0804            1            2            3            5            7
199..........................................................        3,208       8.3030            2            4            7           11           16
200..........................................................        8,382       5.0894            1            2            4            7           10
201..........................................................        3,467       4.0580            1            2            3            5            8
202..........................................................       29,252       4.3530            1            2            4            5            8
203..........................................................       36,870       3.3859            1            2            3            4            6
204..........................................................       25,669       2.8746            1            1            2            4            5
205..........................................................        5,848       5.5050            1            2            4            7           10

[[Page 23865]]

 
206..........................................................       21,532       3.4393            1            2            3            4            6
207..........................................................       39,505      15.0709            6            9           13           18           25
208..........................................................       76,444       7.2241            1            3            6           10           14
215..........................................................          141      14.1844            1            3            9           17           31
216..........................................................        8,616      18.3713            8           11           16           23           31
217..........................................................        7,236      12.3046            6            8           11           15           20
218..........................................................        2,554       9.0568            5            6            8           11           14
219..........................................................       10,525      13.9944            6            8           11           17           26
220..........................................................       13,928       8.5619            5            6            7           10           14
221..........................................................        7,032       6.4428            4            5            6            7           10
222..........................................................        2,771      13.0949            5            7           11           17           23
223..........................................................        5,080       6.2701            1            3            5            8           12
224..........................................................        1,911      11.3673            4            6            9           14           21
225..........................................................        5,076       5.6420            2            3            5            7           10
226..........................................................        7,064       9.3342            1            3            7           12           19
227..........................................................       42,807       2.8263            1            1            1            3            7
228..........................................................        2,974      14.7078            6            8           13           18           26
229..........................................................        3,596       9.1096            4            6            8           11           15
230..........................................................        1,566       6.4757            3            4            6            8           11
231..........................................................        1,446      13.3811            6            8           11           17           24
232..........................................................        1,515       9.1868            5            7            8           11           14
233..........................................................       16,254      14.1787            7            9           12           17           24
234..........................................................       34,309       8.9262            5            6            8           11           13
235..........................................................        9,629      11.2185            5            7            9           14           20
236..........................................................       30,065       6.6177            4            5            6            8           10
237..........................................................       22,384      10.8073            2            5            9           14           21
238..........................................................       42,226       4.6444            1            2            3            6            9
239..........................................................       13,307      15.3499            5            8           12           19           29
240..........................................................       11,658      10.3695            3            5            8           13           19
241..........................................................        2,680       6.7634            3            4            6            8           12
242..........................................................       17,519       8.7738            3            4            7           11           17
243..........................................................       36,074       5.0924            1            2            4            7           10
244..........................................................       62,706       2.9268            1            1            2            4            6
245..........................................................        3,930       3.2237            1            1            2            4            7
246..........................................................       28,818       5.3370            1            2            4            7           12
247..........................................................      188,884       2.1674            1            1            1            3            4
248..........................................................       13,847       5.9831            1            2            4            8           12
249..........................................................       69,978       2.4966            1            1            2            3            5
250..........................................................        6,762       7.7798            1            3            6           10           16
251..........................................................       41,707       2.8343            1            1            2            4            6
252..........................................................       45,567       8.5378            1            3            6           11           18
253..........................................................       44,910       6.0144            1            2            5            8           13
254..........................................................       53,360       2.7299            1            1            2            3            6
255..........................................................        2,521       9.6942            2            4            8           12           18
256..........................................................        3,425       7.4762            2            4            6            9           13
257..........................................................          705       4.8482            1            2            4            7           10
258..........................................................          686       7.3761            2            3            6            9           14
259..........................................................        7,302       2.8020            1            1            2            4            6
260..........................................................        1,549      11.2214            3            5            8           14           22
261..........................................................        3,522       4.2127            1            1            3            6            9
262..........................................................        3,531       2.5902            1            1            2            3            6
263..........................................................          652       5.4126            1            1            3            7           13
264..........................................................       28,273       8.8998            1            3            6           11           19
265..........................................................        1,957       3.4716            1            1            2            4            8
280..........................................................       63,593       7.3381            2            4            6            9           13
281..........................................................       53,704       4.8075            2            3            4            6            9
282..........................................................       54,305       3.2480            1            2            3            4            6
283..........................................................       14,888       5.4547            1            1            3            7           13
284..........................................................        4,139       3.2341            1            1            2            4            7
285..........................................................        2,803       2.2112            1            1            1            3            5
286..........................................................       23,695       6.9333            2            3            5            9           14
287..........................................................      158,158       3.1457            1            1            2            4            6
288..........................................................        2,953      11.7541            4            6            9           14           22
289..........................................................        1,357       8.6610            3            5            7           11           15
290..........................................................          473       6.4947            2            4            5            8           11
291..........................................................      187,597       6.4926            2            3            5            8           12
292..........................................................      204,514       4.9936            2            3            4            6            9
293..........................................................      196,441       3.6816            1            2            3            5            6
294..........................................................        1,415       5.5611            2            3            5            7            9
295..........................................................        1,343       4.3291            2            3            4            6            7

[[Page 23866]]

 
296..........................................................        1,917       3.0303            1            1            1            3            7
297..........................................................          791       1.8217            1            1            1            2            3
298..........................................................          602       1.3040            1            1            1            1            2
299..........................................................       17,750       6.6518            2            3            5            8           12
300..........................................................       44,551       5.0493            2            3            4            6            9
301..........................................................       36,994       3.6992            1            2            3            5            7
302..........................................................        7,587       4.3756            1            2            3            5            8
303..........................................................       70,544       2.5315            1            1            2            3            5
304..........................................................        2,086       5.1942            1            2            4            7           10
305..........................................................       35,079       2.8628            1            1            2            4            5
306..........................................................        1,515       6.2964            1            3            4            8           12
307..........................................................        6,344       3.4455            1            2            3            4            6
308..........................................................       35,699       5.5438            1            2            4            7           11
309..........................................................       79,311       3.9373            1            2            3            5            7
310..........................................................      158,556       2.7530            1            1            2            4            5
311..........................................................       21,034       2.3089            1            1            2            3            4
312..........................................................      165,835       3.1053            1            2            2            4            6
313..........................................................      211,391       2.1067            1            1            2            3            4
314..........................................................       61,613       7.0205            2            3            5            9           14
315..........................................................       29,960       4.6041            1            2            4            6            9
316..........................................................       17,966       2.9978            1            1            2            4            6
326..........................................................       11,226      17.1201            6            9           14           21           32
327..........................................................       10,457      10.0519            3            5            8           13           18
328..........................................................        8,865       4.3610            1            2            3            6            9
329..........................................................       48,110      15.9561            6            9           13           20           29
330..........................................................       63,624       9.7138            4            6            8           12           17
331..........................................................       28,171       5.8793            3            4            5            7            9
332..........................................................        1,823      14.3489            6            8           12           18           25
333..........................................................        5,922       8.8349            4            6            8           10           15
334..........................................................        3,719       5.5052            2            4            5            7            9
335..........................................................        7,182      14.0778            5            8           12           18           25
336..........................................................       12,448       9.0917            3            5            8           11           16
337..........................................................        8,570       5.5883            1            3            5            8           10
338..........................................................        1,501      10.7082            4            6            9           13           19
339..........................................................        3,163       7.0452            3            4            6            9           12
340..........................................................        3,558       4.1521            2            2            4            5            7
341..........................................................          878       7.1287            2            3            5            9           14
342..........................................................        2,544       4.1395            1            2            3            5            8
343..........................................................        6,975       2.1792            1            1            2            3            4
344..........................................................          936      11.7575            4            6            9           15           22
345..........................................................        2,914       7.2447            3            4            6            9           12
346..........................................................        2,759       4.9467            2            3            5            6            8
347..........................................................        1,625       8.8166            2            4            7           11           17
348..........................................................        4,164       5.7366            2            3            5            7           11
349..........................................................        5,155       3.0795            1            1            2            4            6
350..........................................................        1,756       7.9897            2            3            6           10           16
351..........................................................        4,287       4.5573            1            2            4            6            9
352..........................................................        8,183       2.4793            1            1            2            3            5
353..........................................................        3,165       8.4051            2            4            7           11           16
354..........................................................        8,420       5.0816            2            3            4            6            9
355..........................................................       15,316       2.8995            1            1            2            4            5
356..........................................................        8,334      12.9144            3            6           10           16           25
357..........................................................        7,801       8.1406            2            4            6           10           16
358..........................................................        2,477       4.4719            1            2            4            6            9
368..........................................................        3,566       6.5979            2            3            5            8           13
369..........................................................        5,248       4.7487            2            3            4            6            9
370..........................................................        3,554       3.3995            1            2            3            4            6
371..........................................................       24,371       8.7488            3            4            7           11           17
372..........................................................       27,061       6.8532            3            4            6            8           12
373..........................................................       15,249       4.9382            2            3            4            6            8
374..........................................................        9,039       8.5759            2            4            7           11           16
375..........................................................       18,945       6.0287            2            3            5            8           12
376..........................................................        4,279       4.1837            1            2            3            5            8
377..........................................................       51,556       6.3806            2            3            5            8           12
378..........................................................      110,340       4.4472            2            3            4            5            8
379..........................................................       92,136       3.4088            1            2            3            4            6
380..........................................................        3,020       7.2738            2            3            6            9           14
381..........................................................        5,293       5.1734            2            3            4            6            9
382..........................................................        4,492       3.6814            1            2            3            5            7
383..........................................................        1,223       5.5200            2            3            4            7           10

[[Page 23867]]

 
384..........................................................        8,080       3.7490            1            2            3            5            7
385..........................................................        1,996       8.8191            3            4            6           11           18
386..........................................................        7,126       5.6996            2            3            5            7           10
387..........................................................        5,033       4.2935            1            2            4            5            8
388..........................................................       18,540       7.3159            2            3            6            9           14
389..........................................................       45,795       5.0160            2            3            4            6            9
390..........................................................       46,426       3.5522            1            2            3            4            6
391..........................................................       44,299       5.2367            1            2            4            6           10
392..........................................................      282,071       3.4889            1            2            3            4            6
393..........................................................       23,253       6.8917            2            3            5            8           14
394..........................................................       45,853       4.8196            1            2            4            6            9
395..........................................................       24,740       3.3344            1            2            3            4            6
405..........................................................        3,963      17.0056            5            8           13           21           34
406..........................................................        5,300       9.1566            2            5            7           11           18
407..........................................................        2,115       5.4851            1            3            5            7           10
408..........................................................        1,548      14.9961            6            8           12           18           28
409..........................................................        1,737       9.8290            4            6            8           12           18
410..........................................................          598       6.5033            2            4            6            8           11
411..........................................................          956      12.4069            5            7           10           15           22
412..........................................................          955       8.5696            4            6            8           11           14
413..........................................................          756       5.9272            2            4            5            7           10
414..........................................................        5,241      11.7296            5            7           10           14           21
415..........................................................        6,127       7.6236            3            5            7            9           13
416..........................................................        5,328       4.8281            2            3            4            6            8
417..........................................................       16,444       8.3803            3            4            7           10           16
418..........................................................       27,075       5.6341            2            3            5            7           10
419..........................................................       35,887       3.1911            1            1            3            4            6
420..........................................................          766      13.6606            3            6           10           17           26
421..........................................................        1,054       7.6879            2            3            6           10           16
422..........................................................          327       4.3609            1            2            4            6            8
423..........................................................        1,542      15.8599            4            7           12           20           32
424..........................................................          894      10.4172            3            5            8           14           20
425..........................................................          125       5.3760            1            2            4            7           10
432..........................................................       15,140       6.9542            2            3            5            9           14
433..........................................................        9,672       4.8719            1            2            4            6            9
434..........................................................          877       3.6933            1            2            3            5            6
435..........................................................       12,111       7.5614            2            3            6           10           15
436..........................................................       13,158       5.8396            2            3            5            8           11
437..........................................................        3,887       4.2529            1            2            3            6            8
438..........................................................       14,063       7.5128            2            3            5            9           15
439..........................................................       24,364       5.3275            2            3            4            7           10
440..........................................................       25,670       3.8103            1            2            3            5            7
441..........................................................       13,335       7.0467            2            3            5            9           14
442..........................................................       14,144       5.1103            2            2            4            6            9
443..........................................................        6,544       3.7796            1            2            3            5            7
444..........................................................       12,898       6.6243            2            3            5            8           13
445..........................................................       16,794       4.7264            1            2            4            6            9
446..........................................................       15,932       3.2658            1            2            3            4            6
453..........................................................          948      15.6561            5            7           12           19           29
454..........................................................        1,771       8.0237            3            4            6           10           14
455..........................................................        1,969       4.4307            1            3            4            5            7
456..........................................................          946      14.7061            5            7           11           19           28
457..........................................................        2,413       7.4836            3            4            6            9           13
458..........................................................        1,609       4.5438            2            3            4            6            7
459..........................................................        3,508       9.4478            4            5            7           11           17
460..........................................................       51,883       4.2180            2            3            4            5            7
461..........................................................        1,018       8.4342            3            5            6            9           14
462..........................................................       13,194       4.2178            3            3            4            5            6
463..........................................................        5,052      16.5713            5            7           12           20           33
464..........................................................        5,838      10.2205            3            5            8           12           20
465..........................................................        2,398       5.8661            1            3            5            7           11
466..........................................................        4,072       9.1717            3            5            7           11           16
467..........................................................       14,331       5.4882            3            3            4            6            9
468..........................................................       21,133       3.9306            2            3            3            4            6
469..........................................................       30,531       8.2004            3            5            7           10           14
470..........................................................      405,204       3.9281            3            3            3            4            6
471..........................................................        2,283       9.7946            2            4            7           13           20
472..........................................................        6,954       4.0913            1            1            3            5            9
473..........................................................       22,875       1.9623            1            1            1            2            4
474..........................................................        2,918      12.6453            4            6           10           15           24

[[Page 23868]]

 
475..........................................................        3,277       8.3946            3            4            7           11           15
476..........................................................        1,589       4.7885            1            2            4            6            9
477..........................................................        2,582      11.8548            3            6            9           15           22
478..........................................................        8,562       6.6119            1            3            6            9           13
479..........................................................       11,424       2.8188            1            1            1            4            7
480..........................................................       26,724       9.2958            4            5            8           11           16
481..........................................................       72,123       5.9291            3            4            5            7            9
482..........................................................       48,111       4.8427            3            4            4            6            7
483..........................................................        7,100       4.2093            2            2            3            5            8
484..........................................................       17,842       2.4311            1            2            2            3            4
485..........................................................        1,183      12.1116            4            6           10           15           22
486..........................................................        2,186       8.0425            3            5            7           10           14
487..........................................................        1,312       5.6715            3            3            5            7            9
488..........................................................        2,495       5.2236            2            3            4            6           10
489..........................................................        5,763       3.0465            1            2            3            4            5
490..........................................................       22,971       4.3437            1            1            3            5            9
491..........................................................       52,406       2.2104            1            1            2            3            4
492..........................................................        5,216       8.5299            3            5            7           11           15
493..........................................................       16,899       5.2510            2            3            4            6            9
494..........................................................       29,166       3.3992            1            2            3            4            6
495..........................................................        1,970      10.9609            3            5            8           14           21
496..........................................................        5,555       5.9802            2            3            5            7           11
497..........................................................        6,632       3.0054            1            1            2            4            6
498..........................................................        1,163       7.8865            2            3            6           10           16
499..........................................................        1,110       2.9757            1            1            2            4            6
500..........................................................        1,502      10.8309            3            5            8           14           21
501..........................................................        3,872       5.9698            2            3            5            8           12
502..........................................................        6,452       2.9416            1            1            2            4            6
503..........................................................          833       9.4586            3            5            7           11           17
504..........................................................        2,162       6.4510            2            3            6            8           12
505..........................................................        3,004       3.3832            1            2            3            4            6
506..........................................................          810       3.4074            1            1            2            4            7
507..........................................................          836       5.1459            1            2            4            6           10
508..........................................................        2,481       2.0512            1            1            1            2            3
509..........................................................          627       3.1100            1            1            2            3            7
510..........................................................          973       6.4070            2            3            5            8           12
511..........................................................        3,926       3.9758            1            2            3            5            7
512..........................................................       10,961       2.1581            1            1            2            3            4
513..........................................................        1,052       5.0266            1            2            4            6           10
514..........................................................        1,006       2.8191            1            1            2            3            6
515..........................................................        3,818      10.4445            3            5            8           13           20
516..........................................................       11,280       5.9870            1            3            5            8           11
517..........................................................       17,523       3.0079            1            1            2            4            7
533..........................................................          822       6.6861            2            3            5            8           12
534..........................................................        3,392       4.0292            1            2            3            5            7
535..........................................................        6,990       6.2365            2            3            5            8           12
536..........................................................       33,661       3.9328            2            3            3            5            7
537..........................................................          665       4.4722            2            3            4            5            8
538..........................................................        1,056       3.2197            1            2            3            4            6
539..........................................................        3,417       9.7085            3            5            8           12           17
540..........................................................        4,016       7.1257            3            4            6            8           13
541..........................................................        1,618       5.3745            2            3            4            7            9
542..........................................................        5,709       8.7758            3            4            7           11           17
543..........................................................       17,012       5.9463            2            3            5            7           11
544..........................................................       10,798       4.4077            2            3            4            5            8
545..........................................................        4,079       9.0924            2            4            6           11           19
546..........................................................        5,577       5.5338            2            3            4            7           10
547..........................................................        4,533       3.8083            1            2            3            5            7
548..........................................................          580       8.9379            3            4            7           11           17
549..........................................................        1,110       6.3874            2            3            5            8           12
550..........................................................          858       4.4545            2            2            4            6            8
551..........................................................       10,066       7.1058            2            3            6            9           14
552..........................................................       85,179       4.1225            1            2            3            5            7
553..........................................................        3,076       5.9620            2            3            5            7           11
554..........................................................       19,173       3.6913            1            2            3            5            7
555..........................................................        2,013       4.8405            1            2            4            6            9
556..........................................................       18,639       3.1089            1            2            3            4            6
557..........................................................        3,646       6.6100            2            3            5            8           12
558..........................................................       15,089       4.2586            2            2            4            5            7
559..........................................................        1,815       7.5444            2            3            6            9           15

[[Page 23869]]

 
560..........................................................        4,319       4.7217            1            2            4            6            9
561..........................................................        7,107       2.7680            1            1            2            3            5
562..........................................................        5,458       6.3674            2            3            5            8           12
563..........................................................       36,267       3.7016            1            2            3            4            6
564..........................................................        1,661       6.9934            2            3            5            9           13
565..........................................................        3,311       4.9795            2            3            4            6            9
566..........................................................        2,624       3.6825            1            2            3            5            7
573..........................................................        5,477      13.0933            4            6            9           16           26
574..........................................................       11,123       9.3248            3            5            7           11           17
575..........................................................        5,462       5.8521            2            3            5            7           11
576..........................................................          547      12.9506            2            4            9           17           28
577..........................................................        2,228       6.1104            1            2            4            8           13
578..........................................................        3,054       3.3062            1            1            2            4            7
579..........................................................        3,511      10.6830            3            5            8           14           21
580..........................................................       10,711       5.5084            1            2            4            7           12
581..........................................................       12,142       2.6146            1            1            2            3            6
582..........................................................        5,337       2.8943            1            1            2            3            5
583..........................................................        8,748       1.8056            1            1            1            2            3
584..........................................................          668       5.9850            1            2            4            8           13
585..........................................................        1,469       2.2321            1            1            1            2            4
592..........................................................        4,178       8.8712            3            4            7           10           16
593..........................................................       12,304       6.4415            2            3            5            8           11
594..........................................................        2,751       5.0593            2            3            4            6            9
595..........................................................        1,112       8.3327            2            4            6           10           16
596..........................................................        5,308       4.7600            1            2            4            6            8
597..........................................................          458       8.2009            2            3            6           10           16
598..........................................................        1,400       5.7243            2            3            4            7           11
599..........................................................          306       3.7320            1            1            3            4            6
600..........................................................          682       5.0513            2            3            4            7            9
601..........................................................          884       3.8541            1            2            3            5            7
602..........................................................       22,088       7.0278            2            4            6            9           13
603..........................................................      130,121       4.7073            2            3            4            6            8
604..........................................................        2,660       5.6590            1            3            4            7           11
605..........................................................       22,097       3.4622            1            2            3            4            6
606..........................................................        1,350       6.3422            1            3            4            7           12
607..........................................................        7,168       3.7913            1            2            3            5            7
614..........................................................        1,457       7.0336            2            3            5            8           14
615..........................................................        1,546       3.1572            1            2            3            4            5
616..........................................................        1,091      16.9432            6            9           13           20           31
617..........................................................        6,718       8.7904            3            5            7           11           15
618..........................................................          258       6.3605            2            3            6            8           11
619..........................................................          696       8.2011            2            3            5            9           18
620..........................................................        2,186       3.6780            1            2            3            4            7
621..........................................................        7,848       2.1617            1            1            2            3            4
622..........................................................        1,112      13.1574            3            6            9           16           24
623..........................................................        3,077       8.5707            3            4            7           10           15
624..........................................................          383       6.0261            2            3            5            7           10
625..........................................................        1,274       7.0879            1            2            5            9           15
626..........................................................        2,538       3.1233            1            1            2            3            7
627..........................................................       14,026       1.5172            1            1            1            2            2
628..........................................................        3,366      11.1851            2            4            8           14           23
629..........................................................        4,160       8.7418            3            5            7           11           16
630..........................................................          534       5.5281            1            2            4            7           11
637..........................................................       17,104       6.0581            2            3            5            7           12
638..........................................................       42,581       4.2659            1            2            3            5            8
639..........................................................       38,312       3.0382            1            2            2            4            5
640..........................................................       60,806       5.4332            1            2            4            7           11
641..........................................................      201,324       3.8256            1            2            3            5            7
642..........................................................        1,492       5.1810            1            2            4            6            9
643..........................................................        5,176       7.6103            2            4            6            9           14
644..........................................................       11,788       5.4597            2            3            4            7           10
645..........................................................        8,179       3.8912            1            2            3            5            7
652..........................................................       10,067       7.7888            4            5            6            9           13
653..........................................................        1,697      16.8981            7            9           13           21           31
654..........................................................        3,452       9.8624            5            7            8           11           16
655..........................................................        1,633       6.5150            3            5            7            8           10
656..........................................................        3,918      10.1146            4            5            8           12           19
657..........................................................        7,422       5.9603            3            4            5            7           10
658..........................................................        8,271       3.7356            2            2            3            5            6
659..........................................................        4,658      11.2003            3            5            8           14           22

[[Page 23870]]

 
660..........................................................        7,594       6.5146            2            3            5            8           13
661..........................................................        4,260       3.2758            1            2            3            4            6
662..........................................................          949      10.2740            2            4            8           14           20
663..........................................................        2,054       5.2639            1            2            4            7           11
664..........................................................        4,390       2.1223            1            1            1            2            4
665..........................................................          654      11.0627            3            5            9           14           21
666..........................................................        2,092       6.3595            1            2            4            9           14
667..........................................................        3,616       2.8695            1            1            2            3            6
668..........................................................        3,833       8.5265            2            4            7           11           16
669..........................................................       12,746       4.4236            1            2            3            6            9
670..........................................................       11,687       2.5131            1            1            2            3            5
671..........................................................          808       5.9468            1            2            4            8           12
672..........................................................          943       2.5302            1            1            2            3            5
673..........................................................       12,542       9.7323            1            3            7           13           21
674..........................................................       11,715       7.1905            1            2            5            9           15
675..........................................................        7,824       2.0675            1            1            1            2            4
682..........................................................       82,091       7.1569            2            3            5            9           14
683..........................................................      132,320       5.6544            2            3            5            7           10
684..........................................................       44,932       3.8913            1            2            3            5            7
685..........................................................        2,331       3.4822            1            1            2            4            7
686..........................................................        1,597       7.5717            2            3            6            9           15
687..........................................................        3,261       5.3502            1            3            4            7           10
688..........................................................        1,073       3.2591            1            1            2            4            6
689..........................................................       55,995       6.2004            2            3            5            8           11
690..........................................................      198,101       4.2356            2            2            4            5            7
691..........................................................          821       3.9586            1            2            3            5            8
692..........................................................          491       2.3992            1            1            2            3            5
693..........................................................        2,429       4.8345            1            2            4            6           10
694..........................................................       18,000       2.5778            1            1            2            3            5
695..........................................................          975       5.5251            1            3            4            7           11
696..........................................................       10,518       3.2901            1            2            3            4            6
697..........................................................          592       3.1115            1            1            2            4            6
698..........................................................       23,320       6.6546            2            3            5            8           13
699..........................................................       24,207       4.8302            1            2            4            6            9
700..........................................................       12,279       3.5497            1            2            3            4            7
707..........................................................        5,979       4.4131            1            2            3            5            8
708..........................................................       18,063       2.1475            1            1            2            3            4
709..........................................................          762       6.5341            1            2            4            8           15
710..........................................................        1,831       1.7739            1            1            1            2            3
711..........................................................          790       8.1684            1            3            6           10           16
712..........................................................          705       3.0496            1            1            2            4            7
713..........................................................       10,252       4.1916            1            2            3            5            9
714..........................................................       28,797       1.9430            1            1            2            2            3
715..........................................................          531       6.2806            1            2            4            8           13
716..........................................................        1,273       1.4289            1            1            1            1            2
717..........................................................          703       7.2319            2            3            5            9           14
718..........................................................          589       2.7640            1            1            2            3            5
722..........................................................          745       7.5852            2            3            6           10           14
723..........................................................        1,949       5.2678            1            3            4            7           10
724..........................................................          578       3.1522            1            1            2            4            6
725..........................................................          755       5.5007            2            3            4            7           10
726..........................................................        3,716       3.4739            1            2            3            4            6
727..........................................................        1,294       6.3995            2            3            5            8           12
728..........................................................        6,158       4.0404            1            2            3            5            7
729..........................................................          591       5.5736            1            2            4            7           10
730..........................................................          471       3.0786            1            1            2            4            6
734..........................................................        1,362       7.9941            3            4            6            9           15
735..........................................................        1,130       3.3602            1            2            3            4            5
736..........................................................          854      13.7752            5            7           11           17           25
737..........................................................        3,293       7.1786            3            4            6            8           13
738..........................................................          863       3.8714            2            3            3            5            6
739..........................................................        1,013      10.1955            3            5            8           12           20
740..........................................................        4,326       5.2305            2            3            4            6            9
741..........................................................        6,014       2.9940            1            2            3            4            5
742..........................................................       10,950       4.5175            2            2            3            5            8
743..........................................................       32,325       2.2608            1            2            2            3            3
744..........................................................        1,520       5.8355            1            2            4            7           12
745..........................................................        1,694       2.5738            1            1            2            3            5
746..........................................................        2,634       4.2134            1            2            3            5            8
747..........................................................       10,409       1.8856            1            1            2            2            3

[[Page 23871]]

 
748..........................................................       19,857       1.7358            1            1            1            2            3
749..........................................................          982       9.3401            2            4            7           12           19
750..........................................................          435       3.1103            1            1            2            4            6
754..........................................................          978       8.3395            2            4            7           11           16
755..........................................................        2,933       5.6870            2            3            4            7           11
756..........................................................          677       3.1359            1            1            2            4            6
757..........................................................        1,393       8.1436            3            4            6           10           16
758..........................................................        1,605       6.0536            2            3            5            7           11
759..........................................................        1,239       4.4722            2            2            4            5            8
760..........................................................        1,700       3.9594            1            2            3            5            8
761..........................................................        1,749       2.4351            1            1            2            3            5
765..........................................................        2,754       5.0359            2            3            4            5            7
766..........................................................        2,686       3.1601            2            2            3            4            4
767..........................................................          132       3.3712            2            2            2            3            5
768..........................................................            6       3.5000            1            2            3            6            6
769..........................................................           98       4.6224            1            2            3            6           11
770..........................................................          202       2.2277            1            1            1            2            5
774..........................................................        1,506       3.1886            2            2            2            3            5
775..........................................................        5,768       2.2394            1            2            2            3            3
776..........................................................          511       3.3112            1            2            2            4            7
777..........................................................          206       2.2136            1            1            2            3            4
778..........................................................          474       3.0127            1            1            2            3            5
779..........................................................          110       2.1182            1            1            1            2            3
780..........................................................           40       1.4500            1            1            1            1            3
781..........................................................        3,017       3.7630            1            1            2            4            7
782..........................................................          171       2.4971            1            1            1            2            4
790..........................................................            1      25.0000          125          125          125          125          125
799..........................................................          566      14.0583            5            7           11           18           26
800..........................................................          705       7.8610            3            4            6            9           15
801..........................................................          557       4.9336            2            2            4            6            9
802..........................................................          765      12.2706            3            5            9           15           25
803..........................................................        1,070       6.6738            1            3            5            8           14
804..........................................................          987       3.4215            1            1            3            4            6
808..........................................................        6,088       8.2467            3            4            6           10           16
809..........................................................       12,869       5.3247            2            3            4            7           10
810..........................................................        2,786       4.0337            1            2            3            5            7
811..........................................................       21,404       5.6912            1            2            4            7           11
812..........................................................       89,951       3.7401            1            2            3            5            7
813..........................................................       14,232       5.1669            1            2            4            6           10
814..........................................................        1,554       6.7368            2            3            5            8           13
815..........................................................        3,297       4.9706            1            2            4            6            9
816..........................................................        2,147       3.5198            1            2            3            4            7
820..........................................................        1,299      17.7229            5            8           14           23           34
821..........................................................        2,474       7.8646            1            3            6           10           16
822..........................................................        1,893       3.5288            1            1            3            4            7
823..........................................................        2,178      15.4385            5            8           12           20           29
824..........................................................        2,974       8.7492            2            4            7           11           17
825..........................................................        1,748       4.3084            1            1            3            6            9
826..........................................................          524      15.0401            4            7           11           19           29
827..........................................................        1,254       7.9793            2            4            6           10           16
828..........................................................          799       3.7722            1            2            3            5            7
829..........................................................        1,171      10.6576            2            4            7           13           22
830..........................................................          521       3.7179            1            1            2            4            8
834..........................................................        4,028      15.4615            2            4           10           23           36
835..........................................................        2,703      10.4351            2            3            6           12           28
836..........................................................        1,622       5.1843            1            2            3            6           10
837..........................................................        1,043      23.1419            5           10           23           31           42
838..........................................................        1,320      12.2629            3            4            6           21           29
839..........................................................        1,467       6.4104            3            4            5            6           10
840..........................................................        9,659      10.4408            3            5            8           13           21
841..........................................................       10,035       6.9221            2            3            5            9           13
842..........................................................        5,310       4.5563            1            2            4            6            9
843..........................................................        1,350       8.5222            2            4            6           10           17
844..........................................................        2,412       6.0987            2            3            5            8           12
845..........................................................          804       4.3022            1            2            3            6            8
846..........................................................        2,113       8.4179            2            3            5           10           18
847..........................................................       23,862       3.3508            1            2            3            4            6
848..........................................................        1,723       3.1294            1            1            3            4            5
849..........................................................        1,477       5.9709            2            3            5            6           12
853..........................................................       34,852      16.6669            5            8           13           21           30

[[Page 23872]]

 
854..........................................................        6,643      11.1072            4            6            9           14           20
855..........................................................          459       7.0261            2            4            6            9           13
856..........................................................        5,892      15.3839            4            7           12           19           30
857..........................................................        9,614       8.4628            3            4            7           10           16
858..........................................................        3,246       5.6741            2            3            5            7           10
862..........................................................        7,929       8.1778            2            4            6           10           16
863..........................................................       21,420       5.1976            2            3            4            7            9
864..........................................................       18,946       4.0639            1            2            3            5            7
865..........................................................        1,705       6.7009            2            3            4            8           14
866..........................................................        8,182       3.5351            1            2            3            4            7
867..........................................................        5,062       9.6254            2            4            7           12           19
868..........................................................        2,641       5.7819            2            3            4            7           11
869..........................................................        1,103       4.3128            2            2            4            5            7
870..........................................................       21,199      15.4758            6            9           13           19           27
871..........................................................      216,384       7.4839            2            3            6           10           14
872..........................................................       90,892       5.7138            2            3            5            7           10
876..........................................................          857      11.9498            2            5            9           14           24
880..........................................................        9,282       3.1518            1            1            2            4            6
881..........................................................        4,623       4.1888            1            2            3            5            8
882..........................................................        1,556       4.4274            1            2            3            6            9
883..........................................................          757       7.3725            1            2            4            8           15
884..........................................................       19,006       5.4936            2            3            4            6           10
885..........................................................       80,806       7.6211            2            3            6            9           14
886..........................................................          404       6.0767            1            2            4            7           12
887..........................................................          393       4.6209            1            2            3            5            8
894..........................................................        4,369       2.9528            1            1            2            3            4
895..........................................................        6,958      10.4997            3            4            6            7            9
896..........................................................        5,490       6.6087            2            3            5            8           13
897..........................................................       36,053       4.0582            1            2            3            5            6
901..........................................................          924      15.0693            3            6           10           18           30
902..........................................................        2,031       7.7371            2            3            6            9           16
903..........................................................        1,500       4.5680            1            2            4            6            9
904..........................................................        1,046      11.2237            2            4            7           13           23
905..........................................................          811       4.6523            1            2            4            6            8
906..........................................................          710       3.1451            1            1            2            4            6
907..........................................................        8,461      11.6506            2            5            8           14           23
908..........................................................        8,319       6.7682            2            3            5            8           13
909..........................................................        5,447       3.6367            1            1            3            5            7
913..........................................................          804       5.6629            1            3            4            7           12
914..........................................................        6,609       3.4330            1            2            3            4            6
915..........................................................        1,078       4.7356            1            2            3            6            9
916..........................................................        5,508       2.1044            1            1            2            3            4
917..........................................................       15,775       5.1645            1            2            4            6           11
918..........................................................       35,653       2.7260            1            1            2            3            5
919..........................................................       11,089       6.3723            2            3            5            8           13
920..........................................................       13,970       4.3608            1            2            3            5            8
921..........................................................        9,423       2.9687            1            1            2            4            6
922..........................................................        1,047       5.9933            1            2            4            7           12
923..........................................................        3,952       3.2338            1            1            2            4            6
927..........................................................          211      31.1374            7           15           26           41           60
928..........................................................          818      15.9694            4            7           12           21           31
929..........................................................          438       7.6872            1            3            6           10           16
933..........................................................          139       4.3453            1            1            1            4            8
934..........................................................          659       6.1988            1            3            5            8           12
935..........................................................        2,201       5.4330            1            2            4            7           11
939..........................................................          671      10.0611            2            4            7           13           20
940..........................................................        1,320       5.4220            1            2            4            7           12
941..........................................................        1,707       2.7299            1            1            2            3            5
945..........................................................        6,244      10.4947            4            6            8           12           15
946..........................................................        3,055       7.8628            3            5            6            7            8
947..........................................................        9,715       5.0101            1            2            4            6           10
948..........................................................       47,722       3.4806            1            2            3            4            6
949..........................................................          632       4.1092            1            1            2            4            6
950..........................................................          387       3.4858            1            1            2            4            5
951..........................................................          940       4.6436            1            1            2            3            6
955..........................................................          444      12.2658            2            5           10           16           26
956..........................................................        3,976       9.2912            4            5            7           11           17
957..........................................................        1,318      14.8566            2            7           12           19           28
958..........................................................        1,147      10.4080            3            6            8           13           19
959..........................................................          291       6.2921            2            3            5            8           11

[[Page 23873]]

 
963..........................................................        1,586       9.5214            2            4            8           13           19
964..........................................................        2,573       6.2274            2            3            5            8           11
965..........................................................        1,072       4.1371            1            2            3            5            7
969..........................................................          639      18.8279            4            8           14           22           36
970..........................................................          136       9.8309            2            3            7           12           17
974..........................................................        5,920      10.3723            2            4            8           13           21
975..........................................................        4,674       7.0148            2            3            5            9           13
976..........................................................        2,617       4.9308            2            2            4            6            8
977..........................................................        4,565       5.2931            1            2            4            6           10
981..........................................................       25,478      15.1488            5            8           12           19           28
982..........................................................       18,329       9.7455            3            5            8           12           18
983..........................................................        6,112       5.3613            1            2            4            7           11
984..........................................................          671      14.6811            5            8           13           18           25
985..........................................................          903       9.6512            2            5            8           13           18
986..........................................................          731       5.3338            1            2            3            7           12
987..........................................................        8,240      13.0089            4            6           10           16           24
988..........................................................       11,583       7.8090            2            3            6           10           15
989..........................................................        5,796       4.1046            1            1            3            6            9
                                                              -------------
                                                                11,387,276
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Proposed Statewide Average Operating Cost-to-Charge Ratios--
                               March 2008
------------------------------------------------------------------------
                      State                          Urban       Rural
------------------------------------------------------------------------
Alabama.........................................       0.261       0.33
Alaska..........................................       0.401       0.745
Arizona.........................................       0.288       0.418
Arkansas........................................       0.32        0.368
California......................................       0.225       0.303
Colorado........................................       0.281       0.437
Connecticut.....................................       0.399       0.528
Delaware........................................       0.495       0.513
District of Columbia *..........................       0.345  ..........
Florida.........................................       0.238       0.281
Georgia.........................................       0.329       0.39
Hawaii..........................................       0.382       0.453
Idaho...........................................       0.468       0.534
Illinois........................................       0.305       0.395
Indiana.........................................       0.39        0.466
Iowa............................................       0.357       0.444
Kansas..........................................       0.288       0.424
Kentucky........................................       0.37        0.371
Louisiana.......................................       0.299       0.353
Maine...........................................       0.498       0.462
Maryland........................................       0.726       0.793
Massachusetts *.................................       0.471  ..........
Michigan........................................       0.364       0.462
Minnesota.......................................       0.391       0.53
Mississippi.....................................       0.302       0.355
Missouri........................................       0.33        0.399
Montana.........................................       0.422       0.465
Nebraska........................................       0.335       0.46
Nevada..........................................       0.22        0.478
New Hampshire...................................       0.457       0.427
New Jersey *....................................       0.178  ..........
New Mexico......................................       0.377       0.36
New York........................................       0.346       0.522
North Carolina..................................       0.402       0.396
North Dakota....................................       0.428       0.457
Ohio............................................       0.338       0.522
Oklahoma........................................       0.293       0.383
Oregon..........................................       0.452       0.415
Pennsylvania....................................       0.267       0.413
Puerto Rico *...................................       0.474  ..........
Rhode Island *..................................       0.388  ..........
South Carolina..................................       0.284       0.301
South Dakota....................................       0.335       0.43
Tennessee.......................................       0.297       0.371
Texas...........................................       0.257       0.342
Utah............................................       0.414       0.572
Vermont.........................................       0.543       0.619
Virginia........................................       0.358       0.357
Washington......................................       0.385       0.443
West Virginia...................................       0.471       0.462
Wisconsin.......................................       0.425       0.458
Wyoming.........................................       0.431       0.562 
------------------------------------------------------------------------
* All counties in the State or Territory are classified as urban, with
  the exception of Massachusetts, which has areas designated as rural.
  However, no short-term acute care IPPS hospitals are located in those
  areas as of March 2008.


  Table 8B.--Proposed Statewide Average Capital Cost-to-Charge Ratios--
                               March 2008
------------------------------------------------------------------------
                            State                                Ratio
------------------------------------------------------------------------
Alabama.....................................................       0.024
Alaska......................................................       0.036
Arizona.....................................................       0.023
Arkansas....................................................       0.025
California..................................................       0.015
Colorado....................................................       0.028
Connecticut.................................................       0.028
Delaware....................................................       0.035
District of Columbia........................................       0.022
Florida.....................................................       0.022
Georgia.....................................................       0.028
Hawaii......................................................       0.03
Idaho.......................................................       0.038
Illinois....................................................       0.026
Indiana.....................................................       0.037
Iowa........................................................       0.028
Kansas......................................................       0.03
Kentucky....................................................       0.029
Louisiana...................................................       0.026
Maine.......................................................       0.03
Maryland....................................................       0.058
Massachusetts...............................................       0.031
Michigan....................................................       0.03
Minnesota...................................................       0.028
Mississippi.................................................       0.027
Missouri....................................................       0.029
Montana.....................................................       0.034
Nebraska....................................................       0.039
Nevada......................................................       0.021
New Hampshire...............................................       0.032
New Jersey..................................................       0.013
New Mexico..................................................       0.032
New York....................................................       0.026
North Carolina..............................................       0.032
North Dakota................................................       0.037
Ohio........................................................       0.028
Oklahoma....................................................       0.026
Oregon......................................................       0.031
Pennsylvania................................................       0.022
Puerto Rico.................................................       0.042
Rhode Island................................................       0.02
South Carolina..............................................       0.024
South Dakota................................................       0.032
Tennessee...................................................       0.03
Texas.......................................................       0.026
Utah........................................................       0.032
Vermont.....................................................       0.045
Virginia....................................................       0.036
Washington..................................................       0.03
West Virginia...............................................       0.034
Wisconsin...................................................       0.037
Wyoming.....................................................       0.044
------------------------------------------------------------------------


[[Page 23874]]


  Table 8C.--Proposed Statewide Average Total Cost-to-Charge Ratios for
                            LTCHs--March 2008
------------------------------------------------------------------------
                      State                          Urban       Rural
------------------------------------------------------------------------
Alabama.........................................       0.279       0.36
Alaska..........................................       0.432       0.806
Arizona.........................................       0.311       0.448
Arkansas........................................       0.343       0.401
California......................................       0.238       0.322
Colorado........................................       0.307       0.479
Connecticut.....................................       0.426       0.576
Delaware........................................       0.529       0.551
District of Columbia *..........................       0.368  ..........
Florida.........................................       0.259       0.311
Georgia.........................................       0.355       0.424
Hawaii..........................................       0.411       0.487
Idaho...........................................       0.506       0.576
Illinois........................................       0.33        0.427
Indiana.........................................       0.426       0.507
Iowa............................................       0.381       0.483
Kansas..........................................       0.314       0.463
Kentucky........................................       0.398       0.401
Louisiana.......................................       0.325       0.38
Maine...........................................       0.529       0.49
Maryland ***....................................       0.34        0.434
Massachusetts **................................       0.502  ..........
Michigan........................................       0.393       0.497
Minnesota.......................................       0.418       0.569
Mississippi.....................................       0.328       0.384
Missouri........................................       0.357       0.438
Montana.........................................       0.453       0.505
Nebraska........................................       0.371       0.505
Nevada..........................................       0.24        0.539
New Hampshire...................................       0.489       0.459
New Jersey **...................................       0.19   ..........
New Mexico......................................       0.408       0.394
New York........................................       0.372       0.558
North Carolina..................................       0.434       0.431
North Dakota....................................       0.461       0.505
Ohio............................................       0.365       0.563
Oklahoma........................................       0.318       0.414
Oregon..........................................       0.484       0.444
Pennsylvania....................................       0.287       0.443
Puerto Rico **..................................       0.514  ..........
Rhode Island **.................................       0.408  ..........
South Carolina..................................       0.308       0.327
South Dakota....................................       0.365       0.466
Tennessee.......................................       0.326       0.406
Texas...........................................       0.282       0.374
Utah............................................       0.445       0.622
Vermont.........................................       0.594       0.657
Virginia........................................       0.393       0.398
Washington......................................       0.414       0.473
West Virginia...................................       0.505       0.496
Wisconsin.......................................       0.462       0.497
Wyoming.........................................       0.467       0.616 
------------------------------------------------------------------------
\*\ All counties in the State or Territory are classified as urban, with
  the exception of Massachusetts, which has areas designated as rural.
  However, no short-term acute care IPPS hospitals or LTCHs are located
  in those areas as of March 2008.
\**\ National average IPPS total cost-to-charge ratios, as discussed in
  section VI.E. of this proposed rule.


                        Table 9A.--Hospital Reclassifications and Redesignations--FY 2009
----------------------------------------------------------------------------------------------------------------
                                                                Reclassified
               Provider No.                 Geographic  CBSA        CBSA                      LUGAR
----------------------------------------------------------------------------------------------------------------
010001....................................             20020             10500  ................................
010005....................................                01             26620  ................................
010009....................................             19460             26620  ................................
010010....................................                01             13820  ................................
010012....................................                01             40660  ................................
010022....................................                01             12060  ................................
010025....................................                01             17980  ................................
010029....................................             12220             17980  ................................
010035....................................                01             13820  ................................
010052....................................                01             33860  ................................
010054....................................             19460             26620  ................................
010055....................................             20020             37460  ................................
010059....................................             19460             26620  ................................
010061....................................                01             16860  ................................
010065....................................                01             13820  ................................
010083....................................                01             37860  ................................
010085....................................             19460             26620  ................................
010090....................................             33660             37700  ................................
010100....................................                01             37860  ................................
010101....................................                01             13820  ................................
010102....................................                01             33860  ................................
010118....................................                01             33860  ................................
010126....................................                01             33860  ................................
010143....................................                01             26620  ................................
010150....................................                01             33860  ................................
010158....................................                01             22520  ................................
010164....................................                01             13820  ................................
020008....................................                02             11260  ................................
030007....................................             39140             22380  LUGAR
030033....................................                03             22380  ................................
030055....................................             29420             39140  ................................
030069....................................             29420             40140  ................................
030101....................................             29420             29820  ................................
040014....................................                04             30780  ................................
040017....................................                04             22220  ................................
040019....................................                04             32820  ................................
040020....................................             27860             32820  ................................
040027....................................                04             44180  ................................
040039....................................                04             27860  ................................
040041....................................                04             30780  ................................
040069....................................                04             32820  ................................
040071....................................             38220             30780  ................................

[[Page 23875]]

 
040076....................................                04             30780  LUGAR
040078....................................             26300             30780  ................................
040080....................................                04             27860  ................................
040085....................................                04             32820  ................................
040088....................................                04             33740  ................................
040091....................................                04             45500  ................................
040119....................................                04             30780  ................................
050006....................................                05             39820  ................................
050009....................................             34900             46700  ................................
050013....................................             34900             46700  ................................
050014....................................                05             40900  ................................
050022....................................             40140             42044  ................................
050038....................................             41940             42100  ................................
050042....................................                05             39820  ................................
050046....................................             37100             31084  ................................
050054....................................             40140             42044  ................................
050069....................................             42044             31084  ................................
050071....................................             41940             42100  ................................
050073....................................             46700             36084  ................................
050076....................................             41884             36084  ................................
050082....................................             37100             31084  ................................
050089....................................             40140             31084  ................................
050090....................................             42220             41884  ................................
050099....................................             40140             31084  ................................
050101....................................             46700             36084  ................................
050102....................................             40140             42044  ................................
050118....................................             44700             33700  ................................
050125....................................             41940             42100  ................................
050129....................................             40140             31084  ................................
050131....................................             41884             36084  ................................
050133....................................             49700             40900  ................................
050136....................................             42220             41884  ................................
050140....................................             40140             31084  ................................
050150....................................                05             40900  ................................
050153....................................             41940             42100  ................................
050159....................................             37100             31084  ................................
050168....................................             42044             31084  ................................
050173....................................             42044             31084  ................................
050174....................................             42220             41884  ................................
050188....................................             41940             42100  ................................
050193....................................             42044             31084  ................................
050194....................................             42100             41940  ................................
050197....................................             41884             41940  ................................
050224....................................             42044             31084  ................................
050226....................................             42044             31084  ................................
050230....................................             42044             31084  ................................
050236....................................             37100             31084  ................................
050242....................................             42100             41940  ................................
050243....................................             40140             42044  ................................
050245....................................             40140             31084  ................................
050272....................................             40140             31084  ................................
050279....................................             40140             31084  ................................
050291....................................             42220             41884  ................................
050292....................................             40140             42044  ................................
050300....................................             40140             31084  ................................
050301....................................                05             42220  ................................
050308....................................             41940             42100  ................................
050327....................................             40140             31084  ................................
050329....................................             40140             42044  ................................
050335....................................                05             33700  ................................
050348....................................             42044             31084  ................................
050360....................................             41884             36084  ................................
050367....................................             46700             36084  ................................
050380....................................             41940             42100  ................................
050385....................................             42220             41884  ................................
050390....................................             40140             42044  ................................
050394....................................             37100             31084  ................................
050423....................................             40140             42044  ................................
050426....................................             42044             31084  ................................
050441....................................             41940             42100  ................................
050476....................................                05             42220  ................................

[[Page 23876]]

 
050494....................................                05             40900  ................................
050510....................................             41884             36084  ................................
050517....................................             40140             31084  ................................
050526....................................             42044             31084  ................................
050534....................................             40140             42044  ................................
050541....................................             41884             41940  ................................
050543....................................             42044             31084  ................................
050547....................................             42220             41884  ................................
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  ................................
050678....................................             42044             31084  ................................
050680....................................             46700             36084  ................................
050684....................................             40140             42044  ................................
050686....................................             40140             42044  ................................
050688....................................             41940             42100  ................................
050690....................................             42220             41884  ................................
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  ................................
050749....................................             37100             31084  ................................
050758....................................             40140             31084  ................................
060003....................................             14500             19740  ................................
060012....................................             39380             17820  ................................
060023....................................             24300             19740  ................................
060027....................................             14500             19740  ................................
060031....................................             17820             19740  ................................
060049....................................                06             22660  ................................
060075....................................                06             24300  ................................
060096....................................                06             19740  ................................
060103....................................             14500             19740  ................................
060116....................................             14500             19740  ................................
070001....................................             35300             35004  ................................
070003....................................                07             25540  LUGAR
070004....................................                07             25540  ................................
070005....................................             35300             35004  ................................
070006....................................             14860             35644  ................................
070010....................................             14860             35644  ................................
070011....................................                07             25540  ................................
070015....................................                07             35644  ................................
070016....................................             35300             35004  ................................
070017....................................             35300             35004  ................................
070018....................................             14860             35644  ................................
070019....................................             35300             35004  ................................
070022....................................             35300             35004  ................................
070028....................................             14860             35644  ................................
070031....................................             35300             35004  ................................
070033....................................             14860             35644  ................................
070034....................................             14860             35644  ................................
070036....................................             25540             35300  ................................
070038....................................             35300             35004  ................................
070039....................................             35300             35004  ................................
080001....................................             48864             37964  ................................

[[Page 23877]]

 
080003....................................             48864             37964  ................................
080004....................................             20100             48864  ................................
080006....................................                08             20100  ................................
080007....................................                08             36140  ................................
090001....................................             47894             13644  ................................
090004....................................             47894             13644  ................................
090011....................................             47894             13644  ................................
100002....................................             48424             22744  ................................
100014....................................             19660             36740  ................................
100017....................................             19660             36740  ................................
100022....................................             33124             22744  ................................
100023....................................                10             36740  ................................
100024....................................                10             33124  ................................
100045....................................             19660             36740  ................................
100047....................................             39460             14600  ................................
100049....................................                10             29460  ................................
100068....................................             19660             36740  ................................
100072....................................             19660             36740  ................................
100077....................................             39460             14600  ................................
100080....................................             48424             22744  ................................
100081....................................                10             23020  LUGAR
100105....................................             42680             38940  ................................
100109....................................                10             36740  ................................
100130....................................             48424             22744  ................................
100139....................................                10             23540  LUGAR
100150....................................                10             33124  ................................
100156....................................                10             23540  ................................
100157....................................             29460             45300  ................................
100160....................................                10             33124  ................................
100168....................................             48424             22744  ................................
100176....................................             48424             22744  ................................
100217....................................             42680             38940  ................................
100232....................................                10             27260  ................................
100234....................................             48424             22744  ................................
100236....................................             39460             14600  ................................
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  ................................
100292....................................                10             23020  LUGAR
110001....................................             19140             16860  ................................
110002....................................                11             12060  ................................
110016....................................                11             17980  ................................
110023....................................                11             12060  ................................
110029....................................             23580             12060  ................................
110038....................................                11             45220  ................................
110040....................................                11             12060  LUGAR
110041....................................                11             12060  ................................
110054....................................             40660             12060  ................................
110069....................................             47580             31420  ................................
110075....................................                11             42340  ................................
110095....................................                11             10500  ................................
110112....................................                11             10500  ................................
110121....................................                11             45220  ................................
110122....................................             46660             45220  ................................
110125....................................                11             31420  ................................
110128....................................                11             42340  ................................
110146....................................                11             27260  ................................
110150....................................                11             12060  ................................
110153....................................             47580             31420  ................................
110168....................................             40660             12060  ................................
110187....................................                11             12060  LUGAR
110189....................................                11             12060  ................................
120028....................................                12             26180  ................................
130002....................................                13             14260  ................................
130003....................................             30300             28420  ................................

[[Page 23878]]

 
130049....................................             17660             44060  ................................
130067....................................                13             26820  LUGAR
140012....................................                14             16974  ................................
140015....................................                14             41180  ................................
140032....................................                14             41180  ................................
140034....................................                14             41180  ................................
140040....................................                14             37900  ................................
140043....................................                14             19340  ................................
140046....................................                14             41180  ................................
140058....................................                14             41180  ................................
140064....................................                14             37900  ................................
140084....................................             29404             16974  ................................
140100....................................             29404             16974  ................................
140110....................................                14             16974  ................................
140130....................................             29404             16974  ................................
140135....................................             19500             16580  ................................
140143....................................                14             16974  ................................
140155....................................             28100             16974  ................................
140160....................................                14             40420  ................................
140164....................................                14             41180  ................................
140186....................................             28100             16974  ................................
140202....................................             29404             16974  ................................
140291....................................             29404             16974  ................................
150002....................................             23844             16974  ................................
150004....................................             23844             16974  ................................
150006....................................             33140             43780  ................................
150008....................................             23844             16974  ................................
150011....................................                15             26900  ................................
150015....................................             33140             23844  ................................
150018....................................             21140             43780  ................................
150023....................................             45460             26900  ................................
150026....................................             21140             43780  ................................
150030....................................                15             26900  LUGAR
150034....................................             23844             16974  ................................
150042....................................                15             14020  ................................
150045....................................                15             23060  ................................
150048....................................                15             17140  ................................
150051....................................             14020             26900  ................................
150065....................................                15             26900  ................................
150069....................................                15             17140  ................................
150076....................................                15             43780  ................................
150088....................................             11300             26900  ................................
150090....................................             23844             16974  ................................
150091....................................                15             23060  ................................
150102....................................                15             23844  LUGAR
150112....................................             18020             26900  ................................
150113....................................             11300             26900  ................................
150115....................................                15             21780  ................................
150125....................................             23844             16974  ................................
150126....................................             23844             16974  ................................
150133....................................                15             43780  ................................
150146....................................                15             21140  ................................
150147....................................             23844             16974  ................................
160001....................................                16             11180  ................................
160016....................................                16             11180  ................................
160057....................................                16             26980  ................................
160064....................................                16             47940  ................................
160080....................................                16             19340  ................................
160089....................................                16             26980  ................................
160147....................................                16             11180  ................................
170006....................................                17             27900  ................................
170012....................................                17             48620  ................................
170013....................................                17             48620  ................................
170020....................................                17             48620  ................................
170023....................................                17             48620  ................................
170068....................................                17             11100  ................................
170120....................................                17             27900  ................................
170142....................................                17             45820  ................................
170175....................................                17             48620  ................................
170190....................................                17             45820  ................................
170193....................................                17             48620  ................................

[[Page 23879]]

 
180002....................................                18                49  ................................
180005....................................                18             26580  ................................
180011....................................                18             30460  ................................
180012....................................             21060             31140  ................................
180013....................................             14540             34980  ................................
180017....................................                18             21060  ................................
180024....................................                18             31140  ................................
180027....................................                18             17300  ................................
180029....................................                18             30460  ................................
180043....................................                18                44  ................................
180044....................................                18             26580  ................................
180048....................................                18             31140  ................................
180049....................................                18             30460  ................................
180050....................................                18             28700  ................................
180066....................................                18             34980  ................................
180069....................................                18             26580  ................................
180078....................................                18             26580  ................................
180080....................................                18             28940  ................................
180093....................................                18             21780  ................................
180102....................................                18             17300  ................................
180104....................................                18             17300  ................................
180116....................................                18                14  ................................
180124....................................             14540             34980  ................................
180127....................................                18             31140  ................................
180132....................................                18             30460  ................................
190003....................................                19             29180  ................................
190015....................................                19             35380  ................................
190017....................................                19             29180  ................................
190086....................................                19             33740  ................................
190088....................................                19             43340  ................................
190106....................................                19             10780  ................................
190144....................................                19             43340  ................................
190164....................................                19             10780  ................................
190167....................................                19             29180  ................................
190184....................................                19             33740  ................................
190191....................................                19             29180  ................................
190208....................................                19                04  ................................
190218....................................                19             43340  ................................
190257....................................                19             33740  ................................
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  ................................
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  ................................

[[Page 23880]]

 
220163....................................             49340             14484  ................................
220171....................................             15764             14484  ................................
220174....................................             37764             14484  ................................
220175....................................             15764             14484  ................................
220176....................................             49340             14484  ................................
230002....................................             19804             11460  ................................
230003....................................             26100             34740  ................................
230013....................................             47644             19804  ................................
230019....................................             47644             19804  ................................
230020....................................             19804             11460  ................................
230021....................................             35660             28020  ................................
230022....................................                23             29620  ................................
230024....................................             19804             11460  ................................
230029....................................             47644             19804  ................................
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             22420  ................................
230071....................................             47644             19804  ................................
230072....................................             26100             34740  ................................
230077....................................             40980             22420  ................................
230080....................................                23             13020  ................................
230089....................................             19804             11460  ................................
230092....................................             27100             11460  ................................
230095....................................                23             13020  ................................
230096....................................                23             28020  ................................
230097....................................                23             24340  ................................
230099....................................             33780             11460  ................................
230104....................................             19804             11460  ................................
23B104....................................             47644             19804  ................................
230105....................................                23             13020  ................................
230106....................................             24340             34740  ................................
230119....................................             19804             11460  ................................
230121....................................                23             29620  LUGAR
230130....................................             47644             19804  ................................
230135....................................             19804             11460  ................................
230142....................................             19804             11460  ................................
230146....................................             19804             11460  ................................
230151....................................             47644             19804  ................................
230165....................................             19804             11460  ................................
230174....................................             26100             34740  ................................
230176....................................             19804             11460  ................................
230195....................................             47644             19804  ................................
230204....................................             47644             19804  ................................
230207....................................             47644             19804  ................................
230208....................................                23             24340  LUGAR
230222....................................                23             13020  ................................
230223....................................             47644             19804  ................................
230227....................................             47644             19804  ................................
230236....................................             24340             34740  ................................
230244....................................             19804             11460  ................................
230254....................................             47644             19804  ................................
230257....................................             47644             19804  ................................
230264....................................             47644             19804  ................................
230269....................................             47644             19804  ................................
230270....................................             19804             11460  ................................
230273....................................             19804             11460  ................................
230277....................................             47644             19804  ................................
230279....................................             47644             22420  ................................
230301....................................             47644             19804  ................................
240030....................................                24             41060  ................................
240036....................................             41060             33460  ................................
240064....................................                24             20260  ................................
240069....................................                24             33460  ................................
240071....................................                24             33460  ................................

[[Page 23881]]

 
240075....................................                24             41060  ................................
240088....................................                24             41060  ................................
240093....................................                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  ................................
250044....................................                25             22520  ................................
250069....................................                25             46220  ................................
250078....................................             25620             25060  ................................
250081....................................                25             46220  ................................
250082....................................                25             38220  ................................
250094....................................             25620             25060  ................................
250097....................................                25             12940  ................................
250099....................................                25             27140  ................................
250100....................................                25             46220  ................................
250104....................................                25             46220  ................................
250117....................................                25             25060  LUGAR
260009....................................                26             28140  ................................
260015....................................                26             27860  ................................
260017....................................                26             27620  ................................
260022....................................                26                16  ................................
260025....................................                26             41180  ................................
260050....................................                26             41140  ................................
260064....................................                26             17860  ................................
260074....................................                26             17860  ................................
260094....................................                26             44180  ................................
260110....................................                26             44180  ................................
260113....................................                26                14  ................................
260116....................................                26                14  ................................
260119....................................                26             27860  ................................
260175....................................                26             28140  ................................
260183....................................                26             41180  ................................
260186....................................                26             44180  ................................
270003....................................                27             24500  ................................
270014....................................             33540             17660  ................................
270017....................................                27             33540  ................................
270051....................................                27             33540  ................................
280009....................................                28             30700  ................................
280023....................................                28             30700  ................................
280032....................................                28             30700  ................................
280061....................................                28                53  ................................
280065....................................                28             24540  ................................
280125....................................                28             43580  ................................
290002....................................                29             16180  LUGAR
290006....................................                29             39900  ................................
290008....................................                29             14260  ................................
290019....................................             16180             39900  ................................
300001....................................                30             31700  ................................
300011....................................             31700             49340  ................................
300012....................................             31700             49340  ................................
300017....................................             40484             37764  ................................
300019....................................                30             15764  ................................
300020....................................             31700             49340  ................................
300023....................................             40484             37764  ................................
300029....................................             40484             37764  ................................
300034....................................             31700             49340  ................................
310002....................................             35084             35644  ................................
310009....................................             35084             35644  ................................
310014....................................             15804             37964  ................................
310015....................................             35084             35644  ................................
310017....................................             35084             35644  ................................
310018....................................             35084             35644  ................................
310021....................................             45940             35084  ................................
310022....................................             15804             37964  ................................

[[Page 23882]]

 
310029....................................             15804             37964  ................................
310031....................................             15804             20764  ................................
310032....................................             47220             48864  ................................
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  ................................
320005....................................             22140             10740  ................................
320006....................................                32             10740  ................................
320013....................................                32             42140  ................................
320033....................................                32             42140  LUGAR
320063....................................                32             36220  ................................
320065....................................                32             36220  ................................
330004....................................             28740             39100  ................................
330008....................................                33             15380  LUGAR
330023....................................             39100             35644  ................................
330027....................................             35004             35644  ................................
330049....................................             39100             14860  ................................
330067....................................             39100             14860  ................................
330073....................................                33             40380  LUGAR
330085....................................                33             45060  ................................
330090....................................             21300             27060  ................................
330094....................................                33             38340  ................................
330103....................................                33                39  ................................
330106....................................             35004             35644  ................................
330126....................................             39100             35644  ................................
330136....................................                33             45060  ................................
330157....................................                33             45060  ................................
330167....................................             35004             35644  ................................
330181....................................             35004             35644  ................................
330182....................................             35004             35644  ................................
330191....................................             24020             10580  ................................
330198....................................             35004             35644  ................................
330224....................................             28740             39100  ................................
330225....................................             35004             35644  ................................
330229....................................                33             21500  ................................
330235....................................                33             45060  LUGAR
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             22180  ................................
340010....................................             24140             39580  ................................
340013....................................                34             24860  ................................
340014....................................             49180             24660  ................................
340015....................................                34             16740  ................................
340021....................................                34             16740  ................................
340023....................................             11700             24860  ................................
340027....................................                34             24780  ................................
340039....................................                34             16740  ................................
340047....................................             49180             24660  ................................
340050....................................                34             22180  ................................
340051....................................                34             25860  ................................
340068....................................                34             34820  ................................
340069....................................             39580             20500  ................................

[[Page 23883]]

 
340070....................................             15500             24660  ................................
340071....................................                34             39580  LUGAR
340073....................................             39580             20500  ................................
340091....................................             24660             49180  ................................
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  ................................
340148....................................             49180             24660  ................................
340173....................................             39580             20500  ................................
350003....................................                35             13900  ................................
350006....................................                35             13900  ................................
350009....................................                35             22020  ................................
360008....................................                36             26580  ................................
360010....................................                36             10420  ................................
360011....................................                36             18140  ................................
360013....................................                36             30620  ................................
360014....................................                36             18140  ................................
360019....................................             10420             17460  ................................
360020....................................             10420             17460  ................................
360025....................................             41780             45780  ................................
360027....................................             10420             17460  ................................
360036....................................                36             17460  ................................
360039....................................                36             18140  ................................
360054....................................                36             26580  ................................
360065....................................                36             17460  ................................
360078....................................             10420             17460  ................................
360086....................................             44220             19380  ................................
360095....................................                36             45780  ................................
360096....................................                36             49660  LUGAR
360107....................................                36             45780  ................................
360121....................................                36             45780  ................................
360150....................................             10420             17460  ................................
360159....................................                36             18140  ................................
360175....................................                36             18140  ................................
360185....................................                36             49660  LUGAR
360187....................................             44220             19380  ................................
360197....................................                36             18140  ................................
360211....................................             48260             38300  ................................
360245....................................                36             17460  LUGAR
360253....................................             19380             17140  ................................
370004....................................                37             27900  ................................
370006....................................                37             48620  ................................
370014....................................                37             43300  ................................
370015....................................                37             46140  ................................
370016....................................                37             36420  ................................
370018....................................                37             46140  ................................
370025....................................                37             46140  ................................
370026....................................                37             36420  ................................
370030....................................                37             46140  ................................
370047....................................                37             36420  ................................
370049....................................                37             36420  ................................
370113....................................                37             22220  ................................
370149....................................                37             36420  ................................
380001....................................                38             38900  ................................
380022....................................                38             18700  LUGAR
380027....................................                38             21660  ................................
380050....................................                38             32780  ................................
380051....................................             41420             38900  ................................
380090....................................                38             21660  ................................
390006....................................                39             25420  ................................
390013....................................                39             25420  ................................
390016....................................                39             49660  ................................
390031....................................                39             39740  LUGAR

[[Page 23884]]

 
390044....................................             39740             37964  ................................
390046....................................             49620             29540  ................................
390048....................................                39             25420  ................................
390065....................................                39             13644  ................................
390066....................................             30140             25420  ................................
390071....................................                39             48700  LUGAR
390079....................................                39             13780  ................................
390086....................................                39             27780  ................................
390091....................................                39             49660  ................................
390093....................................                39             49660  ................................
390096....................................             39740             37964  ................................
390110....................................             27780             38300  ................................
390113....................................                39             49660  ................................
390138....................................                39             25420  ................................
390150....................................                39             38300  LUGAR
390151....................................                39             13644  ................................
390162....................................             10900             35084  ................................
390163....................................             38300             49660  ................................
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             16740  ................................
420039....................................                42             43900  LUGAR
420062....................................                42             16740  ................................
420067....................................                42             42340  ................................
420068....................................                42             16700  ................................
420069....................................                42             44940  LUGAR
420070....................................             44940             17900  ................................
420071....................................                42             24860  ................................
420080....................................                42             42340  ................................
420083....................................             43900             24860  ................................
420085....................................             34820             48900  ................................
420098....................................                42             34820  ................................
430012....................................                43             43620  ................................
430013....................................                43             43620  ................................
430014....................................                43             22020  ................................
430077....................................             39660             16220  ................................
440002....................................             27180             32820  ................................
440008....................................                44             27180  ................................
440020....................................                44             26620  ................................
440024....................................             17420             16860  ................................
440025....................................                44                34  ................................
440035....................................             17300             34980  ................................
440056....................................             34100             28940  ................................
440059....................................                44             34980  ................................
440060....................................                44             27180  ................................
440067....................................             34100             28700  ................................
440068....................................                44             16860  ................................
440072....................................                44             32820  ................................
440073....................................                44             34980  ................................
440144....................................                44             34980  ................................
440148....................................                44             34980  ................................
440151....................................                44             34980  ................................
440185....................................             17420             16860  ................................
440192....................................                44             34980  ................................
450007....................................                45             41700  ................................
450039....................................             23104             19124  ................................
450064....................................             23104             19124  ................................
450080....................................                45             30980  ................................

[[Page 23885]]

 
450087....................................             23104             19124  ................................
450099....................................                45             11100  ................................
450133....................................             33260             36220  ................................
450135....................................             23104             19124  ................................
450137....................................             23104             19124  ................................
450148....................................             23104             19124  ................................
450178....................................                45             36220  ................................
450187....................................                45             26420  ................................
450196....................................                45             19124  ................................
450211....................................                45             30980  ................................
450214....................................                45             26420  ................................
450224....................................                45             46340  ................................
450283....................................                45             19124  LUGAR
450324....................................             43300             19124  ................................
450347....................................                45             26420  ................................
450351....................................                45             23104  ................................
450389....................................                45             19124  LUGAR
450393....................................             43300             19124  ................................
450395....................................                45             26420  ................................
450419....................................             23104             19124  ................................
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  ................................
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  ................................
450813....................................                45             41700  ................................
450830....................................                45             36220  ................................
450872....................................             23104             19124  ................................
450880....................................             23104             19124  ................................
450886....................................             23104             19124  ................................
460004....................................             36260             41620  ................................
460005....................................             36260             41620  ................................
460007....................................                46             41100  ................................
460021....................................             41100             29820  ................................
460026....................................                46             39340  ................................
460039....................................                46             30860  ................................
460041....................................             36260             41620  ................................
460042....................................             36260             41620  ................................
470001....................................                47                30  ................................
470012....................................                47             38340  ................................
490004....................................             25500             16820  ................................
490005....................................             49020             47894  ................................
490013....................................                49             20500  ................................
490018....................................                49             16820  ................................
490019....................................                49             47894  ................................
490040....................................             47894             13644  ................................
490042....................................             13980             40220  ................................
490043....................................             47894             13644  ................................
490048....................................             40220             31340  ................................
490063....................................             47894             13644  ................................
490079....................................                49             24660  ................................
490097....................................                49             40060  ................................
490101....................................             47894             13644  ................................
490107....................................             47894             13644  ................................
490122....................................             47894             13644  ................................
500002....................................                50             28420  ................................
500003....................................             34580             42644  ................................
500007....................................             34580             42644  ................................
500016....................................             48300             42644  ................................

[[Page 23886]]

 
500021....................................             45104             42644  ................................
500031....................................                50             36500  ................................
500039....................................             14740             42644  ................................
500041....................................             31020             38900  ................................
500072....................................                50             14740  ................................
500079....................................             45104             42644  ................................
500108....................................             45104             42644  ................................
500129....................................             45104             42644  ................................
510001....................................             34060             38300  ................................
510002....................................                51             40220  ................................
510006....................................                51             34060  ................................
510018....................................                51             16620  LUGAR
510024....................................             34060             38300  ................................
510046....................................                51             13980  ................................
510047....................................                51             38300  ................................
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
520037....................................                52             48140  ................................
520059....................................             39540             33340  ................................
520071....................................                52             33340  LUGAR
520076....................................                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  ................................
530015....................................                53             26820  ................................
----------------------------------------------------------------------------------------------------------------


 Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E)
                           of the Act--FY 2009
------------------------------------------------------------------------
                                               Geographic   Redesignated
                Provider No.                      CBSA       rural area
------------------------------------------------------------------------
050192......................................         23420            05
050528......................................         32900            05
050618......................................         40140            05
100048......................................         37860            10
100118......................................         37380            10
100134......................................         27260            10
140167......................................            14            14
170137......................................         29940            17
220051......................................         38340            22
230078......................................         35660            23
250017......................................            25            25
260006......................................         41140            26
260047......................................         27620            26
260195......................................         44180            26
330268......................................         10580            33
360125......................................            36            36
370054......................................         36420            37
380040......................................         13460            38
390130......................................         27780            39
390183......................................            39            39
440135......................................         34980            44
450052......................................            45            45
450078......................................         10180            45
450243......................................         10180            45
450348......................................            45            45
490116......................................         13980            49
500148......................................         48300            50
------------------------------------------------------------------------


    Table 10.--Geometric Mean Plus the Lesser of .75 of the National
Adjusted Operating Standardized Payment Amount (Increased To Reflect the
 Difference Between Costs and Charges) or .75 of One Standard Deviation
 of Mean Charges by Medicare Severity Diagnosis-Related Group (MS-DRG)--
                             March 2008 \1\
------------------------------------------------------------------------
                                                 Number of
                    MS-DRG                         cases      Threshold
------------------------------------------------------------------------
1.............................................          655     $345,754
2.............................................          287      202,892
3.............................................       23,338      258,756
4.............................................       21,431      156,815
5.............................................          634      172,190
6.............................................          228       95,919
7.............................................          356      167,452
8.............................................          482       96,343
9.............................................        1,345      104,341
10............................................          163       77,500
11............................................        1,266       77,654
12............................................        1,909       55,617
13............................................        1,274       39,624
20............................................          887      149,490
21............................................          532      115,973
22............................................          212       81,500
23............................................        3,741       88,473
24............................................        2,103       62,851

[[Page 23887]]

 
25............................................        8,713       82,504
26............................................       11,796       56,523
27............................................       13,711       44,491
28............................................        1,670       80,242
29............................................        3,085       50,231
30............................................        3,425       32,616
31............................................        1,024       67,618
32............................................        2,785       38,809
33............................................        3,621       31,322
34............................................          764       60,605
35............................................        2,238       44,518
36............................................        6,915       38,592
37............................................        4,842       55,045
38............................................       14,152       35,529
39............................................       51,945       25,865
40............................................        4,769       62,151
41............................................        7,588       41,971
42............................................        4,869       36,094
52............................................        1,167       32,407
53............................................          593       22,313
54............................................        5,257       31,973
55............................................       16,334       26,860
56............................................        8,269       29,873
57............................................       47,422       19,707
58............................................          742       29,625
59............................................        2,761       22,941
60............................................        4,080       17,346
61............................................        1,591       55,734
62............................................        2,466       44,297
63............................................        1,327       38,685
64............................................       55,842       35,590
65............................................      105,150       28,434
66............................................       89,467       21,616
67............................................        1,406       31,006
68............................................       11,458       23,218
69............................................      102,005       18,938
70............................................        7,347       34,967
71............................................        9,531       27,718
72............................................        5,746       20,092
73............................................        9,230       28,411
74............................................       31,583       21,471
75............................................        1,240       35,756
76............................................          874       23,183
77............................................        1,214       34,334
78............................................        1,405       25,703
79............................................          931       19,435
80............................................        1,870       26,205
81............................................        7,158       17,937
82............................................        1,764       36,630
83............................................        2,056       30,149
84............................................        2,784       22,390
85............................................        5,896       37,019
86............................................       11,488       27,925
87............................................       13,005       19,836
88............................................          712       31,870
89............................................        2,740       23,572
90............................................        3,094       17,953
91............................................        7,628       30,627
92............................................       16,286       22,388
93............................................       16,162       17,182
94............................................        1,476       57,294
95............................................        1,034       44,072
96............................................          761       37,723
97............................................        1,195       56,725
98............................................        1,007       38,018
99............................................          642       30,539
100...........................................       17,058       30,273
101...........................................       57,248       19,211
102...........................................        1,086       24,512
103...........................................       13,854       16,849
113...........................................          527       33,475
114...........................................          562       20,755
115...........................................        1,060       26,332
116...........................................          566       26,098
117...........................................        1,140       16,472
121...........................................          549       22,487
122...........................................          623       14,246
123...........................................        2,789       18,857
124...........................................          753       25,197
125...........................................        4,693       16,936
129...........................................        1,359       40,771
130...........................................        1,074       29,912
131...........................................          933       39,603
132...........................................          889       28,315
133...........................................        1,988       32,709
134...........................................        3,379       21,267
135...........................................          353       36,814
136...........................................          474       24,169
137...........................................          775       29,030
138...........................................          891       18,731
139...........................................        1,498       20,992
146...........................................          680       36,795
147...........................................        1,369       27,392
148...........................................          860       20,935
149...........................................       38,942       16,006
150...........................................          955       25,517
151...........................................        6,839       13,767
152...........................................        1,735       21,825
153...........................................       11,517       15,282
154...........................................        1,906       28,847
155...........................................        4,498       21,959
156...........................................        4,851       16,219
157...........................................        1,048       29,382
158...........................................        3,229       21,572
159...........................................        2,376       15,149
163...........................................       13,622       83,366
164...........................................       17,895       50,966
165...........................................       13,816       40,520
166...........................................       20,575       60,767
167...........................................       20,538       42,190
168...........................................        5,478       32,296
175...........................................       12,686       34,823
176...........................................       41,375       26,341
177...........................................       63,876       38,177
178...........................................       71,036       31,805
179...........................................       26,205       25,015
180...........................................       22,369       34,979
181...........................................       30,299       28,647
182...........................................        5,485       22,812
183...........................................        1,858       32,624
184...........................................        4,329       23,386
185...........................................        2,521       16,595
186...........................................        9,254       33,122
187...........................................       10,047       27,117
188...........................................        5,031       20,564
189...........................................      113,197       30,640
190...........................................       58,935       28,961
191...........................................      118,443       24,100
192...........................................      185,468       18,078
193...........................................       87,659       30,876
194...........................................      254,760       24,785
195...........................................      134,022       18,110
196...........................................        5,396       32,914
197...........................................        6,822       27,198
198...........................................        4,650       20,752
199...........................................        3,215       34,978
200...........................................        8,396       25,022
201...........................................        3,475       17,803
202...........................................       29,397       20,216
203...........................................       37,161       14,886
204...........................................       25,777       17,542
205...........................................        5,872       27,528
206...........................................       21,625       18,717
207...........................................       39,614       87,097
208...........................................       76,655       43,557
215...........................................          143      173,781
216...........................................        8,640      168,323
217...........................................        7,240      124,423
218...........................................        2,557      104,181
219...........................................       10,538      136,802
220...........................................       13,938       99,436
221...........................................        7,039       87,477
222...........................................        2,772      156,334
223...........................................        5,081      119,825
224...........................................        1,912      145,014
225...........................................        5,074      113,498
226...........................................        7,067      118,743
227...........................................       42,758       93,475
228...........................................        2,975      132,326
229...........................................        3,599       95,382
230...........................................        1,568       80,590
231...........................................        1,445      149,264
232...........................................        1,516      114,499
233...........................................       16,267      125,690
234...........................................       34,348       93,360
235...........................................        9,634       99,860
236...........................................       30,093       73,812
237...........................................       22,441       88,481
238...........................................       42,307       57,831
239...........................................       13,331       62,725
240...........................................       11,688       43,263
241...........................................        2,679       32,205
242...........................................       17,530       66,838
243...........................................       36,091       52,897
244...........................................       62,665       44,466
245...........................................        3,943       73,686
246...........................................       28,838       67,069

[[Page 23888]]

 
247...........................................      188,816       48,746
248...........................................       13,859       60,786
249...........................................       70,027       44,038
250...........................................        6,790       59,714
251...........................................       41,777       41,857
252...........................................       45,667       51,697
253...........................................       44,988       46,446
254...........................................       53,543       37,335
255...........................................        2,525       40,724
256...........................................        3,453       31,694
257...........................................          707       23,510
258...........................................          688       53,299
259...........................................        7,314       38,081
260...........................................        1,553       56,280
261...........................................        3,525       31,484
262...........................................        3,531       25,624
263...........................................          656       30,621
264...........................................       28,327       41,945
265...........................................        1,959       42,694
280...........................................       63,744       37,477
281...........................................       53,825       29,595
282...........................................       54,438       22,672
283...........................................       14,927       32,787
284...........................................        4,145       24,166
285...........................................        2,811       16,215
286...........................................       23,714       42,608
287...........................................      158,325       29,592
288...........................................        2,964       50,314
289...........................................        1,357       37,277
290...........................................          480       31,429
291...........................................      188,057       30,477
292...........................................      205,085       23,997
293...........................................      197,247       17,506
294...........................................        1,417       22,037
295...........................................        1,346       14,125
296...........................................        1,917       28,779
297...........................................          793       17,798
298...........................................          603       12,266
299...........................................       17,830       29,028
300...........................................       44,700       21,461
301...........................................       37,174       15,572
302...........................................        7,607       24,792
303...........................................       70,815       14,928
304...........................................        2,098       25,698
305...........................................       35,311       15,266
306...........................................        1,521       29,058
307...........................................        6,371       18,574
308...........................................       35,795       28,398
309...........................................       79,510       20,681
310...........................................      158,993       14,833
311...........................................       21,229       13,279
312...........................................      166,359       18,189
313...........................................      212,358       14,841
314...........................................       61,733       32,156
315...........................................       30,052       24,173
316...........................................       18,076       16,573
326...........................................       11,247       90,510
327...........................................       10,467       52,332
328...........................................        8,878       34,042
329...........................................       48,192       83,718
330...........................................       63,720       49,785
331...........................................       28,246       37,251
332...........................................        1,828       76,442
333...........................................        5,926       48,536
334...........................................        3,736       36,301
335...........................................        7,186       70,724
336...........................................       12,464       45,785
337...........................................        8,586       34,468
338...........................................        1,501       60,013
339...........................................        3,167       42,250
340...........................................        3,566       31,529
341...........................................          882       45,033
342...........................................        2,548       33,808
343...........................................        6,990       24,135
344...........................................          933       54,766
345...........................................        2,919       36,119
346...........................................        2,766       28,030
347...........................................        1,628       40,240
348...........................................        4,174       30,100
349...........................................        5,178       19,260
350...........................................        1,760       42,667
351...........................................        4,293       30,824
352...........................................        8,211       20,507
353...........................................        3,172       47,221
354...........................................        8,433       33,349
355...........................................       15,386       23,911
356...........................................        8,357       61,777
357...........................................        7,827       42,844
358...........................................        2,484       32,598
368...........................................        3,570       34,021
369...........................................        5,250       26,848
370...........................................        3,562       20,098
371...........................................       24,424       34,233
372...........................................       27,117       28,743
373...........................................       15,293       20,505
374...........................................        9,082       35,802
375...........................................       19,032       28,329
376...........................................        4,321       22,907
377...........................................       51,664       32,372
378...........................................      110,502       24,239
379...........................................       92,325       18,668
380...........................................        3,027       35,357
381...........................................        5,304       27,876
382...........................................        4,499       21,070
383...........................................        1,227       29,549
384...........................................        8,101       21,207
385...........................................        1,998       34,976
386...........................................        7,139       26,903
387...........................................        5,041       20,238
388...........................................       18,589       31,113
389...........................................       45,899       23,260
390...........................................       46,538       16,397
391...........................................       44,419       26,016
392...........................................      282,973       17,753
393...........................................       23,327       30,889
394...........................................       45,966       23,957
395...........................................       24,872       17,482
405...........................................        3,972       86,374
406...........................................        5,304       52,360
407...........................................        2,120       39,348
408...........................................        1,549       71,677
409...........................................        1,737       50,663
410...........................................          601       36,877
411...........................................          957       69,221
412...........................................          961       51,066
413...........................................          760       39,922
414...........................................        5,248       62,853
415...........................................        6,133       43,331
416...........................................        5,338       32,604
417...........................................       16,454       49,649
418...........................................       27,098       39,258
419...........................................       35,942       29,790
420...........................................          768       66,342
421...........................................        1,057       39,447
422...........................................          331       31,257
423...........................................        1,545       71,874
424...........................................          897       47,509
425...........................................          126       32,981
432...........................................       15,201       33,045
433...........................................        9,723       23,926
434...........................................          898       17,085
435...........................................       12,164       34,878
436...........................................       13,203       28,443
437...........................................        3,911       25,366
438...........................................       14,096       33,587
439...........................................       24,418       26,852
440...........................................       25,766       18,781
441...........................................       13,382       31,516
442...........................................       14,214       24,098
443...........................................        6,593       17,782
444...........................................       12,947       33,108
445...........................................       16,870       27,464
446...........................................       16,037       19,832
453...........................................          950      165,424
454...........................................        1,778      121,032
455...........................................        1,988       93,297
456...........................................          947      144,023
457...........................................        2,416       98,535
458...........................................        1,617       82,249
459...........................................        3,516       97,638
460...........................................       52,310       66,514
461...........................................        1,018       82,048
462...........................................       13,179       63,047
463...........................................        5,060       60,604
464...........................................        5,853       43,476
465...........................................        2,416       31,714
466...........................................        4,073       74,467
467...........................................       14,326       57,869
468...........................................       21,140       49,618
469...........................................       30,544       59,370
470...........................................      405,849       44,493
471...........................................        2,288       77,861
472...........................................        7,009       52,304
473...........................................       23,109       42,971
474...........................................        2,925       51,927
475...........................................        3,287       37,186
476...........................................        1,595       25,620

[[Page 23889]]

 
477...........................................        2,589       58,272
478...........................................        8,575       45,067
479...........................................       11,457       35,879
480...........................................       26,755       53,624
481...........................................       72,188       40,303
482...........................................       48,187       34,632
483...........................................        7,107       47,684
484...........................................       17,896       40,860
485...........................................        1,183       60,074
486...........................................        2,189       44,942
487...........................................        1,312       36,049
488...........................................        2,501       35,530
489...........................................        5,791       27,889
490...........................................       23,080       37,310
491...........................................       52,938       23,744
492...........................................        5,221       51,439
493...........................................       16,933       38,816
494...........................................       29,231       29,960
495...........................................        1,974       52,628
496...........................................        5,569       37,148
497...........................................        6,672       28,169
498...........................................        1,167       38,115
499...........................................        1,113       22,378
500...........................................        1,503       47,316
501...........................................        3,878       32,847
502...........................................        6,482       23,489
503...........................................          833       42,531
504...........................................        2,172       32,702
505...........................................        3,036       24,287
506...........................................          815       25,704
507...........................................          838       37,099
508...........................................        2,506       27,713
509...........................................          627       28,236
510...........................................          974       40,828
511...........................................        3,932       32,904
512...........................................       11,002       23,803
513...........................................        1,053       30,121
514...........................................        1,014       20,124
515...........................................        3,820       54,024
516...........................................       11,287       39,608
517...........................................       17,603       32,537
533...........................................          825       27,647
534...........................................        3,414       16,259
535...........................................        7,007       27,756
536...........................................       33,727       15,479
537...........................................          667       21,443
538...........................................        1,059       13,756
539...........................................        3,448       35,081
540...........................................        4,046       28,706
541...........................................        1,658       21,628
542...........................................        5,723       34,804
543...........................................       17,041       26,766
544...........................................       10,817       18,081
545...........................................        4,093       36,357
546...........................................        5,587       26,110
547...........................................        4,571       17,948
548...........................................          585       33,933
549...........................................        1,120       26,761
550...........................................          865       18,763
551...........................................       10,077       30,882
552...........................................       85,429       18,705
553...........................................        3,084       25,449
554...........................................       19,284       15,035
555...........................................        2,025       23,819
556...........................................       18,715       14,407
557...........................................        3,658       29,996
558...........................................       15,153       19,455
559...........................................        1,816       30,350
560...........................................        4,334       21,234
561...........................................        7,125       13,644
562...........................................        5,476       28,172
563...........................................       36,406       15,527
564...........................................        1,667       28,585
565...........................................        3,334       21,320
566...........................................        2,646       16,029
573...........................................        5,490       45,601
574...........................................       11,156       34,288
575...........................................        5,477       25,545
576...........................................          549       51,383
577...........................................        2,233       32,911
578...........................................        3,065       24,256
579...........................................        3,521       45,095
580...........................................       10,746       31,153
581...........................................       12,188       22,362
582...........................................        5,347       24,362
583...........................................        8,780       19,177
584...........................................          670       31,432
585...........................................        1,499       20,658
592...........................................        4,197       31,149
593...........................................       12,368       23,904
594...........................................        2,786       17,143
595...........................................        1,119       31,375
596...........................................        5,334       19,449
597...........................................          465       30,971
598...........................................        1,413       25,450
599...........................................          321       18,124
600...........................................          686       22,523
601...........................................          893       15,565
602...........................................       22,195       28,410
603...........................................      130,827       18,332
604...........................................        2,679       26,853
605...........................................       22,207       16,438
606...........................................        1,358       25,667
607...........................................        7,223       15,152
614...........................................        1,460       47,701
615...........................................        1,550       34,632
616...........................................        1,091       65,719
617...........................................        6,743       38,652
618...........................................          262       29,334
619...........................................          696       56,060
620...........................................        2,183       41,545
621...........................................        7,840       34,898
622...........................................        1,113       43,197
623...........................................        3,081       34,355
624...........................................          387       24,651
625...........................................        1,276       41,939
626...........................................        2,544       28,873
627...........................................       14,040       19,271
628...........................................        3,371       53,828
629...........................................        4,183       42,434
630...........................................          539       33,189
637...........................................       17,173       28,050
638...........................................       42,846       19,293
639...........................................       38,599       13,546
640...........................................       61,027       25,018
641...........................................      202,068       16,467
642...........................................        1,522       23,787
643...........................................        5,194       31,972
644...........................................       11,834       25,437
645...........................................        8,221       17,977
652...........................................       10,083       61,353
653...........................................        1,697       89,458
654...........................................        3,458       56,337
655...........................................        1,633       42,874
656...........................................        3,922       58,696
657...........................................        7,428       41,203
658...........................................        8,291       33,644
659...........................................        4,668       53,703
660...........................................        7,609       38,883
661...........................................        4,273       31,713
662...........................................          952       45,713
663...........................................        2,064       31,902
664...........................................        4,406       24,778
665...........................................          656       47,408
666...........................................        2,094       32,797
667...........................................        3,632       20,211
668...........................................        3,838       42,144
669...........................................       12,767       30,048
670...........................................       11,721       19,264
671...........................................          809       31,091
672...........................................          945       19,988
673...........................................       12,591       45,199
674...........................................       11,735       41,821
675...........................................        7,841       34,014
682...........................................       82,356       31,292
683...........................................      132,588       26,544
684...........................................       45,085       17,817
685...........................................        2,328       19,847
686...........................................        1,603       31,947
687...........................................        3,266       26,251
688...........................................        1,084       18,135
689...........................................       56,256       27,047
690...........................................      198,999       18,127
691...........................................          819       33,914
692...........................................          492       26,929
693...........................................        2,431       28,697
694...........................................       18,046       18,013
695...........................................          981       25,865
696...........................................       10,563       15,132
697...........................................          594       17,528
698...........................................       23,391       29,470
699...........................................       24,279       23,424
700...........................................       12,340       16,877
707...........................................        5,984       37,222
708...........................................       18,084       30,416
709...........................................          765       35,528
710...........................................        1,845       29,560

[[Page 23890]]

 
711...........................................          792       37,675
712...........................................          710       20,316
713...........................................       10,272       26,996
714...........................................       28,875       15,559
715...........................................          532       36,052
716...........................................        1,275       29,420
717...........................................          705       34,114
718...........................................          589       19,293
722...........................................          754       30,816
723...........................................        1,970       24,740
724...........................................          586       15,657
725...........................................          759       24,606
726...........................................        3,733       16,368
727...........................................        1,300       27,843
728...........................................        6,194       17,130
729...........................................          592       25,442
730...........................................          471       14,723
734...........................................        1,364       44,272
735...........................................        1,133       28,372
736...........................................          856       73,117
737...........................................        3,302       41,614
738...........................................          866       28,882
739...........................................        1,015       53,269
740...........................................        4,338       34,448
741...........................................        6,033       24,839
742...........................................       10,977       31,971
743...........................................       32,430       21,234
744...........................................        1,527       30,774
745...........................................        1,700       20,207
746...........................................        2,643       30,028
747...........................................       10,434       21,235
748...........................................       19,915       20,564
749...........................................          982       45,119
750...........................................          437       24,771
754...........................................          986       33,562
755...........................................        2,954       25,879
756...........................................          687       16,172
757...........................................        1,398       32,870
758...........................................        1,612       26,363
759...........................................        1,244       19,100
760...........................................        1,708       19,562
761...........................................        1,773       13,249
765...........................................        2,773       20,365
766...........................................        2,692       13,836
767...........................................          133       18,724
769...........................................           98       28,990
770...........................................          203       16,249
774...........................................        1,517       12,327
775...........................................        5,784        8,750
776...........................................          513       15,047
777...........................................          209       20,244
778...........................................          475        8,942
779...........................................          112       11,223
780...........................................           41        3,917
781...........................................        3,040       13,218
782...........................................          175        8,623
799...........................................          566       82,467
800...........................................          705       50,685
801...........................................          556       37,382
802...........................................          764       53,613
803...........................................        1,071       36,134
804...........................................          995       27,223
808...........................................        6,092       37,130
809...........................................       12,879       27,509
810...........................................        2,801       22,786
811...........................................       21,482       26,846
812...........................................       90,369       18,397
813...........................................       14,238       27,095
814...........................................        1,564       30,406
815...........................................        3,315       25,805
816...........................................        2,154       18,432
820...........................................        1,301       89,835
821...........................................        2,478       43,777
822...........................................        1,894       30,581
823...........................................        2,182       69,584
824...........................................        2,976       44,341
825...........................................        1,756       30,652
826...........................................          524       76,715
827...........................................        1,256       44,122
828...........................................          802       32,076
829...........................................        1,175       47,921
830...........................................          524       28,158
834...........................................        4,031       58,295
835...........................................        2,707       37,287
836...........................................        1,623       25,573
837...........................................        1,044       96,925
838...........................................        1,321       47,431
839...........................................        1,466       30,443
840...........................................        9,683       43,346
841...........................................       10,060       32,240
842...........................................        5,341       25,445
843...........................................        1,354       34,538
844...........................................        2,414       27,673
845...........................................          811       21,496
846...........................................        2,117       38,966
847...........................................       23,925       26,844
848...........................................        1,725       23,146
849...........................................        1,478       29,110
853...........................................       34,961       80,838
854...........................................        6,662       52,593
855...........................................          459       38,661
856...........................................        5,904       65,124
857...........................................        9,631       37,513
858...........................................        3,258       30,272
862...........................................        7,955       34,329
863...........................................       21,482       22,129
864...........................................       19,034       20,781
865...........................................        1,707       29,217
866...........................................        8,201       17,149
867...........................................        5,076       38,916
868...........................................        2,659       25,425
869...........................................        1,139       18,507
870...........................................       21,356       94,830
871...........................................      216,894       35,333
872...........................................       91,026       27,030
876...........................................          860       42,167
880...........................................        9,304       15,133
881...........................................        4,658       12,046
882...........................................        1,558       12,634
883...........................................          758       17,971
884...........................................       19,126       19,197
885...........................................       81,314       15,242
886...........................................          407       13,905
887...........................................          399       16,694
894...........................................        4,798        7,599
895...........................................       10,278       12,773
896...........................................        5,570       26,933
897...........................................       38,298       13,086
901...........................................          926       54,456
902...........................................        2,036       33,188
903...........................................        1,508       23,579
904...........................................        1,047       43,056
905...........................................          812       26,185
906...........................................          716       24,257
907...........................................        8,469       56,134
908...........................................        8,340       36,960
909...........................................        5,470       27,977
913...........................................          807       27,237
914...........................................        6,655       16,360
915...........................................        1,080       26,134
916...........................................        5,527       10,518
917...........................................       15,818       29,720
918...........................................       35,758       14,390
919...........................................       11,106       30,394
920...........................................       14,005       22,313
921...........................................        9,462       14,923
922...........................................        1,055       28,288
923...........................................        3,976       15,419
927...........................................          213      182,484
928...........................................          819       65,145
929...........................................          440       37,218
933...........................................          145       31,568
934...........................................          663       24,756
935...........................................        2,220       22,937
939...........................................          673       46,257
940...........................................        1,322       33,961
941...........................................        1,720       26,932
945...........................................        6,687       20,290
946...........................................        4,359       15,730
947...........................................        9,751       24,756
948...........................................       47,916       15,920
949...........................................          682       18,328
950...........................................          420       12,682
951...........................................          951       15,279
955...........................................          449       87,860
956...........................................        3,984       57,503
957...........................................        1,325      101,860
958...........................................        1,156       67,071
959...........................................          295       47,759
963...........................................        1,592       50,127
964...........................................        2,581       34,357
965...........................................        1,077       25,020
969...........................................          644       78,213
970...........................................          138       45,746
974...........................................        5,952       41,989
975...........................................        4,710       29,607
976...........................................        2,654       22,430

[[Page 23891]]

 
977...........................................        4,633       25,054
981...........................................       25,506       78,693
982...........................................       18,355       55,049
983...........................................        6,144       40,105
984...........................................          671       59,501
985...........................................          904       42,990
986...........................................          732       29,607
987...........................................        8,256       55,744
988...........................................       11,611       37,995
989...........................................        5,817       27,744
999...........................................           26      15,387
------------------------------------------------------------------------
\1\ Cases taken from the FY 2007 MedPAR file; MS-DRGs are from GROUPER
  Version 26.0.


 Table 11.--Proposed FY 2009 MS-LTC-DRGS, Proposed Relative Weights, Proposed Geometric Average Length of Stay,
                                    and Proposed Short-Stay Outlier Threshold
----------------------------------------------------------------------------------------------------------------
                                                                                                       Proposed
                                                                                          Proposed    short-stay
 Proposed MS-LTC-    Proposed base MS-   Proposed MS-LTC-DRG    FY 2007      Proposed    geometric     outlier
        DRG               LTC-DRG               title          LTCH cases    relative     average       (SSO)
                                                                              weight     length of    threshold
                                                                                            stay         \1\
----------------------------------------------------------------------------------------------------------------
1.................  1.................  Heart transplant or             0       0.0000          0.0          0.0
                                         implant of heart
                                         assist system w MCC.
2.................  1.................  Heart transplant or             0       0.0000          0.0          0.0
                                         implant of heart
                                         assist system w/o
                                         MCC.
3.................  3.................  ECMO or trach w MV            286       4.5889         66.5         55.4
                                         96+ hrs or PDX exc
                                         face, mouth & neck
                                         w maj O.R..
4.................  4.................  Trach w MV 96+ hrs          1,201       2.9992         44.4         37.0
                                         or PDX exc face,
                                         mouth & neck w/o
                                         maj O.R..
5.................  5.................  Liver transplant w              0       0.0000          0.0          0.0
                                         MCC or intestinal
                                         transplant.
6.................  5.................  Liver transplant w/o            0       0.0000          0.0          0.0
                                         MCC.
7.................  7.................  Lung transplant.....            0       0.0000          0.0          0.0
8.................  8.................  Simultaneous                    0       0.0000          0.0          0.0
                                         pancreas/kidney
                                         transplant.
9.................  9.................  Bone marrow                     0       1.2617         31.5         26.3
                                         transplant.
10................  10................  Pancreas transplant.            0       0.0000          0.0          0.0
11................  11................  Tracheostomy for                1       1.7509         37.9         31.6
                                         face, mouth & neck
                                         diagnoses w MCC.
12................  11................  Tracheostomy for                1       1.7509         37.9         31.6
                                         face, mouth & neck
                                         diagnoses w CC.
13................  11................  Tracheostomy for                0       1.7509         37.9         31.6
                                         face, mouth & neck
                                         diagnoses w/o CC/
                                         MCC.
20................  20................  Intracranial                    0       1.7509         37.9         31.6
                                         vascular procedures
                                         w PDX hemorrhage w
                                         MCC.
21................  20................  Intracranial                    0       1.7509         37.9         31.6
                                         vascular procedures
                                         w PDX hemorrhage w
                                         CC.
22................  20................  Intracranial                    0       1.7509         37.9         31.6
                                         vascular procedures
                                         w PDX hemorrhage w/
                                         o CC/MCC.
23................  23................  Craniotomy w major              2       1.2617         31.5         26.3
                                         device implant or
                                         acute complex CNS
                                         PDX w MCC*.
24................  23................  Craniotomy w major              1       1.2617         31.5         26.3
                                         device implant or
                                         acute complex CNS
                                         PDX w/o MCC*.
25................  25................  Craniotomy &                    1       1.7509         37.9         31.6
                                         endovascular
                                         intracranial
                                         procedures w MCC.
26................  25................  Craniotomy &                    3       1.7509         37.9         31.6
                                         endovascular
                                         intracranial
                                         procedures w CC.
27................  25................  Craniotomy &                    1       0.8596         25.2         21.0
                                         endovascular
                                         intracranial
                                         procedures w/o CC/
                                         MCC.
28................  28................  Spinal procedures w            11       1.2617         31.5         26.3
                                         MCC.
29................  28................  Spinal procedures w             9       1.2617         31.5         26.3
                                         CC.
30................  28................  Spinal procedures w/            1       1.2617         31.5         26.3
                                         o CC/MCC.
31................  31................  Ventricular shunt               5       1.7509         37.9         31.6
                                         procedures w MCC.
32................  31................  Ventricular shunt               1       1.7509         37.9         31.6
                                         procedures w CC.
33................  31................  Ventricular shunt               0       1.7509         37.9         31.6
                                         procedures w/o CC/
                                         MCC.
34................  34................  Carotid artery stent            0       1.2617         31.5         26.3
                                         procedure w MCC.
35................  34................  Carotid artery stent            0       1.2617         31.5         26.3
                                         procedurew CC.
36................  34................  Carotid artery stent            0       1.2617         31.5         26.3
                                         procedure w/o CC/
                                         MCC.
37................  37................  Extracranial                    7       1.2617         31.5         26.3
                                         procedures w MCC.
38................  37................  Extracranial                    6       1.2617         31.5         26.3
                                         procedures w CC*.
39................  37................  Extracranial                    0       1.2617         31.5         26.3
                                         procedures w/o CC/
                                         MCC.

[[Page 23892]]

 
40................  40................  Periph & cranial              143       1.2451         34.8         29.0
                                         nerve & other nerv
                                         syst proc w MCC.
41................  40................  Periph & cranial               87       1.0890         34.5         28.8
                                         nerve & other nerv
                                         syst proc w CC.
42................  40................  Periph & cranial                6       1.0890         34.5         28.8
                                         nerve & other nerv
                                         syst proc w/o CC/
                                         MCC*.
52................  52................  Spinal disorders &             83       0.9943         31.3         26.1
                                         injuries w CC/MCC.
53................  52................  Spinal disorders &              7       0.8596         25.2         21.0
                                         injuries w/o CC/MCC.
54................  54................  Nervous system                 31       1.0109         26.7         22.3
                                         neoplasms w MCC.
55................  54................  Nervous system                 50       0.6542         21.6         18.0
                                         neoplasms w/o MCC.
56................  56................  Degenerative nervous        1,180       0.8022         25.3         21.1
                                         system disorders w
                                         MCC.
57................  56................  Degenerative nervous        1,945       0.6033         24.0         20.0
                                         system disorders w/
                                         o MCC.
58................  58................  Multiple sclerosis &           19       0.8596         25.2         21.0
                                         cerebellar ataxia w
                                         MCC.
59................  58................  Multiple sclerosis &           23       0.6327         21.6         18.0
                                         cerebellar ataxia w
                                         CC.
60................  58................  Multiple sclerosis &           10       0.6327         21.6         18.0
                                         cerebellar ataxia w/
                                         o CC/MCC.
61................  61................  Acute ischemic                  0       0.8823         23.5         19.6
                                         stroke w use of
                                         thrombolytic agent
                                         w MCC.
62................  61................  Acute ischemic                  0       0.5770         22.8         19.0
                                         stroke w use of
                                         thrombolytic agent
                                         w CC.
63................  61................  Acute ischemic                  0       0.4824         19.6         16.3
                                         stroke w use of
                                         thrombolytic agent
                                         w/o CC/MCC.
64................  64................  Intracranial                  107       0.7831         24.5         20.4
                                         hemorrhage or
                                         cerebral infarction
                                         w MCC.
65................  64................  Intracranial                   67       0.6217         24.0         20.0
                                         hemorrhage or
                                         cerebral infarction
                                         w CC.
66................  64................  Intracranial                   24       0.4824         19.6         16.3
                                         hemorrhage or
                                         cerebral infarction
                                         w/o CC/MCC.
67................  67................  Nonspecific cva &               4       0.4824         19.6         16.3
                                         precerebral
                                         occlusion w/o
                                         infarct w MCC.
68................  67................  Nonspecific cva &               4       0.4824         19.6         16.3
                                         precerebral
                                         occlusion w/o
                                         infarct w/o MCC.
69................  69................  Transient ischemia..           13       0.4824         19.6         16.3
70................  70................  Nonspecific                    87       0.8823         23.5         19.6
                                         cerebrovascular
                                         disorders w MCC.
71................  70................  Nonspecific                    52       0.5770         22.8         19.0
                                         cerebrovascular
                                         disorders w CC.
72................  70................  Nonspecific                     8       0.4824         19.6         16.3
                                         cerebrovascular
                                         disorders w/o CC/
                                         MCC.
73................  73................  Cranial & peripheral          116       0.8910         24.6         20.5
                                         nerve disorders w
                                         MCC.
74................  73................  Cranial & peripheral          173       0.6057         23.1         19.3
                                         nerve disorders w/o
                                         MCC.
75................  75................  Viral meningitis w             15       0.6327         21.6         18.0
                                         CC/MCC.
76................  75................  Viral meningitis w/o            0       0.6327         21.6         18.0
                                         CC/MCC.
77................  77................  Hypertensive                    4       1.2617         31.5         26.3
                                         encephalopathy w
                                         MCC.
78................  77................  Hypertensive                    1       0.6327         21.6         18.0
                                         encephalopathy w CC.
79................  77................  Hypertensive                    1       0.4824         19.6         16.3
                                         encephalopathy w/o
                                         CC/MCC.
80................  80................  Nontraumatic stupor            47       0.7859         29.2         24.3
                                         & coma w MCC.
81................  80................  Nontraumatic stupor           110       0.7028         28.2         23.5
                                         & coma w/o MCC.
82................  82................  Traumatic stupor &              9       0.8596         25.2         21.0
                                         coma, coma >1 hr w
                                         MCC.
83................  82................  Traumatic stupor &             12       0.6327         21.6         18.0
                                         coma, coma >1 hr w
                                         CC.
84................  82................  Traumatic stupor &              3       0.6327         21.6         18.0
                                         coma, coma >1 hr w/
                                         o CC/MCC.
85................  85................  Traumatic stupor &             78       0.8652         26.1         21.8
                                         coma, coma <1 hr w
                                         MCC.
86................  85................  Traumatic stupor &             81       0.6630         24.1         20.1
                                         coma, coma <1 hr w
                                         CC.
87................  85................  Traumatic stupor &             15       0.4824         19.6         16.3
                                         coma, coma <1 hr w/
                                         o CC/MCC.
88................  88................  Concussion w MCC....            0       0.4824         19.6         16.3
89................  88................  Concussion w CC.....            1       0.4824         19.6         16.3
90................  88................  Concussion w/o CC/              0       0.4824         19.6         16.3
                                         MCC.
91................  91................  Other disorders of            218       0.9248         25.9         21.6
                                         nervous system w
                                         MCC.
92................  91................  Other disorders of            138       0.6661         25.0         20.8
                                         nervous system w CC.
93................  91................  Other disorders of             43       0.6046         22.0         18.3
                                         nervous system w/o
                                         CC/MCC.
94................  94................  Bacterial &                   203       1.0466         29.2         24.3
                                         tuberculous
                                         infections of
                                         nervous system w
                                         MCC.
95................  94................  Bacterial &                   106       0.9763         28.9         24.1
                                         tuberculous
                                         infections of
                                         nervous system w CC.
96................  94................  Bacterial &                    31       0.7559         27.6         23.0
                                         tuberculous
                                         infections of
                                         nervous system w/o
                                         CC/MCC.
97................  97................  Non-bacterial infect           48       1.0415         26.0         21.7
                                         of nervous sys exc
                                         viral meningitis w
                                         MCC.
98................  97................  Non-bacterial infect           22       0.8596         25.2         21.0
                                         of nervous sys exc
                                         viral meningitis w
                                         CC.
99................  97................  Non-bacterial infect            6       0.6327         21.6         18.0
                                         of nervous sys exc
                                         viral meningitis w/
                                         o CC/MCC.
100...............  100...............  Seizures w MCC......           47       0.6380         21.8         18.2
101...............  100...............  Seizures w/o MCC....           55       0.6132         25.4         21.2
102...............  102...............  Headaches w MCC.....            9       0.6327         21.6         18.0
103...............  102...............  Headaches w/o MCC...            4       0.6327         21.6         18.0
113...............  113...............  Orbital procedures w            1       0.8596         25.2         21.0
                                         CC/MCC.

[[Page 23893]]

 
114...............  113...............  Orbital procedures w/           0       0.8596         25.2         21.0
                                         o CC/MCC.
115...............  115...............  Extraocular                     0       0.4824         19.6         16.3
                                         procedures except
                                         orbit.
116...............  116...............  Intraocular                     1       0.8596         25.2         21.0
                                         procedures w CC/MCC.
117...............  116...............  Intraocular                     0       0.4824         19.6         16.3
                                         procedures w/o CC/
                                         MCC.
121...............  121...............  Acute major eye                10       0.6327         21.6         18.0
                                         infections w CC/MCC.
122...............  121...............  Acute major eye                 1       0.6327         21.6         18.0
                                         infections w/o CC/
                                         MCC.
123...............  123...............  Neurological eye                0       0.4824         19.6         16.3
                                         disorders.
124...............  124...............  Other disorders of              2       0.6327         21.6         18.0
                                         the eye w MCC.
125...............  124...............  Other disorders of              8       0.4824         19.6         16.3
                                         the eye w/o MCC.
129...............  129...............  Major head & neck               0       1.3344         30.2         25.2
                                         procedures w CC/MCC
                                         or major device.
130...............  129...............  Major head & neck               0       0.4824         19.6         16.3
                                         procedures w/o CC/
                                         MCC.
131...............  131...............  Cranial/facial                  0       1.7509         37.9         31.6
                                         procedures w CC/MCC.
132...............  131...............  Cranial/facial                  1       1.7509         37.9         31.6
                                         procedures w/o CC/
                                         MCC.
133...............  133...............  Other ear, nose,               10       1.2617         31.5         26.3
                                         mouth & throat O.R.
                                         procedures w CC/MCC.
134...............  133...............  Other ear, nose,                0       1.2617         31.5         26.3
                                         mouth & throat O.R.
                                         procedures w/o CC/
                                         MCC.
135...............  135...............  Sinus & mastoid                 2       0.4824         19.6         16.3
                                         procedures w CC/MCC.
136...............  135...............  Sinus & mastoid                 1       0.4824         19.6         16.3
                                         procedures w/o CC/
                                         MCC*.
137...............  137...............  Mouth procedures w              1       1.7509         37.9         31.6
                                         CC/MCC.
138...............  137...............  Mouth procedures w/o            0       1.7509         37.9         31.6
                                         CC/MCC.
139...............  139...............  Salivary gland                  0       1.7509         37.9         31.6
                                         procedures.
146...............  146...............  Ear, nose, mouth &             40       1.3344         30.2         25.2
                                         throat malignancy w
                                         MCC.
147...............  146...............  Ear, nose, mouth &             26       0.9930         22.4         18.7
                                         throat malignancy w
                                         CC.
148...............  146...............  Ear, nose, mouth &              6       0.4824         19.6         16.3
                                         throat malignancy w/
                                         o CC/MCC.
149...............  149...............  Dysequilibrium......           11       0.4824         19.6         16.3
150...............  150...............  Epistaxis w MCC.....            0       0.8596         25.2         21.0
151...............  150...............  Epistaxis w/o MCC...            0       0.6327         21.6         18.0
152...............  152...............  Otitis media & URI w            9       0.8596         25.2         21.0
                                         MCC.
153...............  152...............  Otitis media & URI w/          23       0.6327         21.6         18.0
                                         o MCC.
154...............  154...............  Nasal trauma &                 50       0.7707         22.0         18.3
                                         deformity w MCC.
155...............  154...............  Nasal trauma &                 47       0.7011         21.1         17.6
                                         deformity w CC.
156...............  154...............  Nasal trauma &                 13       0.6327         21.6         18.0
                                         deformity w/o CC/
                                         MCC.
157...............  157...............  Dental & Oral                  12       0.6327         21.6         18.0
                                         Diseases w MCC.
158...............  157...............  Dental & Oral                  21       0.6327         21.6         18.0
                                         Diseases w CC.
159...............  157...............  Dental & Oral                   5       0.4824         19.6         16.3
                                         Diseases w/o CC/MCC.
163...............  163...............  Major chest                    45       2.5063         33.5         27.9
                                         procedures w MCC.
164...............  163...............  Major chest                     6       1.2617         31.5         26.3
                                         procedures w CC.
165...............  163...............  Major chest                     1       0.8596         25.2         21.0
                                         procedures w/o CC/
                                         MCC.
166...............  166...............  Other resp system           1,506       2.4992         41.8         34.8
                                         O.R. procedures w
                                         MCC.
167...............  166...............  Other resp system             211       1.8587         36.2         30.2
                                         O.R. procedures w
                                         CC.
168...............  166...............  Other resp system               8       0.8596         25.2         21.0
                                         O.R. procedures w/o
                                         CC/MCC.
175...............  175...............  Pulmonary embolism w          128       0.6640         21.9         18.3
                                         MCC.
176...............  175...............  Pulmonary embolism w/         139       0.5479         20.0         16.7
                                         o MCC.
177...............  177...............  Respiratory                 3,181       0.8784         22.8         19.0
                                         infections &
                                         inflammations w MCC.
178...............  177...............  Respiratory                 2,334       0.7414         22.1         18.4
                                         infections &
                                         inflammations w CC.
179...............  177...............  Respiratory                   394       0.6225         19.4         16.2
                                         infections &
                                         inflammations w/o
                                         CC/MCC.
180...............  180...............  Respiratory                   149       0.7975         20.9         17.4
                                         neoplasms w MCC.
181...............  180...............  Respiratory                   109       0.6255         18.7         15.6
                                         neoplasms w CC.
182...............  180...............  Respiratory                    11       0.6255         18.7         15.6
                                         neoplasms w/o CC/
                                         MCC*.
183...............  183...............  Major chest trauma w            1       0.4824         19.6         16.3
                                         MCC.
184...............  183...............  Major chest trauma w            2       0.4824         19.6         16.3
                                         CC.
185...............  183...............  Major chest trauma w/           1       0.4824         19.6         16.3
                                         o CC/MCC.
186...............  186...............  Pleural effusion w            121       0.7576         20.5         17.1
                                         MCC.
187...............  186...............  Pleural effusion w             60       0.6176         20.5         17.1
                                         CC.
188...............  186...............  Pleural effusion w/o           15       0.6176         20.5         17.1
                                         CC/MCC*.
189...............  189...............  Pulmonary edema &           6,586       0.9608         23.9         19.9
                                         respiratory failure.
190...............  190...............  Chronic obstructive         1,652       0.7477         20.5         17.1
                                         pulmonary disease w
                                         MCC.
191...............  190...............  Chronic obstructive         1,343       0.6220         19.4         16.2
                                         pulmonary disease w
                                         CC.
192...............  190...............  Chronic obstructive           764       0.5358         17.3         14.4
                                         pulmonary disease w/
                                         o CC/MCC.
193...............  193...............  Simple pneumonia &          1,805       0.7698         21.6         18.0
                                         pleurisy w MCC.
194...............  193...............  Simple pneumonia &          2,026       0.6368         20.1         16.8
                                         pleurisy w CC.
195...............  193...............  Simple pneumonia &            382       0.5374         17.4         14.5
                                         pleurisy w/o CC/MCC.
196...............  196...............  Interstitial lung             110       0.7122         20.1         16.8
                                         disease w MCC.
197...............  196...............  Interstitial lung              85       0.5716         17.6         14.7
                                         disease w CC.
198...............  196...............  Interstitial lung              40       0.5059         15.9         13.3
                                         disease w/o CC/MCC.

[[Page 23894]]

 
199...............  199...............  Pneumothorax w MCC..           49       0.7639         21.8         18.2
200...............  199...............  Pneumothorax w CC...           32       0.5906         17.8         14.8
201...............  199...............  Pneumothorax w/o CC/            5       0.4824         19.6         16.3
                                         MCC.
202...............  202...............  Bronchitis & asthma            88       0.6509         19.6         16.3
                                         w CC/MCC.
203...............  202...............  Bronchitis & asthma            21       0.6327         21.6         18.0
                                         w/o CC/MCC.
204...............  204...............  Respiratory signs &           233       0.8315         22.8         19.0
                                         symptoms.
205...............  205...............  Other respiratory             324       0.8236         22.3         18.6
                                         system diagnoses w
                                         MCC.
206...............  205...............  Other respiratory             171       0.7182         21.5         17.9
                                         system diagnoses w/
                                         o MCC.
207...............  207...............  Respiratory system         13,186       2.0793         34.5         28.8
                                         diagnosis w
                                         ventilator support
                                         96+ hours.
208...............  208...............  Respiratory system          1,452       1.1752         23.6         19.7
                                         diagnosis w
                                         ventilator support
                                         <96 hours.
215...............  215...............  Other heart assist              0       0.8596         25.2         21.0
                                         system implant.
216...............  216...............  Cardiac valve & oth             0       1.2617         31.5         26.3
                                         maj cardiothoracic
                                         proc w card cath w
                                         MMCC.
217...............  216...............  Cardiac valve & oth             0       0.8596         25.2         21.0
                                         maj cardiothoracic
                                         proc w card cath w
                                         MCC.
218...............  216...............  Cardiac valve & oth             0       0.8596         25.2         21.0
                                         maj cardiothoracic
                                         proc w card cath w/
                                         o CC/MMCC.
219...............  219...............  Cardiac valve & oth             0       1.2617         31.5         26.3
                                         maj cardiothoracic
                                         proc w/o card cath
                                         w MMCC.
220...............  219...............  Cardiac valve & oth             0       0.8596         25.2         21.0
                                         maj cardiothoracic
                                         proc w/o card cath
                                         w MCC.
221...............  219...............  Cardiac valve & oth             0       0.8596         25.2         21.0
                                         maj cardiothoracic
                                         proc w/o card cath
                                         w/o CC/MCC.
222...............  222...............  Cardiac defib                   0       1.7509         37.9         31.6
                                         implant w cardiac
                                         cath w AMI/HF/shock
                                         w MMCC.
223...............  222...............  Cardiac defib                   0       1.7509         37.9         31.6
                                         implant w cardiac
                                         cath w AMI/HF/shock
                                         w/o MMCC.
224...............  224...............  Cardiac defib                   0       1.7509         37.9         31.6
                                         implant w cardiac
                                         cath w/o AMI/HF/
                                         shock w MMCC.
225...............  224...............  Cardiac defib                   0       1.7509         37.9         31.6
                                         implant w cardiac
                                         cath w/o AMI/HF/
                                         shock w/o MMCC.
226...............  226...............  Cardiac                        11       1.7509         37.9         31.6
                                         defibrillator
                                         implant w/o cardiac
                                         cath w MMCC.
227...............  226...............  Cardiac                         9       1.7509         37.9         31.6
                                         defibrillator
                                         implant w/o cardiac
                                         cath w/o MMCC.
228...............  228...............  Other cardiothoracic            0       1.4637         33.3         27.8
                                         procedures w MMCC.
229...............  228...............  Other cardiothoracic            0       1.2121         28.9         24.1
                                         procedures w MCC.
230...............  228...............  Other cardiothoracic            0       0.6327         21.6         18.0
                                         procedures w/o CC/
                                         MMCC.
231...............  231...............  Coronary bypass w               0       1.2617         31.5         26.3
                                         PTCA w MMCC.
232...............  231...............  Coronary bypass w               0       0.8596         25.2         21.0
                                         PTCA w/o MMCC.
233...............  233...............  Coronary bypass w               0       1.2617         31.5         26.3
                                         cardiac cath w MMCC.
234...............  233...............  Coronary bypass w               0       0.8596         25.2         21.0
                                         cardiac cath w/o
                                         MMCC.
235...............  235...............  Coronary bypass w/o             0       1.2617         31.5         26.3
                                         cardiac cath w MMCC.
236...............  235...............  Coronary bypass w/o             0       0.8596         25.2         21.0
                                         cardiac cath w/o
                                         MMCC.
237...............  237...............  Major cardiovascular            7       1.2617         31.5         26.3
                                         procedures w MMCC.
238...............  237...............  Major cardiovascular            2       0.8596         25.2         21.0
                                         procedures w/o MMCC.
239...............  239...............  Amputation for circ           163       1.5067         36.6         30.5
                                         sys disorders exc
                                         upper limb & toe w
                                         MMCC.
240...............  239...............  Amputation for circ            83       1.1559         34.1         28.4
                                         sys disorders exc
                                         upper limb & toe w
                                         MCC.
241...............  239...............  Amputation for circ            10       0.8596         25.2         21.0
                                         sys disorders exc
                                         upper limb & toe w/
                                         o CC/MMCC.
242...............  242...............  Permanent cardiac              12       1.7509         37.9         31.6
                                         pacemaker implant w
                                         MCC*.
243...............  242...............  Permanent cardiac               5       1.7509         37.9         31.6
                                         pacemaker implant w
                                         MCC.
244...............  242...............  Permanent cardiac               1       1.7509         37.9         31.6
                                         pacemaker implant w/
                                         o CC/MMCC.
245...............  245...............  AICD generator                  0       1.7509         37.9         31.6
                                         procedures.
246...............  246...............  Percutaneous                    3       1.2617         31.5         26.3
                                         cardiovascular proc
                                         w drug-eluting
                                         stent w MMCC.
247...............  246...............  Percutaneous                    1       1.2617         31.5         26.3
                                         cardiovascular proc
                                         w drug-eluting
                                         stent w/o MMCC.
248...............  248...............  Percutaneous                    2       1.2617         31.5         26.3
                                         cardiovasc proc w
                                         non-drug-eluting
                                         stent w MMCC.
249...............  248...............  Percutaneous                    1       1.2617         31.5         26.3
                                         cardiovasc proc w
                                         non-drug-eluting
                                         stent w/o MCC*.
250...............  250...............  Perc cardiovasc proc            3       1.7509         37.9         31.6
                                         w/o coronary artery
                                         stent or AMI w MMCC.

[[Page 23895]]

 
251...............  250...............  Perc cardiovasc proc            0       1.7509         37.9         31.6
                                         w/o coronary artery
                                         stent or AMI w/o
                                         MMCC.
252...............  252...............  Other vascular                134       1.4637         33.3         27.8
                                         procedures w MMCC.
253...............  252...............  Other vascular                 51       1.2121         28.9         24.1
                                         procedures w MCC.
254...............  252...............  Other vascular                  3       0.6327         21.6         18.0
                                         procedures w/o CC/
                                         MMCC.
255...............  255...............  Upper limb & toe               61       1.2589         33.8         28.2
                                         amputation for circ
                                         system disorders w
                                         MMCC.
256...............  255...............  Upper limb & toe               42       0.9416         30.0         25.0
                                         amputation for circ
                                         system disorders w
                                         MCC.
257...............  255...............  Upper limb & toe                1       0.4824         19.6         16.3
                                         amputation for circ
                                         system disorders w/
                                         o CC/MMCC.
258...............  258...............  Cardiac pacemaker               0       1.2617         31.5         26.3
                                         device replacement
                                         w MMCC.
259...............  258...............  Cardiac pacemaker               1       1.2617         31.5         26.3
                                         device replacement
                                         w/o MMCC.
260...............  260...............  Cardiac pacemaker               2       1.2617         31.5         26.3
                                         revision except
                                         device replacement
                                         w MMCC.
261...............  260...............  Cardiac pacemaker               1       0.8596         25.2         21.0
                                         revision except
                                         device replacement
                                         w CC*.
262...............  260...............  Cardiac pacemaker               1       0.8596         25.2         21.0
                                         revision except
                                         device replacement
                                         w/o CC/MCC*.
263...............  263...............  Vein ligation &                 3       0.4824         19.6         16.3
                                         stripping.
264...............  264...............  Other circulatory             608       1.0954         31.1         25.9
                                         system O.R.
                                         procedures.
265...............  265...............  AICD lead procedures            0       1.2617         31.5         26.3
280...............  280...............  Circulatory                   259       0.7832         23.0         19.2
                                         disorders w AMI,
                                         discharged alive w
                                         MMCC.
281...............  280...............  Circulatory                   110       0.5772         20.6         17.2
                                         disorders w AMI,
                                         discharged alive w
                                         MCC.
282...............  280...............  Circulatory                    35       0.5060         19.9         16.6
                                         disorders w AMI,
                                         discharged alive w/
                                         o CC/MMCC.
283...............  283...............  Circulatory                    56       0.7924         16.1         13.4
                                         disorders w AMI,
                                         expired w MMCC.
284...............  283...............  Circulatory                    17       0.7924         16.1         13.4
                                         disorders w AMI,
                                         expired w CC*.
285...............  283...............  Circulatory                     0       0.7924         16.1         13.4
                                         disorders w AMI,
                                         expired w/o CC/MMCC.
286...............  286...............  Circulatory                     8       1.2617         31.5         26.3
                                         disorders except
                                         AMI, w card cath w
                                         MMCC.
287...............  286...............  Circulatory                     9       0.8596         25.2         21.0
                                         disorders except
                                         AMI, w card cath w/
                                         o MMCC.
288...............  288...............  Acute & subacute              594       1.0060         26.1         21.8
                                         endocarditis w MMCC.
289...............  288...............  Acute & subacute              217       0.7920         26.1         21.8
                                         endocarditis w MCC.
290...............  288...............  Acute & subacute               48       0.6873         24.3         20.3
                                         endocarditis w/o CC/
                                         MMCC.
291...............  291...............  Heart failure &             1,728       0.7727         21.9         18.3
                                         shock w MMCC.
292...............  291...............  Heart failure &               901       0.6294         21.2         17.7
                                         shock w MCC.
293...............  291...............  Heart failure &               362       0.5168         18.8         15.7
                                         shock w/o CC/MMCC.
294...............  294...............  Deep vein                       6       0.6327         21.6         18.0
                                         thrombophlebitis w
                                         CC/MMCC.
295...............  294...............  Deep vein                       0       0.6327         21.6         18.0
                                         thrombophlebitis w/
                                         o CC/MMCC.
296...............  296...............  Cardiac arrest,                 0       0.7924         16.1         13.4
                                         unexplained w MMCC.
297...............  296...............  Cardiac arrest,                 0       0.7924         16.1         13.4
                                         unexplained w MCC.
298...............  296...............  Cardiac arrest,                 0       0.7924         16.1         13.4
                                         unexplained w/o CC/
                                         MMCC.
299...............  299...............  Peripheral vascular           587       0.7804         23.4         19.5
                                         disorders w MMCC.
300...............  299...............  Peripheral vascular           751       0.5847         22.0         18.3
                                         disorders w MCC.
301...............  299...............  Peripheral vascular            78       0.5385         20.3         16.9
                                         disorders w/o CC/
                                         MMCC.
302...............  302...............  Atherosclerosis w              59       0.7597         21.8         18.2
                                         MMCC.
303...............  302...............  Atherosclerosis w/o            61       0.5692         20.1         16.8
                                         MMCC.
304...............  304...............  Hypertension w MMCC.            6       0.4824         19.6         16.3
305...............  304...............  Hypertension w/o               15       0.4824         19.6         16.3
                                         MMCC.
306...............  306...............  Cardiac congenital &           59       0.8224         22.7         18.9
                                         valvular disorders
                                         w MMCC.
307...............  306...............  Cardiac congenital &           38       0.7367         22.9         19.1
                                         valvular disorders
                                         w/o MMCC.
308...............  308...............  Cardiac arrhythmia &           96       0.8384         25.0         20.8
                                         conduction
                                         disorders w MMCC.
309...............  308...............  Cardiac arrhythmia &          107       0.5679         20.8         17.3
                                         conduction
                                         disorders w MCC.
310...............  308...............  Cardiac arrhythmia &           36       0.4590         19.4         16.2
                                         conduction
                                         disorders w/o CC/
                                         MCC.
311...............  311...............  Angina pectoris.....            7       0.4824         19.6         16.3
312...............  312...............  Syncope & collapse..           58       0.5083         19.7         16.4
313...............  313...............  Chest pain..........            6       0.4824         19.6         16.3
314...............  314...............  Other circulatory           1,305       0.8758         22.9         19.1
                                         system diagnoses w
                                         MMCC.
315...............  314...............  Other circulatory             285       0.6575         21.0         17.5
                                         system diagnoses w
                                         MCC.
316...............  314...............  Other circulatory              72       0.6026         21.0         17.5
                                         system diagnoses w/
                                         o CC/MMCC.
326...............  326...............  Stomach, esophageal            19       1.7509         37.9         31.6
                                         & duodenal proc w
                                         MMCC.
327...............  326...............  Stomach, esophageal             3       1.2617         31.5         26.3
                                         & duodenal proc w
                                         MCC.
328...............  326...............  Stomach, esophageal             1       1.2617         31.5         26.3
                                         & duodenal proc w/o
                                         CC/MCC*.
329...............  329...............  Major small & large            31       2.2757         41.8         34.8
                                         bowel procedures w
                                         MMCC.
330...............  329...............  Major small & large            12       1.7509         37.9         31.6
                                         bowel procedures w
                                         MCC.
331...............  329...............  Major small & large             1       1.7509         37.9         31.6
                                         bowel procedures w/
                                         o CC/MMCC.
332...............  332...............  Rectal resection w              0       1.6757         34.2         28.5
                                         MMCC.

[[Page 23896]]

 
333...............  332...............  Rectal resection w              0       1.1606         30.0         25.0
                                         MCC.
334...............  332...............  Rectal resection w/o            0       1.1606         30.0         25.0
                                         CC/MMCC.
335...............  335...............  Peritoneal                      6       1.7509         37.9         31.6
                                         adhesiolysis w MMCC.
336...............  335...............  Peritoneal                      0       1.7509         37.9         31.6
                                         adhesiolysis w MCC.
337...............  335...............  Peritoneal                      0       1.7509         37.9         31.6
                                         adhesiolysis w/o CC/
                                         MMCC.
338...............  338...............  Appendectomy w                  0       0.9726         25.1         20.9
                                         complicated
                                         principal diag w
                                         MMCC.
339...............  338...............  Appendectomy w                  0       0.7768         23.2         19.3
                                         complicated
                                         principal diag w
                                         MCC.
340...............  338...............  Appendectomy w                  0       0.5958         19.6         16.3
                                         complicated
                                         principal diag w/o
                                         CC/MMCC.
341...............  341...............  Appendectomy w/o                0       0.9726         25.1         20.9
                                         complicated
                                         principal diag w
                                         MMCC.
342...............  341...............  Appendectomy w/o                0       0.7768         23.2         19.3
                                         complicated
                                         principal diag w
                                         MCC.
343...............  341...............  Appendectomy w/o                0       0.5958         19.6         16.3
                                         complicated
                                         principal diag w/o
                                         CC/MMCC.
344...............  344...............  Minor small & large             5       1.7509         37.9         31.6
                                         bowel procedures w
                                         MMCC.
345...............  344...............  Minor small & large             0       1.7509         37.9         31.6
                                         bowel procedures w
                                         MCC.
346...............  344...............  Minor small & large             0       1.7509         37.9         31.6
                                         bowel procedures w/
                                         o CC/MMCC.
347...............  347...............  Anal & stomal                   3       1.7509         37.9         31.6
                                         procedures w MMCC.
348...............  347...............  Anal & stomal                   3       1.2617         31.5         26.3
                                         procedures w MCC.
349...............  347...............  Anal & stomal                   0       1.2617         31.5         26.3
                                         procedures w/o CC/
                                         MMCC.
350...............  350...............  Inguinal & femoral              0       1.2617         31.5         26.3
                                         hernia procedures w
                                         MMCC.
351...............  350...............  Inguinal & femoral              0       1.2617         31.5         26.3
                                         hernia procedures w
                                         MCC.
352...............  350...............  Inguinal & femoral              0       1.2617         31.5         26.3
                                         hernia procedures w/
                                         o CC/MMCC.
353...............  353...............  Hernia procedures               1       1.7509         37.9         31.6
                                         except inguinal &
                                         femoral w MMCC.
354...............  353...............  Hernia procedures               1       0.6327         21.6         18.0
                                         except inguinal &
                                         femoral w MCC.
355...............  353...............  Hernia procedures               0       0.6327         21.6         18.0
                                         except inguinal &
                                         femoral w/o CC/MMCC.
356...............  356...............  Other digestive               141       1.6757         34.2         28.5
                                         system O.R.
                                         procedures w MMCC.
357...............  356...............  Other digestive                36       1.1606         30.0         25.0
                                         system O.R.
                                         procedures w MCC.
358...............  356...............  Other digestive                 4       1.1606         30.0         25.0
                                         system O.R.
                                         procedures w/o CC/
                                         MCC*.
368...............  368...............  Major esophageal               26       0.9161         21.1         17.6
                                         disorders w MMCC.
369...............  368...............  Major esophageal               14       0.8596         25.2         21.0
                                         disorders w MCC.
370...............  368...............  Major esophageal                4       0.8596         25.2         21.0
                                         disorders w/o CC/
                                         MMCC.
371...............  371...............  Major                         722       0.9726         25.1         20.9
                                         gastrointestinal
                                         disorders &
                                         peritoneal
                                         infections w MMCC.
372...............  371...............  Major                         350       0.7768         23.2         19.3
                                         gastrointestinal
                                         disorders &
                                         peritoneal
                                         infections w MCC.
373...............  371...............  Major                          68       0.5958         19.6         16.3
                                         gastrointestinal
                                         disorders &
                                         peritoneal
                                         infections w/o CC/
                                         MCC.
374...............  374...............  Digestive malignancy           96       0.9011         21.5         17.9
                                         w MMCC.
375...............  374...............  Digestive malignancy           90       0.7804         23.4         19.5
                                         w MCC.
376...............  374...............  Digestive malignancy            3       0.6327         21.6         18.0
                                         w/o CC/MMCC.
377...............  377...............  G.I. hemorrhage w              90       0.8200         23.8         19.8
                                         MMCC.
378...............  377...............  G.I. hemorrhage w              53       0.6902         23.8         19.8
                                         MCC.
379...............  377...............  G.I. hemorrhage w/o            18       0.6327         21.6         18.0
                                         CC/MMCC.
380...............  380...............  Complicated peptic             22       0.8596         25.2         21.0
                                         ulcer w MMCC.
381...............  380...............  Complicated peptic             17       0.6327         21.6         18.0
                                         ulcer w MCC.
382...............  380...............  Complicated peptic              5       0.4824         19.6         16.3
                                         ulcer w/o CC/MMCC.
383...............  383...............  Uncomplicated peptic            0       0.8596         25.2         21.0
                                         ulcer w MMCC.
384...............  383...............  Uncomplicated peptic            7       0.8596         25.2         21.0
                                         ulcer w/o MMCC.
385...............  385...............  Inflammatory bowel             36       0.8076         23.3         19.4
                                         disease w MMCC.
386...............  385...............  Inflammatory bowel             37       0.7126         23.1         19.3
                                         disease w MCC.
387...............  385...............  Inflammatory bowel              5       0.4824         19.6         16.3
                                         disease w/o CC/MMCC.
388...............  388...............  G.I. obstruction w            213       0.9486         22.5         18.8
                                         MMCC.
389...............  388...............  G.I. obstruction w             97       0.7302         20.9         17.4
                                         MCC.
390...............  388...............  G.I. obstruction w/o           17       0.6327         21.6         18.0
                                         CC/MMCC.
391...............  391...............  Esophagitis,                  255       0.7914         21.9         18.3
                                         gastroent & misc
                                         digest disorders w
                                         MMCC.
392...............  391...............  Esophagitis,                  292       0.6568         21.0         17.5
                                         gastroent & misc
                                         digest disorders w/
                                         o MMCC.
393...............  393...............  Other digestive               779       1.0684         25.7         21.4
                                         system diagnoses w
                                         MMCC.
394...............  393...............  Other digestive               449       0.7872         22.6         18.8
                                         system diagnoses w
                                         MCC.
395...............  393...............  Other digestive                33       0.5783         22.1         18.4
                                         system diagnoses w/
                                         o CC/MMCC.
405...............  405...............  Pancreas, liver &              10       1.2617         31.5         26.3
                                         shunt procedures w
                                         MMCC.
406...............  405...............  Pancreas, liver &               2       1.2617         31.5         26.3
                                         shunt procedures w
                                         CC*.
407...............  405...............  Pancreas, liver &               0       1.2617         31.5         26.3
                                         shunt procedures w/
                                         o CC/MMCC.
408...............  408...............  Biliary tract proc              0       0.6327         21.6         18.0
                                         except only
                                         cholecyst w or w/o
                                         c.d.e. w MMCC.
409...............  408...............  Biliary tract proc              1       0.6327         21.6         18.0
                                         except only
                                         cholecyst w or w/o
                                         c.d.e. w MCC.

[[Page 23897]]

 
410...............  408...............  Biliary tract proc              0       0.6327         21.6         18.0
                                         except only
                                         cholecyst w or w/o
                                         c.d.e. w/o CC/MMCC.
411...............  411...............  Cholecystectomy w               1       1.7509         37.9         31.6
                                         c.d.e. w MMCC.
412...............  411...............  Cholecystectomy w               0       1.7509         37.9         31.6
                                         c.d.e. w MCC.
413...............  411...............  Cholecystectomy w               0       1.7509         37.9         31.6
                                         c.d.e. w/o CC/MMCC.
414...............  414...............  Cholecystectomy                 2       1.7509         37.9         31.6
                                         except by
                                         laparoscope w/o
                                         c.d.e. w MMCC.
415...............  414...............  Cholecystectomy                 3       1.7509         37.9         31.6
                                         except by
                                         laparoscope w/o
                                         c.d.e. w MCC.
416...............  414...............  Cholecystectomy                 0       1.7509         37.9         31.6
                                         except by
                                         laparoscope w/o
                                         c.d.e. w/o CC/MMCC.
417...............  417...............  Laparoscopic                   11       1.7509         37.9         31.6
                                         cholecystectomy w/o
                                         c.d.e. w MCC*.
418...............  417...............  Laparoscopic                    5       1.7509         37.9         31.6
                                         cholecystectomy w/o
                                         c.d.e. w MCC.
419...............  417...............  Laparoscopic                    0       1.7509         37.9         31.6
                                         cholecystectomy w/o
                                         c.d.e. w/o CC/MMCC.
420...............  420...............  Hepatobiliary                   0       0.8596         25.2         21.0
                                         diagnostic
                                         procedures w MMCC.
421...............  420...............  Hepatobiliary                   0       0.8596         25.2         21.0
                                         diagnostic
                                         procedures w MCC.
422...............  420...............  Hepatobiliary                   0       0.8596         25.2         21.0
                                         diagnostic
                                         procedures w/o CC/
                                         MMCC.
423...............  423...............  Other hepatobiliary            23       1.7509         37.9         31.6
                                         or pancreas O.R.
                                         procedures w MMCC.
424...............  423...............  Other hepatobiliary             2       0.8596         25.2         21.0
                                         or pancreas O.R.
                                         procedures w MCC.
425...............  423...............  Other hepatobiliary             0       0.8596         25.2         21.0
                                         or pancreas O.R.
                                         procedures w/o CC/
                                         MMCC.
432...............  432...............  Cirrhosis &                    73       0.6977         20.9         17.4
                                         alcoholic hepatitis
                                         w MMCC.
433...............  432...............  Cirrhosis &                    24       0.6327         21.6         18.0
                                         alcoholic hepatitis
                                         w MCC.
434...............  432...............  Cirrhosis &                     0       0.6327         21.6         18.0
                                         alcoholic hepatitis
                                         w/o CC/MMCC.
435...............  435...............  Malignancy of                  53       0.8340         22.0         18.3
                                         hepatobiliary
                                         system or pancreas
                                         w MMCC.
436...............  435...............  Malignancy of                  26       0.4904         17.2         14.3
                                         hepatobiliary
                                         system or pancreas
                                         w MCC.
437...............  435...............  Malignancy of                   4       0.4824         19.6         16.3
                                         hepatobiliary
                                         system or pancreas
                                         w/o CC/MMCC.
438...............  438...............  Disorders of                  243       1.0807         23.5         19.6
                                         pancreas except
                                         malignancy w MMCC.
439...............  438...............  Disorders of                  144       0.7533         22.0         18.3
                                         pancreas except
                                         malignancy w MCC.
440...............  438...............  Disorders of                   24       0.6327         21.6         18.0
                                         pancreas except
                                         malignancy w/o CC/
                                         MMCC.
441...............  441...............  Disorders of liver            123       0.8206         23.1         19.3
                                         except
                                         malig,cirr,alc hepa
                                         w MMCC.
442...............  441...............  Disorders of liver             62       0.7145         21.7         18.1
                                         except
                                         malig,cirr,alc hepa
                                         w MCC.
443...............  441...............  Disorders of liver             14       0.4824         19.6         16.3
                                         except
                                         malig,cirr,alc hepa
                                         w/o CC/MMCC.
444...............  444...............  Disorders of the              104       0.8334         22.7         18.9
                                         biliary tract w
                                         MMCC.
445...............  444...............  Disorders of the               35       0.6140         20.7         17.3
                                         biliary tract w MCC.
446...............  444...............  Disorders of the                8       0.6140         20.7         17.3
                                         biliary tract w/o
                                         CC/MCC*.
453...............  453...............  Combined anterior/              0       1.7509         37.9         31.6
                                         posterior spinal
                                         fusion w MMCC.
454...............  453...............  Combined anterior/              0       1.7509         37.9         31.6
                                         posterior spinal
                                         fusion w MCC.
455...............  453...............  Combined anterior/              0       1.7509         37.9         31.6
                                         posterior spinal
                                         fusion w/o CC/MMCC.
456...............  456...............  Spinal fusion exc               1       1.7509         37.9         31.6
                                         cerv w spinal curv,
                                         malig or 9+ fusions
                                         w MMCC.
457...............  456...............  Spinal fusion exc               3       1.7509         37.9         31.6
                                         cerv w spinal curv,
                                         malig or 9+ fusions
                                         w MCC.
458...............  456...............  Spinal fusion exc               0       1.7509         37.9         31.6
                                         cerv w spinal curv,
                                         malig or 9+ fusions
                                         w/o CC/MMCC.
459...............  459...............  Spinal fusion except            1       1.7509         37.9         31.6
                                         cervical w MMCC.
460...............  459...............  Spinal fusion except            0       1.7509         37.9         31.6
                                         cervical w/o MMCC.
461...............  461...............  Bilateral or                    0       1.7509         37.9         31.6
                                         multiple major
                                         joint procs of
                                         lower extremity w
                                         MMCC.
462...............  461...............  Bilateral or                    0       0.8596         25.2         21.0
                                         multiple major
                                         joint procs of
                                         lower extremity w/o
                                         MMCC.
463...............  463...............  Wnd debrid & skn              526       1.4126         38.7         32.3
                                         grft exc hand, for
                                         musculo-conn tiss
                                         dis w MMCC.
464...............  463...............  Wnd debrid & skn              311       1.0643         34.0         28.3
                                         grft exc hand, for
                                         musculo-conn tiss
                                         dis w MCC.
465...............  463...............  Wnd debrid & skn               61       0.9863         34.0         28.3
                                         grft exc hand, for
                                         musculo-conn tiss
                                         dis w/o CC/MCC.
466...............  466...............  Revision of hip or              3       1.2617         31.5         26.3
                                         knee replacement w
                                         MMCC.
467...............  466...............  Revision of hip or              4       1.2617         31.5         26.3
                                         knee replacement w
                                         MCC.
468...............  466...............  Revision of hip or              1       0.4824         19.6         16.3
                                         knee replacement w/
                                         o CC/MMCC.
469...............  469...............  Major joint                     3       1.7509         37.9         31.6
                                         replacement or
                                         reattachment of
                                         lower extremity w
                                         MCC*.
470...............  469...............  Major joint                     3       1.7509         37.9         31.6
                                         replacement or
                                         reattachment of
                                         lower extremity w/o
                                         MMCC.

[[Page 23898]]

 
471...............  471...............  Cervical spinal                 2       0.8596         25.2         21.0
                                         fusion w MMCC.
472...............  471...............  Cervical spinal                 1       0.8596         25.2         21.0
                                         fusion w MCC.
473...............  471...............  Cervical spinal                 0       0.8596         25.2         21.0
                                         fusion w/o CC/MMCC.
474...............  474...............  Amputation for                 91       1.5642         38.4         32.0
                                         musculoskeletal sys
                                         & conn tissue dis w
                                         MMCC.
475...............  474...............  Amputation for                 67       1.1116         33.9         28.3
                                         musculoskeletal sys
                                         & conn tissue dis w
                                         MCC.
476...............  474...............  Amputation for                  4       0.8596         25.2         21.0
                                         musculoskeletal sys
                                         & conn tissue dis w/
                                         o CC/MMCC.
477...............  477...............  Biopsies of                    22       1.7509         37.9         31.6
                                         musculoskeletal
                                         system & connective
                                         tissue w MMCC.
478...............  477...............  Biopsies of                    12       1.2617         31.5         26.3
                                         musculoskeletal
                                         system & connective
                                         tissue w MCC.
479...............  477...............  Biopsies of                     0       1.2617         31.5         26.3
                                         musculoskeletal
                                         system & connective
                                         tissue w/o CC/MMCC.
480...............  480...............  Hip & femur                    21       1.7509         37.9         31.6
                                         procedures except
                                         major joint w MMCC.
481...............  480...............  Hip & femur                    11       1.2617         31.5         26.3
                                         procedures except
                                         major joint w MCC.
482...............  480...............  Hip & femur                     2       0.8596         25.2         21.0
                                         procedures except
                                         major joint w/o CC/
                                         MMCC.
483...............  483...............  Major joint & limb              0       1.7509         37.9         31.6
                                         reattachment proc
                                         of upper extremity
                                         w CC/MMCC.
484...............  483...............  Major joint & limb              0       0.8596         25.2         21.0
                                         reattachment proc
                                         of upper extremity
                                         w/o CC/MMCC.
485...............  485...............  Knee procedures w              10       1.2617         31.5         26.3
                                         pdx of infection w
                                         MMCC.
486...............  485...............  Knee procedures w              10       1.2617         31.5         26.3
                                         pdx of infection w
                                         MCC.
487...............  485...............  Knee procedures w               2       1.2617         31.5         26.3
                                         pdx of infection w/
                                         o CC/MCC*.
488...............  488...............  Knee procedures w/o             1       1.7509         37.9         31.6
                                         pdx of infection w
                                         CC/MMCC.
489...............  488...............  Knee procedures w/o             1       0.6327         21.6         18.0
                                         pdx of infection w/
                                         o CC/MMCC.
490...............  490...............  Back & neck                     8       1.2617         31.5         26.3
                                         procedures except
                                         spinal fusion w CC/
                                         MCC or disc devices.
491...............  490...............  Back & neck                     0       1.2617         31.5         26.3
                                         procedures except
                                         spinal fusion w/o
                                         CC/MMCC.
492...............  492...............  Lower extrem & humer           10       1.2617         31.5         26.3
                                         proc except hip,
                                         foot, femur w MMCC.
493...............  492...............  Lower extrem & humer           10       1.2617         31.5         26.3
                                         proc except hip,
                                         foot, femur w MCC.
494...............  492...............  Lower extrem & humer            1       0.8596         25.2         21.0
                                         proc except hip,
                                         foot, femur w/o CC/
                                         MMCC.
495...............  495...............  Local excision &               42       1.2616         36.9         30.8
                                         removal int fix
                                         devices exc hip &
                                         femur w MMCC.
496...............  495...............  Local excision &               20       1.2616         36.9         30.8
                                         removal int fix
                                         devices exc hip &
                                         femur w CC*.
497...............  495...............  Local excision &                5       1.2616         36.9         30.8
                                         removal int fix
                                         devices exc hip &
                                         femur w/o CC/MCC*.
498...............  498...............  Local excision &                9       1.7509         37.9         31.6
                                         removal int fix
                                         devices of hip &
                                         femur w CC/MCC.
499...............  498...............  Local excision &                0       1.7509         37.9         31.6
                                         removal int fix
                                         devices of hip &
                                         femur w/o CC/MCC.
500...............  500...............  Soft tissue                    68       1.3427         36.7         30.6
                                         procedures w MMCC.
501...............  500...............  Soft tissue                    28       1.0746         33.3         27.8
                                         procedures w MCC.
502...............  500...............  Soft tissue                     4       0.8596         25.2         21.0
                                         procedures w/o CC/
                                         MMCC.
503...............  503...............  Foot procedures w              15       1.2617         31.5         26.3
                                         MMCC.
504...............  503...............  Foot procedures w              22       0.8596         25.2         21.0
                                         MCC.
505...............  503...............  Foot procedures w/o             3       0.8596         25.2         21.0
                                         CC/MMCC.
506...............  506...............  Major thumb or joint            0       1.2617         31.5         26.3
                                         procedures.
507...............  507...............  Major shoulder or               1       1.7509         37.9         31.6
                                         elbow joint
                                         procedures w CC/
                                         MMCC.
508...............  507...............  Major shoulder or               0       1.7509         37.9         31.6
                                         elbow joint
                                         procedures w/o CC/
                                         MMCC.
509...............  509...............  Arthroscopy.........            0       0.8596         25.2         21.0
510...............  510...............  Shoulder, elbow or              1       0.8596         25.2         21.0
                                         forearm proc, exc
                                         major joint proc w
                                         MCC*.
511...............  510...............  Shoulder, elbow or              2       0.8596         25.2         21.0
                                         forearm proc, exc
                                         major joint proc w
                                         CC*.
512...............  510...............  Shoulder, elbow or              0       0.8596         25.2         21.0
                                         forearm proc, exc
                                         major joint proc w/
                                         o CC/MCC.
513...............  513...............  Hand or wrist proc,             6       1.2617         31.5         26.3
                                         except major thumb
                                         or joint proc w CC/
                                         MMCC.
514...............  513...............  Hand or wrist proc,             1       1.2617         31.5         26.3
                                         except major thumb
                                         or joint proc w/o
                                         CC/MCC*.

[[Page 23899]]

 
515...............  515...............  Other musculoskelet            60       1.3728         31.5         26.3
                                         sys & conn tiss
                                         O.R. proc w MMCC.
516...............  515...............  Other musculoskelet            27       0.9133         28.0         23.3
                                         sys & conn tiss
                                         O.R. proc w MCC.
517...............  515...............  Other musculoskelet             0       0.9133         28.0         23.3
                                         sys & conn tiss
                                         O.R. proc w/o CC/
                                         MMCC.
533...............  533...............  Fractures of femur w            3       0.6327         21.6         18.0
                                         MMCC.
534...............  533...............  Fractures of femur w/           6       0.6327         21.6         18.0
                                         o MMCC.
535...............  535...............  Fractures of hip &             16       0.8596         25.2         21.0
                                         pelvis w MMCC.
536...............  535...............  Fractures of hip &             25       0.6130         26.9         22.4
                                         pelvis w/o MMCC.
537...............  537...............  Sprains, strains, &             1       0.4824         19.6         16.3
                                         dislocations of
                                         hip, pelvis & thigh
                                         w CC/MMCC.
538...............  537...............  Sprains, strains, &             0       0.4824         19.6         16.3
                                         dislocations of
                                         hip, pelvis & thigh
                                         w/o CC/MCC.
539...............  539...............  Osteomyelitis w MMCC        1,317       0.9928         30.2         25.2
540...............  539...............  Osteomyelitis w MCC.          848       0.7632         27.6         23.0
541...............  539...............  Osteomyelitis w/o CC/         227       0.6901         27.1         22.6
                                         MMCC.
542...............  542...............  Pathological                   23       0.8596         25.2         21.0
                                         fractures &
                                         musculoskelet &
                                         conn tiss malig w
                                         MMCC.
543...............  542...............  Pathological                   42       0.5682         20.5         17.1
                                         fractures &
                                         musculoskelet &
                                         conn tiss malig w
                                         MCC.
544...............  542...............  Pathological                   17       0.4824         19.6         16.3
                                         fractures &
                                         musculoskelet &
                                         conn tiss malig w/o
                                         CC/MMCC.
545...............  545...............  Connective tissue              50       0.9093         23.5         19.6
                                         disorders w MMCC.
546...............  545...............  Connective tissue              38       0.8478         25.5         21.3
                                         disorders w MCC.
547...............  545...............  Connective tissue               5       0.4824         19.6         16.3
                                         disorders w/o CC/
                                         MMCC.
548...............  548...............  Septic arthritis w            172       0.8843         26.1         21.8
                                         MMCC.
549...............  548...............  Septic arthritis w            200       0.7080         26.9         22.4
                                         MCC.
550...............  548...............  Septic arthritis w/o           73       0.6067         24.2         20.2
                                         CC/MMCC.
551...............  551...............  Medical back                   83       0.8867         26.5         22.1
                                         problems w MMCC.
552...............  551...............  Medical back                  156       0.6146         24.2         20.2
                                         problems w/o MMCC.
553...............  553...............  Bone diseases &                15       0.6327         21.6         18.0
                                         arthropathies w
                                         MMCC.
554...............  553...............  Bone diseases &                59       0.5022         21.3         17.8
                                         arthropathies w/o
                                         MMCC.
555...............  555...............  Signs & symptoms of             3       0.8596         25.2         21.0
                                         musculoskeletal
                                         system & conn
                                         tissue w MMCC.
556...............  555...............  Signs & symptoms of             8       0.4824         19.6         16.3
                                         musculoskeletal
                                         system & conn
                                         tissue w/o MCC.
557...............  557...............  Tendonitis, myositis           84       0.8284         24.6         20.5
                                         & bursitis w MMCC.
558...............  557...............  Tendonitis, myositis          134       0.6519         23.0         19.2
                                         & bursitis w/o MMCC.
559...............  559...............  Aftercare,                  1,368       0.8146         26.1         21.8
                                         musculoskeletal
                                         system & connective
                                         tissue w MMCC.
560...............  559...............  Aftercare,                  1,613       0.6469         24.7         20.6
                                         musculoskeletal
                                         system & connective
                                         tissue w MCC.
561...............  559...............  Aftercare,                    730       0.5579         22.8         19.0
                                         musculoskeletal
                                         system & connective
                                         tissue w/o CC/MMCC.
562...............  562...............  Fx, sprn, strn &                5       0.8596         25.2         21.0
                                         disl except femur,
                                         hip, pelvis & thigh
                                         w MMCC.
563...............  562...............  Fx, sprn, strn &                9       0.4824         19.6         16.3
                                         disl except femur,
                                         hip, pelvis & thigh
                                         w/o MMCC.
564...............  564...............  Other                         307       0.8803         24.2         20.2
                                         musculoskeletal sys
                                         & connective tissue
                                         diagnoses w MMCC.
565...............  564...............  Other                         199       0.6473         22.7         18.9
                                         musculoskeletal sys
                                         & connective tissue
                                         diagnoses w MCC.
566...............  564...............  Other                          60       0.6236         22.5         18.8
                                         musculoskeletal sys
                                         & connective tissue
                                         diagnoses w/o CC/
                                         MMCC.
573...............  573...............  Skin graft &/or             1,814       1.3944         38.2         31.8
                                         debrid for skn
                                         ulcer or cellulitis
                                         w MMCC.
574...............  573...............  Skin graft &/or             1,761       1.0779         36.0         30.0
                                         debrid for skn
                                         ulcer or cellulitis
                                         w MCC.
575...............  573...............  Skin graft &/or               200       0.9033         30.1         25.1
                                         debrid for skn
                                         ulcer or cellulitis
                                         w/o CC/MMCC.
576...............  576...............  Skin graft &/or                27       1.7840         37.6         31.3
                                         debrid exc for skin
                                         ulcer or cellulitis
                                         w MMCC.
577...............  576...............  Skin graft &/or                28       0.8093         27.3         22.8
                                         debrid exc for skin
                                         ulcer or cellulitis
                                         w MCC.
578...............  576...............  Skin graft &/or                11       0.6327         21.6         18.0
                                         debrid exc for skin
                                         ulcer or cellulitis
                                         w/o CC/MMCC.
579...............  579...............  Other skin, subcut            476       1.3648         36.5         30.4
                                         tiss & breast proc
                                         w MMCC.
580...............  579...............  Other skin, subcut            398       1.0585         33.5         27.9
                                         tiss & breast proc
                                         w MCC.
581...............  579...............  Other skin, subcut             34       0.8032         30.1         25.1
                                         tiss & breast proc
                                         w/o CC/MMCC.
582...............  582...............  Mastectomy for                  1       1.7509         37.9         31.6
                                         malignancy w CC/
                                         MMCC.
583...............  582...............  Mastectomy for                  0       1.7509         37.9         31.6
                                         malignancy w/o CC/
                                         MMCC.

[[Page 23900]]

 
584...............  584...............  Breast biopsy, local            2       0.6327         21.6         18.0
                                         excision & other
                                         breast procedures w
                                         CC/MMCC.
585...............  584...............  Breast biopsy, local            0       0.6327         21.6         18.0
                                         excision & other
                                         breast procedures w/
                                         o CC/MMCC.
592...............  592...............  Skin ulcers w MMCC..        3,044       0.9490         27.0         22.5
593...............  592...............  Skin ulcers w MCC...        2,805       0.7171         26.1         21.8
594...............  592...............  Skin ulcers w/o CC/           435       0.6109         24.8         20.7
                                         MMCC.
595...............  595...............  Major skin disorders           28       0.8138         25.3         21.1
                                         w MMCC.
596...............  595...............  Major skin disorders           39       0.6547         22.4         18.7
                                         w/o MMCC.
597...............  597...............  Malignant breast                7       1.2617         31.5         26.3
                                         disorders w MMCC.
598...............  597...............  Malignant breast                7       0.8596         25.2         21.0
                                         disorders w MCC.
599...............  597...............  Malignant breast                1       0.8596         25.2         21.0
                                         disorders w/o CC/
                                         MCC*.
600...............  600...............  Non-malignant breast           17       0.8596         25.2         21.0
                                         disorders w CC/MMCC.
601...............  600...............  Non-malignant breast            6       0.4824         19.6         16.3
                                         disorders w/o CC/
                                         MMCC.
602...............  602...............  Cellulitis w MMCC...          829       0.6963         21.7         18.1
603...............  602...............  Cellulitis w/o MMCC.        1,634       0.5333         19.9         16.6
604...............  604...............  Trauma to the skin,            29       0.8236         24.4         20.3
                                         subcut tiss &
                                         breast w MMCC.
605...............  604...............  Trauma to the skin,            53       0.6053         23.8         19.8
                                         subcut tiss &
                                         breast w/o MMCC.
606...............  606...............  Minor skin disorders           63       0.8273         24.5         20.4
                                         w MMCC.
607...............  606...............  Minor skin disorders           93       0.5599         20.7         17.3
                                         w/o MMCC.
614...............  614...............  Adrenal & pituitary             0       1.0449         32.5         27.1
                                         procedures w CC/
                                         MMCC.
615...............  614...............  Adrenal & pituitary             0       0.8596         25.2         21.0
                                         procedures w/o CC/
                                         MMCC.
616...............  616...............  Amputat of lower               70       1.4804         38.4         32.0
                                         limb for endocrine,
                                         nutrit,& metabol
                                         dis w MMCC.
617...............  616...............  Amputat of lower              132       1.1478         33.1         27.6
                                         limb for endocrine,
                                         nutrit,& metabol
                                         dis w MCC.
618...............  616...............  Amputat of lower                2       0.4824         19.6         16.3
                                         limb for endocrine,
                                         nutrit,& metabol
                                         dis w/o CC/MMCC.
619...............  619...............  O.R. procedures for             1       1.7509         37.9         31.6
                                         obesity w MMCC.
620...............  619...............  O.R. procedures for             0       1.7509         37.9         31.6
                                         obesity w MCC.
621...............  619...............  O.R. procedures for             0       1.7509         37.9         31.6
                                         obesity w/o CC/MMCC.
622...............  622...............  Skin grafts & wound           171       1.2978         35.7         29.8
                                         debrid for endoc,
                                         nutrit & metab dis
                                         w MCC.
623...............  622...............  Skin grafts & wound           357       1.0065         30.9         25.8
                                         debrid for endoc,
                                         nutrit & metab dis
                                         w MCC.
624...............  622...............  Skin grafts & wound            21       0.6327         21.6         18.0
                                         debrid for endoc,
                                         nutrit & metab dis
                                         w/o CC/MMCC.
625...............  625...............  Thyroid, parathyroid            1       1.2617         31.5         26.3
                                         & thyroglossal
                                         procedures w MMCC.
626...............  625...............  Thyroid, parathyroid            1       0.8596         25.2         21.0
                                         & thyroglossal
                                         procedures w MCC.
627...............  625...............  Thyroid, parathyroid            0       0.8596         25.2         21.0
                                         & thyroglossal
                                         procedures w/o CC/
                                         MMCC.
628...............  628...............  Other endocrine,               48       1.3769         32.3         26.9
                                         nutrit & metab O.R.
                                         proc w MMCC.
629...............  628...............  Other endocrine,              110       1.0449         32.5         27.1
                                         nutrit & metab O.R.
                                         proc w MCC.
630...............  628...............  Other endocrine,                2       0.8596         25.2         21.0
                                         nutrit & metab O.R.
                                         proc w/o CC/MMCC.
637...............  637...............  Diabetes w MMCC.....          421       0.9264         26.6         22.2
638...............  637...............  Diabetes w MCC......        1,052       0.6950         24.5         20.4
639...............  637...............  Diabetes w/o CC/MMCC           71       0.5777         20.8         17.3
640...............  640...............  Nutritional & misc            638       0.8424         23.1         19.3
                                         metabolic disorders
                                         w MMCC.
641...............  640...............  Nutritional & misc            548       0.6217         21.5         17.9
                                         metabolic disorders
                                         w/o MMCC.
642...............  642...............  Inborn errors of                5       0.4824         19.6         16.3
                                         metabolism.
643...............  643...............  Endocrine disorders            30       0.6833         24.0         20.0
                                         w MMCC.
644...............  643...............  Endocrine disorders            28       0.5393         21.1         17.6
                                         w MCC.
645...............  643...............  Endocrine disorders             1       0.4824         19.6         16.3
                                         w/o CC/MCC.
652...............  652...............  Kidney transplant...            0       0.0000          0.0          0.0
653...............  653...............  Major bladder                   2       1.7509         37.9         31.6
                                         procedures w MCC.
654...............  653...............  Major bladder                   0       1.7509         37.9         31.6
                                         procedures w MCC.
655...............  653...............  Major bladder                   0       1.7509         37.9         31.6
                                         procedures w/o CC/
                                         MMCC.
656...............  656...............  Kidney & ureter                 1       1.7509         37.9         31.6
                                         procedures for
                                         neoplasm w MMCC.
657...............  656...............  Kidney & ureter                 0       1.7509         37.9         31.6
                                         procedures
                                         forneoplasm w MCC.
658...............  656...............  Kidney & ureter                 0       1.7509         37.9         31.6
                                         procedures for
                                         neoplasm w/o CC/
                                         MMCC.
659...............  659...............  Kidney & ureter                 6       1.2617         31.5         26.3
                                         procedures for non-
                                         neoplasm w MMCC.
660...............  659...............  Kidney & ureter                 6       1.2617         31.5         26.3
                                         procedures for non-
                                         neoplasm w MCC.
661...............  659...............  Kidney & ureter                 1       0.6327         21.6         18.0
                                         procedures for non-
                                         neoplasm w/o CC/
                                         MMCC.
662...............  662...............  Minor bladder                   2       1.7509         37.9         31.6
                                         procedures w MMCC.
663...............  662...............  Minor bladder                   2       0.6327         21.6         18.0
                                         procedures w MCC.
664...............  662...............  Minor bladder                   0       0.6327         21.6         18.0
                                         procedures w/o CC/
                                         MCC.

[[Page 23901]]

 
665...............  665...............  Prostatectomy w MCC*            2       0.8596         25.2         21.0
666...............  665...............  Prostatectomy w CC*.            1       0.8596         25.2         21.0
667...............  665...............  Prostatectomy w/o CC/           0       0.8596         25.2         21.0
                                         MMCC.
668...............  668...............  Transurethral                   4       0.8596         25.2         21.0
                                         procedures w MMCC.
669...............  668...............  Transurethral                   3       0.6327         21.6         18.0
                                         procedures w MCC.
670...............  668...............  Transurethral                   0       0.6327         21.6         18.0
                                         procedures w/o CC/
                                         MMCC.
671...............  671...............  Urethral procedures             1       0.6327         21.6         18.0
                                         w CC/MMCC.
672...............  671...............  Urethral procedures             0       0.6327         21.6         18.0
                                         w/o CC/MMCC.
673...............  673...............  Other kidney &                227       1.4418         33.8         28.2
                                         urinary tract
                                         procedures w MMCC.
674...............  673...............  Other kidney &                 67       1.1430         29.1         24.3
                                         urinary tract
                                         procedures w MCC.
675...............  673...............  Other kidney &                  0       1.1430         29.1         24.3
                                         urinary tract
                                         procedures w/o CC/
                                         MMCC.
682...............  682...............  Renal failure w MMCC        1,458       0.8945         23.8         19.8
683...............  682...............  Renal failure w MCC.          713       0.7478         22.8         19.0
684...............  682...............  Renal failure w/o CC/          91       0.6647         20.6         17.2
                                         MMCC.
685...............  685...............  Admit for renal                32       0.8341         25.1         20.9
                                         dialysis.
686...............  686...............  Kidney & urinary               15       0.8596         25.2         21.0
                                         tract neoplasms w
                                         MMCC.
687...............  686...............  Kidney & urinary               18       0.8596         25.2         21.0
                                         tract neoplasms w
                                         MCC.
688...............  686...............  Kidney & urinary                3       0.6327         21.6         18.0
                                         tract neoplasms w/o
                                         CC/MMCC.
689...............  689...............  Kidney & urinary              868       0.6712         22.6         18.8
                                         tract infections w
                                         MMCC.
690...............  689...............  Kidney & urinary              782       0.5266         20.5         17.1
                                         tract infections w/
                                         o MMCC.
691...............  691...............  Urinary stones w esw            0       0.4824         19.6         16.3
                                         lithotripsy w CC/
                                         MMCC.
692...............  691...............  Urinary stones w esw            0       0.4824         19.6         16.3
                                         lithotripsy w/o CC/
                                         MMCC.
693...............  693...............  Urinary stones w/o              3       0.8596         25.2         21.0
                                         esw lithotripsy w
                                         MMCC.
694...............  693...............  Urinary stones w/ot             5       0.4824         19.6         16.3
                                         esw lithotripsy w/o
                                         MMCC.
695...............  695...............  Kidney & urinary                4       1.2617         31.5         26.3
                                         tract signs &
                                         symptoms w MMCC.
696...............  695...............  Kidney & urinary                7       0.6327         21.6         18.0
                                         tract signs &
                                         symptoms w/o MMCC.
697...............  697...............  Urethral stricture..            0       0.6327         21.6         18.0
698...............  698...............  Other kidney &                285       0.9527         23.5         19.6
                                         urinary tract
                                         diagnoses w MMCC.
699...............  698...............  Other kidney &                142       0.6606         22.0         18.3
                                         urinary tract
                                         diagnoses w MCC.
700...............  698...............  Other kidney &                 33       0.5695         21.1         17.6
                                         urinary tract
                                         diagnoses w/o CC/
                                         MMCC.
707...............  707...............  Major male pelvic               0       1.2617         31.5         26.3
                                         procedures w CC/
                                         MMCC.
708...............  707...............  Major male pelvic               0       0.6327         21.6         18.0
                                         procedures w/o CC/
                                         MMCC.
709...............  709...............  Penis procedures w             15       1.7509         37.9         31.6
                                         CC/MMCC.
710...............  709...............  Penis procedures w/o            0       1.7509         37.9         31.6
                                         CC/MMCC.
711...............  711...............  Testes procedures w             6       1.2617         31.5         26.3
                                         CC/MMCC.
712...............  711...............  Testes procedures w/            0       1.2617         31.5         26.3
                                         o CC/MMCC.
713...............  713...............  Transurethral                   2       1.7509         37.9         31.6
                                         prostatectomy w CC/
                                         MMCC.
714...............  713...............  Transurethral                   0       1.7509         37.9         31.6
                                         prostatectomy w/o
                                         CC/MMCC.
715...............  715...............  Other male                      0       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. proc for
                                         malignancy w CC/
                                         MMCC.
716...............  715...............  Other male                      0       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. proc for
                                         malignancy w/o CC/
                                         MMCC.
717...............  717...............  Other male                     11       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. proc exc
                                         malignancy w CC/
                                         MMCC.
718...............  717...............  Other male                      0       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. proc exc
                                         malignancy w/o CC/
                                         MMCC.
722...............  722...............  Malignancy, male               15       0.6327         21.6         18.0
                                         reproductive system
                                         w MMCC.
723...............  722...............  Malignancy, male               15       0.4824         19.6         16.3
                                         reproductive system
                                         w MCC.
724...............  722...............  Malignancy, male                0       0.4824         19.6         16.3
                                         reproductive system
                                         w/o CC/MMCC.
725...............  725...............  Benign prostatic                1       0.8596         25.2         21.0
                                         hypertrophy w MMCC.
726...............  725...............  Benign prostatic                2       0.4824         19.6         16.3
                                         hypertrophy w/o
                                         MMCC.
727...............  727...............  Inflammation of the            27       0.7907         23.1         19.3
                                         male reproductive
                                         system w MMCC.
728...............  727...............  Inflammation of the            51       0.5259         20.4         17.0
                                         male reproductive
                                         system w/o MMCC.
729...............  729...............  Other male                     49       0.8878         26.2         21.8
                                         reproductive system
                                         diagnoses w CC/MMCC.
730...............  729...............  Other male                      8       0.4824         19.6         16.3
                                         reproductive system
                                         diagnoses w/o CC/
                                         MMCC.
734...............  734...............  Pelvic evisceration,            0       1.2617         31.5         26.3
                                         rad hysterectomy &
                                         rad vulvectomy w CC/
                                         MMCC.
735...............  734...............  Pelvic evisceration,            0       1.2617         31.5         26.3
                                         rad hysterectomy &
                                         rad vulvectomy w/o
                                         CC/MMCC.
736...............  736...............  Uterine & adnexa                0       1.2617         31.5         26.3
                                         proc for ovarian or
                                         adnexal malignancy
                                         w MMCC.
737...............  736...............  Uterine & adnexa                0       0.8596         25.2         21.0
                                         proc for ovarian or
                                         adnexal malignancy
                                         w MCC.
738...............  736...............  Uterine & adnexa                0       0.4824         19.6         16.3
                                         proc for ovarian or
                                         adnexal malignancy
                                         w/o CC/MMCC.
739...............  739...............  Uterine,adnexa proc             1       1.2617         31.5         26.3
                                         for non-ovarian/
                                         adnexal malig w
                                         MMCC.

[[Page 23902]]

 
740...............  739...............  Uterine,adnexa proc             0       1.2617         31.5         26.3
                                         for non-ovarian/
                                         adnexal malig w MCC.
741...............  739...............  Uterine,adnexa proc             0       1.2617         31.5         26.3
                                         for non-ovarian/
                                         adnexal malig w/o
                                         CC/MMCC.
742...............  742...............  Uterine & adnexa                0       0.8596         25.2         21.0
                                         proc for non-
                                         malignancy w CC/
                                         MMCC.
743...............  742...............  Uterine & adnexa                0       0.4824         19.6         16.3
                                         proc for non-
                                         malignancy w/o CC/
                                         MMCC.
744...............  744...............  D&C, conization,                1       0.8596         25.2         21.0
                                         laparascopy & tubal
                                         interruption w CC/
                                         MMCC.
745...............  744...............  D&C, conization,                0       0.8596         25.2         21.0
                                         laparascopy & tubal
                                         interruption w/o CC/
                                         MMCC.
746...............  746...............  Vagina, cervix &                1       1.7509         37.9         31.6
                                         vulva procedures w
                                         CC/MMCC.
747...............  746...............  Vagina, cervix &                0       1.7509         37.9         31.6
                                         vulva procedures w/
                                         o CC/MMCC.
748...............  748...............  Female reproductive             0       1.2617         31.5         26.3
                                         system
                                         reconstructive
                                         procedures.
749...............  749...............  Other female                    4       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. procedures w
                                         CC/MMCC.
750...............  749...............  Other female                    0       1.2617         31.5         26.3
                                         reproductive system
                                         O.R. procedures w/o
                                         CC/MMCC.
754...............  754...............  Malignancy, female             22       1.2617         31.5         26.3
                                         reproductive system
                                         w MMCC.
755...............  754...............  Malignancy, female             21       0.8596         25.2         21.0
                                         reproductive system
                                         w MCC.
756...............  754...............  Malignancy, female              1       0.4824         19.6         16.3
                                         reproductive system
                                         w/o CC/MMCC.
757...............  757...............  Infections, female             52       0.7580         23.7         19.8
                                         reproductive system
                                         w MCC*.
758...............  757...............  Infections, female             27       0.7580         23.7         19.8
                                         reproductive system
                                         w CC*.
759...............  757...............  Infections, female              5       0.7580         23.7         19.8
                                         reproductive system
                                         w/o CC/MCC*.
760...............  760...............  Menstrual & other               0       0.8596         25.2         21.0
                                         female reproductive
                                         system disorders w
                                         CC/MMCC.
761...............  760...............  Menstrual & other               0       0.8596         25.2         21.0
                                         female reproductive
                                         system disorders w/
                                         o CC/MMCC.
765...............  765...............  Cesarean section w              0       0.8596         25.2         21.0
                                         CC/MMCC.
766...............  765...............  Cesarean section w/o            0       0.8596         25.2         21.0
                                         CC/MMCC.
767...............  767...............  Vaginal delivery w              0       0.8596         25.2         21.0
                                         sterilization &/or
                                         D&C.
768...............  768...............  Vaginal delivery w              0       0.8596         25.2         21.0
                                         O.R. proc except
                                         steril &/or D&C.
769...............  769...............  Postpartum & post               0       0.8596         25.2         21.0
                                         abortion diagnoses
                                         w O.R. procedure.
770...............  770...............  Abortion w D&C,                 0       0.8596         25.2         21.0
                                         aspiration
                                         curettage or
                                         hysterotomy.
774...............  774...............  Vaginal delivery w              0       0.8596         25.2         21.0
                                         complicating
                                         diagnoses.
775...............  775...............  Vaginal delivery w/o            0       0.8596         25.2         21.0
                                         complicating
                                         diagnoses.
776...............  776...............  Postpartum & post               0       0.8596         25.2         21.0
                                         abortion diagnoses
                                         w/o O.R. procedure.
777...............  777...............  Ectopic pregnancy...            0       0.8596         25.2         21.0
778...............  778...............  Threatened abortion.            0       0.7580         23.7         19.8
779...............  779...............  Abortion w/o D&C....            0       0.7580         23.7         19.8
780...............  780...............  False labor.........            0       0.7580         23.7         19.8
781...............  781...............  Other antepartum                1       0.4824         19.6         16.3
                                         diagnoses w medical
                                         complications.
782...............  782...............  Other antepartum                0       0.4824         19.6         16.3
                                         diagnoses w/o
                                         medical
                                         complications.
789...............  789...............  Neonates, died or               0       0.4824         19.6         16.3
                                         transferred to
                                         another acute care
                                         facility.
790...............  790...............  Extreme immaturity              0       0.4824         19.6         16.3
                                         or respiratory
                                         distress syndrome,
                                         neonate.
791...............  791...............  Prematurity w major             0       0.4824         19.6         16.3
                                         problems.
792...............  792...............  Prematurity w/o                 0       0.4824         19.6         16.3
                                         major problems.
793...............  793...............  Full term neonate w             0       0.4824         19.6         16.3
                                         major problems.
794...............  794...............  Neonate w other                 0       0.4824         19.6         16.3
                                         significant
                                         problems.
795...............  795...............  Normal newborn......            0       0.4824         19.6         16.3
799...............  799...............  Splenectomy w MCC...            0       0.8596         25.2         21.0
800...............  799...............  Splenectomy w CC....            1       0.8596         25.2         21.0
801...............  799...............  Splenectomy w/o CC/             0       0.8596         25.2         21.0
                                         MMCC.
802...............  802...............  Other O.R. proc of              4       1.2617         31.5         26.3
                                         the blood & blood
                                         forming organs w
                                         MMCC.
803...............  802...............  Other O.R. proc of              0       1.2617         31.5         26.3
                                         the blood & blood
                                         forming organs w
                                         MCC.
804...............  802...............  Other O.R. proc of              0       1.2617         31.5         26.3
                                         the blood & blood
                                         forming organs w/o
                                         CC/MMCC.
808...............  808...............  Major hematol/immun            17       1.2617         31.5         26.3
                                         diag exc sickle
                                         cell crisis &
                                         coagul w MMCC.
809...............  808...............  Major hematol/immun            11       0.8596         25.2         21.0
                                         diag exc sickle
                                         cell crisis &
                                         coagul w MCC.
810...............  808...............  Major hematol/immun             1       0.4824         19.6         16.3
                                         diag exc sickle
                                         cell crisis &
                                         coagul w/o CC/MMCC.
811...............  811...............  Red blood cell                 43       0.7905         22.8         19.0
                                         disorders w MMCC.
812...............  811...............  Red blood cell                 58       0.5349         20.4         17.0
                                         disorders w/o MMCC.

[[Page 23903]]

 
813...............  813...............  Coagulation                    55       0.8402         23.2         19.3
                                         disorders.
814...............  814...............  Reticuloendothelial            16       0.8596         25.2         21.0
                                         & immunity
                                         disorders w MMCC.
815...............  814...............  Reticuloendothelial             7       0.6327         21.6         18.0
                                         & immunity
                                         disorders w MCC.
816...............  814...............  Reticuloendothelial             1       0.4824         19.6         16.3
                                         & immunity
                                         disorders w/o CC/
                                         MMCC.
820...............  820...............  Lymphoma & leukemia             0       1.2617         31.5         26.3
                                         w major O.R.
                                         procedure w MMCC.
821...............  820...............  Lymphoma & leukemia             0       0.8596         25.2         21.0
                                         w major O.R.
                                         procedure w MCC.
822...............  820...............  Lymphoma & leukemia             0       0.8596         25.2         21.0
                                         w major O.R.
                                         procedure w/o CC/
                                         MMCC.
823...............  823...............  Lymphoma & non-acute           11       1.2617         31.5         26.3
                                         leukemia w other
                                         O.R. proc w MMCC.
824...............  823...............  Lymphoma & non-acute            4       0.8596         25.2         21.0
                                         leukemia w other
                                         O.R. proc w MCC.
825...............  823...............  Lymphoma & non-acute            0       0.8596         25.2         21.0
                                         leukemia w other
                                         O.R. proc w/o CC/
                                         MMCC.
826...............  826...............  Myeloprolif disord              1       1.7509         37.9         31.6
                                         or poorly diff
                                         neopl w maj O.R.
                                         proc w MMCC.
827...............  826...............  Myeloprolif disord              1       1.7509         37.9         31.6
                                         or poorly diff
                                         neopl w maj O.R.
                                         proc w MCC.
828...............  826...............  Myeloprolif disord              0       1.7509         37.9         31.6
                                         or poorly diff
                                         neopl w maj O.R.
                                         proc w/o CC/MMCC.
829...............  829...............  Myeloprolif disord              7       1.7509         37.9         31.6
                                         or poorly diff
                                         neopl w other O.R.
                                         proc w CC/MMCC.
830...............  829...............  Myeloprolif disord              0       1.7509         37.9         31.6
                                         or poorly diff
                                         neopl w other O.R.
                                         proc w/o CC/MMCC.
834...............  834...............  Acute leukemia w/o             14       0.8596         25.2         21.0
                                         major O.R.
                                         procedure w MMCC.
835...............  834...............  Acute leukemia w/o             14       0.8596         25.2         21.0
                                         major O.R.
                                         procedure w CC*.
836...............  834...............  Acute leukemia w/o              2       0.8596         25.2         21.0
                                         major O.R.
                                         procedure w/o CC/
                                         MCC*.
837...............  837...............  Chemo w acute                   0       1.7509         37.9         31.6
                                         leukemia as sdx or
                                         w high dose chemo
                                         agent w MMCC.
838...............  837...............  Chemo w acute                   0       1.7509         37.9         31.6
                                         leukemia as sdx or
                                         w high dose chemo
                                         agent w MCC.
839...............  837...............  Chemo w acute                   0       1.7509         37.9         31.6
                                         leukemia as sdx or
                                         w high dose chemo
                                         agent w/o CC/MMCC.
840...............  840...............  Lymphoma & non-acute          133       0.9227         23.1         19.3
                                         leukemia w MMCC.
841...............  840...............  Lymphoma & non-acute           63       0.7247         19.7         16.4
                                         leukemia w MCC.
842...............  840...............  Lymphoma & non-acute            7       0.6327         21.6         18.0
                                         leukemia w/o CC/
                                         MMCC.
843...............  843...............  Other myeloprolif              20       0.8596         25.2         21.0
                                         dis or poorly diff
                                         neopl diag w MMCC.
844...............  843...............  Other myeloprolif              11       0.6327         21.6         18.0
                                         dis or poorly diff
                                         neopl diag w MCC.
845...............  843...............  Other myeloprolif               3       0.6327         21.6         18.0
                                         dis or poorly diff
                                         neopl diag w/o CC/
                                         MMCC.
846...............  846...............  Chemotherapy w/o               49       1.4778         30.0         25.0
                                         acute leukemia as
                                         secondary diagnosis
                                         w MMCC.
847...............  846...............  Chemotherapy w/o               43       1.0877         23.8         19.8
                                         acute leukemia as
                                         secondary diagnosis
                                         w MCC.
848...............  846...............  Chemotherapy w/o                0       1.0877         23.8         19.8
                                         acute leukemia as
                                         secondary diagnosis
                                         w/o CC/MMCC.
849...............  849...............  Radiotherapy........          141       0.7949         21.6         18.0
853...............  853...............  Infectious &                  837       1.7864         37.3         31.1
                                         parasitic diseases
                                         w O.R. procedure w
                                         MMCC.
854...............  853...............  Infectious &                  104       1.1703         33.0         27.5
                                         parasitic diseases
                                         w O.R. procedure w
                                         MCC.
855...............  853...............  Infectious &                    5       1.1703         33.0         27.5
                                         parasitic diseases
                                         w O.R. procedure w/
                                         o CC/MCC*.
856...............  856...............  Postoperative or              301       1.5591         36.7         30.6
                                         post-traumatic
                                         infections w O.R.
                                         proc w MMCC.
857...............  856...............  Postoperative or              213       1.0707         32.6         27.2
                                         post-traumatic
                                         infections w O.R.
                                         proc w MCC.
858...............  856...............  Postoperative or               32       0.8943         26.8         22.3
                                         post-traumatic
                                         infections w O.R.
                                         proc w/o CC/MMCC.
862...............  862...............  Postoperative & post-       1,163       0.9629         25.3         21.1
                                         traumatic
                                         infections w MMCC.
863...............  862...............  Postoperative & post-       1,231       0.7018         23.8         19.8
                                         traumatic
                                         infections w/o MMCC.
864...............  864...............  Fever of unknown               11       0.4824         19.6         16.3
                                         origin.
865...............  865...............  Viral illness w MMCC           36       0.7998         22.2         18.5
866...............  865...............  Viral illness w/o              14       0.6327         21.6         18.0
                                         MMCC.
867...............  867...............  Other infectious &            357       1.1296         23.4         19.5
                                         parasitic diseases
                                         diagnoses w MMCC.
868...............  867...............  Other infectious &             86       0.7458         22.6         18.8
                                         parasitic diseases
                                         diagnoses w MCC.
869...............  867...............  Other infectious &              7       0.4824         19.6         16.3
                                         parasitic diseases
                                         diagnoses w/o CC/
                                         MMCC.

[[Page 23904]]

 
870...............  870...............  Septicemia w MV 96+           894       2.2127         33.0         27.5
                                         hours.
871...............  871...............  Septicemia w/o MV           4,507       0.8713         23.4         19.5
                                         96+ hours w MMCC.
872...............  871...............  Septicemia w/o MV           1,608       0.6584         21.8         18.2
                                         96+ hours w/o MMCC.
876...............  876...............  O.R. procedure w               12       0.6327         21.6         18.0
                                         principal diagnoses
                                         of mental illness.
880...............  880...............  Acute adjustment               11       0.4824         19.6         16.3
                                         reaction &
                                         psychosocial
                                         dysfunction.
881...............  881...............  Depressive neuroses.           14       0.6327         21.6         18.0
882...............  882...............  Neuroses except                16       0.4824         19.6         16.3
                                         depressive.
883...............  883...............  Disorders of                   12       0.8596         25.2         21.0
                                         personality &
                                         impulse control.
884...............  884...............  Organic disturbances          146       0.5159         25.4         21.2
                                         & mental
                                         retardation.
885...............  885...............  Psychoses...........        1,218       0.4206         23.9         19.9
886...............  886...............  Behavioral &                   18       0.4824         19.6         16.3
                                         developmental
                                         disorders.
887...............  887...............  Other mental                    0       0.6327         21.6         18.0
                                         disorder diagnoses.
894...............  894...............  Alcohol/drug abuse              0       0.6327         21.6         18.0
                                         or dependence, left
                                         ama.
895...............  895...............  Alcohol/drug abuse              2       0.4824         19.6         16.3
                                         or dependence w
                                         rehabilitation
                                         therapy.
896...............  896...............  Alcohol/drug abuse              7       1.2617         31.5         26.3
                                         or dependence w/o
                                         rehabilitation
                                         therapy w MMCC.
897...............  896...............  Alcohol/drug abuse             17       0.4824         19.6         16.3
                                         or dependence w/o
                                         rehabilitation
                                         therapy w/o MMCC.
901...............  901...............  Wound debridements            217       1.5251         35.9         29.9
                                         for injuries w MMCC.
902...............  901...............  Wound debridements            129       1.0552         30.1         25.1
                                         for injuries w MCC.
903...............  901...............  Wound debridements             23       0.8596         25.2         21.0
                                         for injuries w/o CC/
                                         MMCC.
904...............  904...............  Skin grafts for                78       1.3404         35.6         29.7
                                         injuries w CC/MMCC.
905...............  904...............  Skin grafts for                 6       0.8596         25.2         21.0
                                         injuries w/o CC/
                                         MMCC.
906...............  906...............  Hand procedures for             1       1.7509         37.9         31.6
                                         injuries.
907...............  907...............  Other O.R.                     91       1.6273         37.5         31.3
                                         procedures for
                                         injuries w MMCC.
908...............  907...............  Other O.R.                     63       1.1167         34.0         28.3
                                         procedures for
                                         injuries w MCC.
909...............  907...............  Other O.R.                      6       1.1167         34.0         28.3
                                         procedures for
                                         injuries w/o CC/
                                         MCC*.
913...............  913...............  Traumatic injury w             37       0.7480         24.8         20.7
                                         MMCC.
914...............  913...............  Traumatic injury w/o           66       0.6073         21.8         18.2
                                         MMCC.
915...............  915...............  Allergic reactions w            0       0.4824         19.6         16.3
                                         MMCC.
916...............  915...............  Allergic reactions w/           0       0.4824         19.6         16.3
                                         o MMCC.
917...............  917...............  Poisoning & toxic               8       0.4824         19.6         16.3
                                         effects of drugs w
                                         MMCC.
918...............  917...............  Poisoning & toxic               9       0.4824         19.6         16.3
                                         effects of drugs w/
                                         o MMCC.
919...............  919...............  Complications of            1,235       1.0924         26.9         22.4
                                         treatment w MMCC.
920...............  919...............  Complications of              841       0.8582         26.0         21.7
                                         treatment w MCC.
921...............  919...............  Complications of              117       0.6163         20.1         16.8
                                         treatment w/o CC/
                                         MMCC.
922...............  922...............  Other injury,                   7       0.8596         25.2         21.0
                                         poisoning & toxic
                                         effect diag w MMCC.
923...............  922...............  Other injury,                  11       0.6327         21.6         18.0
                                         poisoning & toxic
                                         effect diag w/o
                                         MMCC.
927...............  927...............  Extensive burns or              1       1.7509         37.9         31.6
                                         full thickness
                                         burns w MV 96+ hrs
                                         w skin graft.
928...............  928...............  Full thickness burn             9       1.2617         31.5         26.3
                                         w skin graft or
                                         inhal inj w CC/MMCC.
929...............  928...............  Full thickness burn             2       0.6327         21.6         18.0
                                         w skin graft or
                                         inhal inj w/o CC/
                                         MMCC.
933...............  933...............  Extensive burns or             10       1.2617         31.5         26.3
                                         full thickness
                                         burns w MV 96+ hrs
                                         w/o skin graft.
934...............  934...............  Full thickness burn            40       0.7755         24.2         20.2
                                         w/o skin grft or
                                         inhal inj.
935...............  935...............  Non-extensive burns.           46       0.7815         24.5         20.4
939...............  939...............  O.R. proc w                   267       1.3463         34.1         28.4
                                         diagnoses of other
                                         contact w health
                                         services w MCC.
940...............  939...............  O.R. proc w                   135       0.9993         30.6         25.5
                                         diagnoses of other
                                         contact w health
                                         services w MCC.
941...............  939...............  O.R. proc w                    15       0.8596         25.2         21.0
                                         diagnoses of other
                                         contact w health
                                         services w/o CC/
                                         MMCC.
945...............  945...............  Rehabilitation w CC/        2,220       0.6154         22.1         18.4
                                         MMCC.
946...............  945...............  Rehabilitation w/o            428       0.4311         18.9         15.8
                                         CC/MMCC.
947...............  947...............  Signs & symptoms w             57       0.6548         22.2         18.5
                                         MMCC.
948...............  947...............  Signs & symptoms w/o           69       0.5737         22.2         18.5
                                         MMCC.
949...............  949...............  Aftercare w CC/MMCC.        3,802       0.7034         22.5         18.8
950...............  949...............  Aftercare w/o CC/             546       0.5002         19.2         16.0
                                         MMCC.
951...............  951...............  Other factors                  28       1.2726         27.0         22.5
                                         influencing health
                                         status.
955...............  955...............  Craniotomy for                  0       1.7509         37.9         31.6
                                         multiple
                                         significant trauma.
956...............  956...............  Limb reattachment,              0       0.8596         25.2         21.0
                                         hip & femur proc
                                         for multiple
                                         significant trauma.
957...............  957...............  Other O.R.                      1       1.2617         31.5         26.3
                                         procedures for
                                         multiple
                                         significant trauma
                                         w MMCC.
958...............  957...............  Other O.R.                      1       0.4824         19.6         16.3
                                         procedures for
                                         multiple
                                         significant trauma
                                         w MCC.

[[Page 23905]]

 
959...............  957...............  Other O.R.                      0       0.4824         19.6         16.3
                                         procedures for
                                         multiple
                                         significant trauma
                                         w/o CC/MMCC.
963...............  963...............  Other multiple                 15       0.8596         25.2         21.0
                                         significant trauma
                                         w MMCC.
964...............  963...............  Other multiple                  5       0.6327         21.6         18.0
                                         significant trauma
                                         w MCC.
965...............  963...............  Other multiple                  3       0.4824         19.6         16.3
                                         significant trauma
                                         w/o CC/MMCC.
969...............  969...............  HIV w extensive O.R.           13       1.2617         31.5         26.3
                                         procedure w MMCC.
970...............  969...............  HIV w extensive O.R.            3       1.2617         31.5         26.3
                                         procedure w/o MCC*.
974...............  974...............  HIV w major related           196       1.0056         21.9         18.3
                                         condition w MMCC.
975...............  974...............  HIV w major related            85       0.6433         18.3         15.3
                                         condition w MCC.
976...............  974...............  HIV w major related            16       0.6327         21.6         18.0
                                         condition w/o CC/
                                         MMCC.
977...............  977...............  HIV w or w/o other             45       0.6975         19.0         15.8
                                         related condition.
981...............  981...............  Extensive O.R.              1,143       2.3516         43.1         35.9
                                         procedure unrelated
                                         to principal
                                         diagnosis w MMCC.
982...............  981...............  Extensive O.R.                290       1.4645         35.2         29.3
                                         procedure unrelated
                                         to principal
                                         diagnosis w MCC.
983...............  981...............  Extensive O.R.                 26       1.1662         31.9         26.6
                                         procedure unrelated
                                         to principal
                                         diagnosis w/o CC/
                                         MMCC.
984...............  984...............  Prostatic O.R.                 16       1.2617         31.5         26.3
                                         procedure unrelated
                                         to principal
                                         diagnosis w MMCC.
985...............  984...............  Prostatic O.R.                  9       1.2617         31.5         26.3
                                         procedure unrelated
                                         to principal
                                         diagnosis w MCC.
986...............  984...............  Prostatic O.R.                  0       1.2617         31.5         26.3
                                         procedure unrelated
                                         to principal
                                         diagnosis w/o CC/
                                         MMCC.
987...............  987...............  Non-extensive O.R.            419       1.7561         36.4         30.3
                                         proc unrelated to
                                         principal diagnosis
                                         w MMCC.
988...............  987...............  Non-extensive O.R.            218       1.1596         33.9         28.3
                                         proc unrelated to
                                         principal diagnosis
                                         w MCC.
989...............  987...............  Non-extensive O.R.             10       0.8596         25.2         21.0
                                         proc unrelated to
                                         principal diagnosis
                                         w/o CC/MMCC.
998...............  998...............  Ungroupable.........            0       0.0000          0.0          0.0
999...............  999...............  Principal diagnosis             0       0.0000          0.0         0.0
                                         invalid as
                                         discharge diagnosis.
----------------------------------------------------------------------------------------------------------------
\1\ The proposed SSO Threshold is calculated as \5/6\th of the geometric average length of stay of the proposed
  MS-LTC-DRG (as specified at Sec.  412.529 in conjunction with Sec.  412.503).
* In determining the proposed MS-LTC-DRG relative weights, these proposed MS-LTC-DRGs were adjusted for
  nonmonotonicity as discussed in section II.I.4. (step 6) of the preamble of this proposed rule.

Appendix A--Regulatory Impact Analysis

I. Overall Impact

    We have examined the impacts of this proposed rule as required 
by Executive Order 12866 (September 1993, Regulatory Planning and 
Review) and the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), Executive 
Order 13132 on Federalism, and the Congressional Review Act (5 
U.S.C. 804(2)).
    Executive Order 12866 (as amended by Executive Order 13258) 
directs agencies to assess all costs and benefits of available 
regulatory alternatives and, if regulation is necessary, to select 
regulatory approaches that maximize net benefits (including 
potential economic, environmental, public health and safety effects, 
distributive impacts, and equity). A regulatory impact analysis 
(RIA) must be prepared for major rules with economically significant 
effects ($100 million or more in any 1 year).
    We have determined that this proposed rule is a major rule as 
defined in 5 U.S.C. 804(2). We estimate that the proposed changes 
for FY 2009 operating and capital payments would redistribute in 
excess of $100 million among different types of inpatient cases. The 
market basket update to the IPPS rates required by the statute, in 
conjunction with other payment changes in this proposed rule, would 
result in an approximate $4 billion increase in FY 2009 operating 
and capital payments. Our impact estimate includes the -0.9 percent 
adjustment for documentation and coding changes to the IPPS 
standardized amounts and capital Federal rates for FY 2009 in 
accordance with section 7 of Pub. L. 110-90. For purposes of the 
impact analysis, we also assume an additional 1.8 percent increase 
in case-mix between FY 2008 and FY 2009 because we believe the 
adoption of the MS-DRGs will result in case-mix growth due to 
documentation and coding changes that do not reflect real changes in 
patient severity of illness. The estimates of IPPS operating 
payments 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 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 
$31.5 million or less in any 1 year). (For details on the latest 
standards for heath care providers, we refer readers to page 33 of 
the Table of Small Business Size Standards at the Small Business 
Administration Web site at: http://www.sba.gov/services/contractingopportunities/sizestandardstopics/tableofsize/index.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 this proposed rule would have a significant 
impact on small entities as explained in this Appendix. Because we 
acknowledge that many of the affected entities are small entities, 
the analysis discussed throughout the preamble of this proposed rule 
constitutes our initial regulatory flexibility analysis. Therefore, 
we are soliciting comments on our estimates and analysis of the 
impact of the proposed rule on those small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact

[[Page 23906]]

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, we continue to 
classify these hospitals as urban hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 
104-4) also requires that agencies assess anticipated costs and 
benefits before issuing any rule whose mandates require spending in 
any 1 year of $100 million in 1995 dollars, updated annually for 
inflation. That threshold level is currently approximately $130 
million. This proposed rule will not mandate any requirements for 
State, local, or tribal governments, nor will it affect private 
sector costs.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on 
State and local governments, preempts State law, or otherwise has 
Federalism implications. As stated above, this proposed rule would 
not have a substantial effect on State and local governments.
    The following analysis, in conjunction with the remainder of 
this document, demonstrates that this 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

    The primary objective of the IPPS is to create incentives for 
hospitals to operate efficiently and minimize unnecessary costs 
while at the same time ensuring that payments are sufficient to 
adequately compensate hospitals for their legitimate costs. In 
addition, we share national goals of preserving the Medicare 
Hospital Insurance Trust Fund.
    We believe the proposed changes in this proposed rule would 
further each of these goals while maintaining the financial 
viability of the hospital industry and ensuring access to high 
quality health care for Medicare beneficiaries. We expect that these 
proposed changes would ensure that the outcomes of this payment 
system are reasonable and equitable while avoiding or minimizing 
unintended adverse consequences.

III. Limitations of Our Analysis

    The following quantitative analysis presents the projected 
effects of our proposed policy changes, as well as statutory changes 
effective for FY 2009, on various hospital groups. We estimate the 
effects of individual proposed policy changes by estimating payments 
per case while holding all other payment policies constant. We use 
the best data available, but, generally, we do not attempt to make 
adjustments for future changes in such variables as admissions, 
lengths of stay, or case-mix. However, in the FY 2008 IPPS final 
rule, 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 Public 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. Following 
enactment of Pub. L. 110-90, we revised the FY 2008 standardized 
amounts (as well as other affected payment factors and thresholds) 
to reflect the -0.6 percent FY 2008 documentation and coding 
adjustment. The proposed FY 2009 IPPS national standardized amount 
included in this proposed rule reflects the documentation and coding 
adjustment of -0.9 percent for FY 2009. While we have adopted the 
statutorily mandated documentation and coding adjustments for 
payment purposes, we continue to believe that an increase in case-
mix of 1.8 percent between FY 2008 and FY 2009 is likely as a result 
of the adoption of the MS DRGs. The impacts shown below illustrate 
the impact of the FY 2009 IPPS changes on hospital operating 
payments, including the -0.9 percent FY 2009 documentation and 
coding adjustment to the IPPS national standardized amounts, both 
prior to and following the expected 1.8 percent growth in case-mix 
between FY 2008 and FY 2009. As we have done in the previous rules, 
we are soliciting comments and information about the anticipated 
effects of the proposed changes on hospitals and our methodology for 
estimating them.

IV. Hospitals Included in and Excluded From the IPPS

    The prospective payment systems for hospital inpatient operating 
and capital-related costs encompass most general short-term, acute 
care hospitals that participate in the Medicare program. There were 
35 Indian Health Service hospitals in our database, which we 
excluded from the analysis due to the special characteristics of the 
prospective payment methodology for these hospitals. Among other 
short-term, acute care hospitals, only the 46 such hospitals in 
Maryland remain excluded from the IPPS under the waiver at section 
1814(b)(3) of the Act.
    As of March 2008, there are 3,528 IPPS hospitals to be included 
in our analysis. This represents about 58 percent of all Medicare-
participating hospitals. The majority of this impact analysis 
focuses on this set of hospitals. There are also approximately 1,311 
CAHs. These small, limited service hospitals are paid on the basis 
of reasonable costs rather than under the IPPS. There are also 1,219 
specialty hospitals and 2,291 specialty units that are excluded from 
the IPPS. These specialty hospitals include IPFs, IRFs, LTCHs, 
RNHCIs, children's hospitals, and cancer hospitals. Changes in 
payments for IPFs and IRFs are made through other separate 
rulemaking. Payment impacts for these specialty hospitals and units 
are not included in this proposed rule. There is also a separate 
rule to update and make changes to the LTCH PPS for its current July 
1 through June 30 rate year (RY). However, we have traditionally 
used the IPPS rule to update the LTCH patient classifications and 
relative weights because the LTCH PPS uses the same DRGs as the 
IPPS, resulting in the LTCH relative weights being reclassified and 
recalibrated according to the same schedule as the IPPS (that is, 
for each Federal fiscal year). The impacts of our policy changes on 
LTCHs, where applicable, are discussed below. (We note that, as 
discussed in section II.I. of the preamble of this proposed rule, in 
the RY 2009 LTCH PPS proposed rule 73 FR 5351 through 5352), we 
proposed to move the annual LTCH PPS RY update (currently effective 
July 1) to be effective October 1 through September 30 (the Federal 
fiscal year) each year beginning October 1, 2009. Under this 
proposal, RY 2009 would be extended 3 months, such that RY 2009 
would be the 15-month period of July 1, 2008 through September 30, 
2009.)

V. Effects on Excluded Hospitals and Hospital Units

    As of March 2008, there were 1,219 hospitals excluded from the 
IPPS. Of these 1,219 hospitals, 314 IPFs, 78 children's hospitals, 
11 cancer hospitals, and 19 RNHCIs are either being paid on a 
reasonable cost basis or have a portion of the PPS payment based on 
reasonable cost principles subject to the rate-of-increase ceiling 
under Sec.  413.40. The remaining providers, 221 IRFs, 394 LTCHs, 
and 182 IPFs, are paid 100 percent of the Federal prospective rate 
under the IRF PPS and the LTCH PPS, respectively, or 100 percent of 
the Federal per diem amount under the IPF PPS. As stated above, IRFs 
and IPFs are not affected by this proposed rule. The impacts of the 
changes to LTCHs are discussed separately below. In addition, there 
are 1,319 IPFs co-located in hospitals otherwise subject to the 
IPPS, 788 of which are paid on a blend of the IPF PPS per diem 
payment and the reasonable cost-based payment. The remaining 531 IPF 
units are paid 100 percent of the Federal amount under the IPF PPS. 
There are 972 IRFs (paid under the IRF PPS) co-located in hospitals 
otherwise subject to the IPPS.
    In the past, hospitals and units excluded from the IPPS have 
been paid based on their reasonable costs subject to limits as 
established by the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA). Hospitals that continue to be paid fully on a reasonable 
cost basis are subject to TEFRA limits for FY 2009. For these 
hospitals

[[Page 23907]]

(cancer and children's hospitals), consistent with section 
1886(b)(3)(B)(ii) of the Act, we are proposing an update that is the 
percentage increase in the FY 2009 IPPS operating market basket, 
which is estimated to be 3.0 percent, based on Global Insights, 
Inc.'s 2008 first quarter forecast of the IPPS operating market 
basket increase. In addition, in accordance with Sec.  403.752(a) of 
the regulations, RNHCIs are paid under Sec.  413.40, which also uses 
section 1886(b)(3)(B)(ii) of the Act to update target amounts by the 
rate-of-increase percentage. For RNHCIs, the proposed update is the 
percentage increase in the FY 2009 IPPS operating market basket 
increase, which is estimated to be 3.0 percent, based on Global 
Insight, Inc.'s 2008 first quarter forecast of the IPPS operating 
market basket increase.
    The final rule implementing the IPF PPS (69 FR 66922) 
established a 3-year transition to the IPF PPS during which some 
providers received a blend of the IPF PPS per diem payment and the 
TEFRA reasonable cost-based payment. This transitional period for a 
blended payment amount for IPFs ended for cost reporting periods 
that began on or after January 1, 2008. Because the reasonable cost-
based amount is zero percent for cost reporting periods beginning 
during CY 2008, no IPF will have a portion of its PPS payment that 
is based in part on reasonable cost subject to the rate-of-increase 
ceiling during FY 2009. Thus, there is no longer a need for an 
update factor for IPFs' TEFRA target amount for FY 2009 and 
thereafter.
    The impact on excluded hospitals and hospital units of the 
proposed update in the rate-of-increase limit depends on the 
cumulative cost increases experienced by each excluded hospital or 
unit since its applicable base period. For excluded hospitals and 
units that have maintained their cost increases at a level below the 
rate-of-increase limits since their base period, the major effect is 
on the level of incentive payments these hospitals and hospital 
units receive. Conversely, for excluded hospitals and hospital units 
with per-case cost increases above the cumulative update in their 
rate-of-increase limits, the major effect is the amount of excess 
costs that will not be reimbursed.
    We note that, under Sec.  413.40(d)(3), an excluded hospital or 
unit whose costs exceed 110 percent of its rate-of-increase limit 
receives its rate-of-increase limit plus 50 percent of the 
difference between its reasonable costs and 110 percent of the 
limit, not to exceed 110 percent of its limit. In addition, under 
the various provisions set forth in Sec.  413.40, certain excluded 
hospitals and hospital units can obtain payment adjustments for 
justifiable increases in operating costs that exceed the limit.

VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS 
for Operating Costs

A. Basis and Methodology of Estimates

    In this proposed rule, we are announcing proposed policy changes 
and payment rate updates for the IPPS for operating costs. Changes 
to the capital payments are discussed in section VIII. of this 
Appendix.
    Based on the overall percentage change in payments per case 
estimated using our payment simulation model, we estimate that total 
FY 2009 operating payments will increase 4.1 percent compared to FY 
2008, largely due to the statutorily mandated update to the IPPS 
rates. This amount also reflects the -0.9 percent FY 2009 
documentation and coding adjustment to the IPPS national 
standardized amounts and our assumption of an additional 1.8 percent 
increase in case-mix between FY 2008 and FY 2009 as a result of 
improvements in documentation and coding that do not represent real 
increases in underlying resource demands and patient acuity due to 
the adoption of the MS-DRGs. 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 changes to each 
system. This section deals with changes to the operating prospective 
payment system. Our payment simulation model relies on the most 
recent available data to enable us to estimate the impacts on 
payments per case of certain changes in this proposed rule. However, 
there are other changes for which we do not have data available that 
would allow us to estimate the payment impacts using this model. For 
those changes, we have attempted to predict the payment impacts 
based upon our experience and other more limited data.
    The data used in developing the quantitative analyses of changes 
in payments per case presented below are taken from the FY 2007 
MedPAR file and the most current Provider-Specific File that is used 
for payment purposes. Although the analyses of the changes to the 
operating PPS do not incorporate cost data, data from the most 
recently available hospital cost report were used to categorize 
hospitals. Our analysis has several qualifications. First, in this 
analysis, we do not make adjustments for future changes in such 
variables as admissions, lengths of stay, or underlying growth in 
real case-mix. Second, due to the interdependent nature of the IPPS 
payment components, it is very difficult to precisely quantify the 
impact associated with each 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 2007 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 FY 2009 changes to the capital IPPS are 
discussed in section VIII. of this Appendix.
    The changes discussed separately below are the following:
    <bullet> The effects of the annual reclassification of diagnoses 
and procedures, full implementation of the MS-DRG system and 100 
percent cost-based DRG relative weights,
    <bullet> The effects of the changes in hospitals' wage index 
values reflecting wage data from hospitals' cost reporting periods 
beginning during FY 2005, compared to the FY 2004 wage data.
    <bullet> The effects of the recalibration of the DRG relative 
weights as required by section 1886(d)(4)(C) of the Act, including 
the wage and recalibration budget neutrality factors.
    <bullet> The effects of geographic reclassifications by the 
MGCRB that will be effective in FY 2009.
    <bullet> The effects of the proposal to apply the rural floor 
budget neutrality adjustment at the State level, redistributing 
payments within the State, rather than adjusting payments to 
hospitals in other States.
    <bullet> The effects of the proposal to apply the imputed rural 
floor budget neutrality adjustment to the wage index at the State-
level, rather than applying it to the standardized amount at the 
national level.
    <bullet> 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.
    <bullet> The effect of the budget neutrality adjustment being 
made for the adoption of the MS-DRGs under section 1886(d)(3)(A)(iv) 
of the Act for the change in aggregate payments that is a result of 
changes in the coding or classification of discharges that do not 
reflect real changes in case-mix.
    <bullet> The total estimated change in payments based on the 
proposed FY 2009 policies relative to payments based on FY 2008 
policies.
    To illustrate the impacts of the proposed FY 2009 changes, our 
analysis begins with a FY 2008 baseline simulation model using: the 
proposed FY 2009 update of 3.0 percent; the FY 2008 DRG GROUPER 
(Version 25.0); the most current CBSA designations for hospitals 
based on OMB's MSA definitions; the FY 2008 wage index; and no MGCRB 
reclassifications. Outlier payments are set at 5.1 percent of total 
operating DRG and outlier payments.
    Section 1886(b)(3)(B)(viii) of the Act, as added by section 
5001(a) of Pub. L. 109-171, provides that for FY 2007 and subsequent 
years, the update factor will be reduced by 2.0 percentage points 
for any hospital that does not submit quality data in a form and 
manner and at a time specified by the Secretary. At the time this 
impact was prepared, 186 providers did not receive the full market 
basket rate-of-increase for FY 2008 because they failed the quality 
data submission process. For purposes of the simulations shown 
below, we modeled the proposed payment changes for FY 2009 using a 
reduced update for these 186 hospitals. However, we do not have 
enough information to determine which hospitals will not receive the 
full market basket rate-of-increase for FY 2009 at this time.
    Each policy change, statutorily or otherwise, is then added 
incrementally to

[[Page 23908]]

this baseline, finally arriving at an FY 2009 model incorporating 
all of the proposed changes. This simulation allows us to isolate 
the effects of each proposed change.
    Our final comparison illustrates the proposed percent change in 
payments per case from FY 2008 to FY 2009. Three factors not 
discussed separately have significant impacts here. The first is the 
update to the standardized amount. In accordance with section 
1886(b)(3)(B)(i) of the Act, we are updating the standardized 
amounts for FY 2009 using the most recently forecasted hospital 
market basket increase for FY 2009 of 3.0 percent. (Hospitals that 
fail to comply with the quality data submission requirements to 
receive the full update will receive an update reduced by 2.0 
percentage points to 1.0 percent.) Under section 1886(b)(3)(B)(iv) 
of the Act, the updates to the hospital-specific amounts for SCHs 
and for MDHs are also equal to the market basket increase, or 3.0 
percent.
    A second significant factor that affects the proposed changes in 
hospitals' payments per case from FY 2008 to FY 2009 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 2008 that are no longer reclassified in FY 2009. 
Conversely, payments may increase for hospitals not reclassified in 
FY 2008 that are reclassified in FY 2009. Particularly with the 
expiration of section 508 of Pub. L. 108-173, the reclassification 
provision, these impacts can be quite substantial, so if a 
relatively small number of hospitals in a particular category lose 
their reclassification status, the percentage change in payments for 
the category may be below the national mean.
    A third significant factor is that we currently estimate that 
actual outlier payments during FY 2008 will be 4.8 percent of total 
DRG payments. When the FY 2008 final rule was published, we 
projected FY 2008 outlier payments would be 5.1 percent of total DRG 
plus outlier payments; the average standardized amounts were offset 
correspondingly. The effects of the lower than expected outlier 
payments during FY 2009 (as discussed in the Addendum to this 
proposed rule) are reflected in the analyses below comparing our 
current estimates of FY 2008 payments per case to estimated FY 2009 
payments per case (with outlier payments projected to equal 5.1 
percent of total DRG payments).

B. Analysis of Table I

    Table I displays the results of our analysis of the proposed 
changes for FY 2009. 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 3,528 hospitals included 
in the analysis.
    The next four rows of Table I contain hospitals categorized 
according to their geographic location: all urban, which is further 
divided into large urban and other urban; and rural. There are 2,542 
hospitals located in urban areas included in our analysis. Among 
these, there are 1,402 hospitals located in large urban areas 
(populations over 1 million), and 1,140 hospitals in other urban 
areas (populations of 1 million or fewer). In addition, there are 
986 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 2009 payment classifications, including any 
reclassifications under section 1886(d)(10) of the Act. For example, 
the rows labeled urban, large urban, other urban, and rural show 
that the number of hospitals paid based on these categorizations 
after consideration of geographic reclassifications (including 
reclassifications under section 1886(d)(8)(B) and section 
1886(d)(8)(E) of the Act that have implications for capital 
payments) are 2,584, 1,424, 1,160 and 944, respectively.
    The next three groupings examine the impacts of the proposed 
changes on hospitals grouped by whether or not they have GME 
residency programs (teaching hospitals that receive an IME 
adjustment) or receive DSH payments, or some combination of these 
two adjustments. There are 2,485 nonteaching hospitals in our 
analysis, 805 teaching hospitals with fewer than 100 residents, and 
238 teaching hospitals with 100 or more residents.
    In the DSH categories, hospitals are grouped according to their 
DSH payment status, and whether they are considered urban or rural 
for DSH purposes. The next category groups together hospitals 
considered urban after geographic reclassification, in terms of 
whether they receive the IME adjustment, the DSH adjustment, both, 
or neither.
    The next five rows examine the impacts of the proposed changes 
on rural hospitals by special payment groups (SCHs, RRCs, and MDHs). 
There were 197 RRCs, 355 SCHs, 156 MDHs, 102 hospitals that are both 
SCHs and RRCs, and 12 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 2005 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 2009. The second grouping 
shows the MGCRB rural reclassifications. The final category shows 
the impact of the proposed policy changes on the 20 cardiac 
specialty hospitals in our analysis.

                                                Table I.--Impact Analysis of Proposed Changes for FY 2009
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                         Application
                                                                                                         of proposed
                                                                                                         rural floor                  All         All
                                                   Proposed                Proposed                      and imputed               proposed    proposed
                                                    FY 2009                 FY 2009                         rural      Proposed     FY 2009     FY 2009
                                       Number of  cost based   Proposed    DRG, rel.    FY 2009 MGCRB       floor,      FY 2009   changes w/  changes w/
                                       hospitals      DRG       FY 2009    wts. and   Reclassifications   including      out-         CMI         CMI
                                          \1\      Weights &   wage data  wage index         \5\           proposed    migration  adjustment  adjustment
                                                    MS-DRG        \3\       changes                         within    adjustment   prior to       and
                                                    changes                   \4\                           state         \7\      estimated   estimated
                                                      \2\                                                   budget                CMI growth  CMI growth
                                                                                                          neutrality                  \8\         \9\
                                                                                                             \6\
                                             (1)         (2)         (3)         (4)             (5)             (6)         (7)         (8)         (9)
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Hospitals.......................       3,528         0.1        -0.1           0               0               0           0         2.3         4.1
By Geographic Location:
    Urban hospitals.................       2,542         0.2        -0.1         0.1            -0.2               0           0         2.4         4.2
    Large urban areas...............       1,402         0.5        -0.1         0.3            -0.4            -0.1           0         2.6         4.4
    Other urban areas...............       1,140           0           0        -0.1            -0.1             0.1           0         2.2         3.9
    Rural hospitals.................         986          -1           0        -1.1             2.1            -0.1         0.1         1.5         3.3
Bed Size (Urban):
     0-99 beds......................         643        -0.7        -0.1        -0.8            -0.4             0.1           0         1.6         3.4
    100-199 beds....................         829         0.1           0           0            -0.1             0.1           0         2.2           4
    200-299 beds....................         483         0.2           0         0.2            -0.2            -0.1           0         2.4         4.2
    300-499 beds....................         411         0.3           0         0.3            -0.2               0           0         2.6         4.3
    500 or more beds................         176         0.5        -0.3         0.1            -0.3               0           0         2.5         4.3
Bed Size (Rural):
    0-49 beds.......................         338        -2.3         0.1        -2.3             0.6               0         0.2         0.7         2.5
    50-99 beds......................         373        -1.2           0        -1.3             1.1            -0.1         0.2         1.2           3
    100-149 beds....................         166        -0.9         0.1        -0.8             2.5               0         0.1         1.5         3.3
    150-199 beds....................          67        -0.6        -0.1        -0.8               3            -0.1           0           2         3.8

[[Page 23909]]

 
    200 or more beds................          42        -0.3        -0.1        -0.4             3.2            -0.1           0         2.1         3.9
Urban by Region:
    New England.....................         121           0           0        -0.1             0.5             0.1           0         1.2           3
    Middle Atlantic.................         348           0        -0.5        -0.5             0.1               0           0         1.2           3
    South Atlantic..................         385         0.4        -0.3         0.1            -0.4               0           0         2.7         4.4
    East North Central..............         394         0.5        -0.5        -0.1            -0.4               0           0         2.4         4.1
    East South Central..............         163        -0.1        -0.2        -0.2            -0.2               0           0         2.4         4.2
    West North Central..............         157        -0.1         0.2         0.1            -0.7               0           0         2.8         4.5
    West South Central..............         371         0.4           0         0.3            -0.6               0           0         2.9         4.7
    Mountain........................         157         0.3         0.1         0.5            -0.2               0           0         3.2           5
    Pacific.........................         393         0.4         0.9         1.2            -0.2               0           0         3.4         5.2
    Puerto Rico.....................          53        -0.2        -0.7        -0.9            -0.7               0           0         1.4         3.2
Rural by Region:
    New England.....................          23        -0.8        -0.4        -1.3             2.4            -0.9           0         0.6         2.3
    Middle Atlantic.................          70        -0.9        -0.1        -1.1               2               0         0.1         1.3         3.1
    South Atlantic..................         172        -0.6        -0.1        -0.7             2.2               0         0.1         1.9         3.7
    East North Central..............         121        -0.9        -0.3        -1.3             1.6               0         0.1         1.4         3.2
    East South Central..............         176        -1.3        -0.1        -1.4             2.7               0         0.1         1.6         3.4
    West North Central..............         113        -0.9         0.1        -0.8             1.7               0         0.1         1.6         3.4
    West South Central..............         200        -1.7         0.5        -1.3             2.5               0         0.1         1.3         3.1
    Mountain........................          75        -0.9           0          -1             0.5               0         0.1         1.2         3.1
    Pacific.........................          36        -0.7         0.6        -0.2             1.8            -0.3           0         1.8         3.6
By Payment Classification:
    Urban hospitals.................       2,584         0.2        -0.1         0.1            -0.2               0           0         2.4         4.2
    Large urban areas...............       1,424         0.4        -0.1         0.3            -0.4            -0.1           0         2.6         4.4
    Other urban areas...............       1,160           0           0        -0.1               0             0.1           0         2.2         3.9
    Rural areas.....................         944          -1           0        -1.1               2            -0.1         0.1         1.5         3.3
Teaching Status:
    Nonteaching.....................       2,485        -0.2           0        -0.2             0.3               0           0         2.2           4
    Fewer than 100 residents........         805         0.2           0         0.1            -0.2               0           0         2.4         4.2
    100 or more residents...........         238         0.5        -0.3         0.2            -0.3               0           0         2.5         4.2
Urban DSH:
    Non-DSH.........................         838        -0.3        -0.2        -0.4            -0.1               0           0         1.8         3.6
    100 or more beds................       1,534         0.4        -0.1         0.3            -0.3               0           0         2.6         4.3
    Less than 100 beds..............         354        -0.7           0        -0.8               0               0           0         1.6         3.4
Rural DSH:
    SCH.............................         389        -1.5           0        -1.5             0.4               0         0.1         1.5         3.3
    RRC.............................         206        -0.6           0        -0.6             3.4            -0.1           0         1.9         3.7
    100 or more beds................          39        -0.8           0        -0.9             1.3               0         0.4         1.3         3.1
    Less than 100 beds..............         168        -1.7           0        -1.8             1.3               0         0.3         0.6         2.4
Urban teaching and DSH:
    Both teaching and DSH...........         811         0.4        -0.1         0.3            -0.4               0           0         2.5         4.3
    Teaching and no DSH.............         172        -0.1        -0.2        -0.3               0               0           0         1.8         3.6
    No teaching and DSH.............       1,077         0.2           0         0.2               0             0.1           0         2.5         4.3
    No teaching and no DSH..........         524        -0.2        -0.2        -0.4            -0.3               0           0         1.9         3.7
Special Hospital Types:
    RRC.............................         197        -0.4        -0.1        -0.4             3.2               0           0         2.3         4.1
    SCH.............................         355        -1.3         0.1        -1.3             0.4               0         0.1         1.2           3
    MDH.............................         156        -1.8         0.1        -1.8             0.5               0         0.2           2         3.8
    SCH and RRC.....................         102        -0.5         0.1        -0.5             1.7               0           0         2.2         4.1
    MDH and RRC.....................          12        -1.3         0.1        -1.3             0.9            -0.3           0           1         2.8
Type of Ownership:
    Voluntary.......................       2,027         0.1        -0.1           0               0               0           0         2.3           4
    Proprietary.....................         827           0           0        -0.1               0            -0.1           0         2.4         4.1
    Government......................         587         0.1        -0.1           0             0.1             0.1           0         2.6         4.4
Medicare Utilization as a Percent of
 Inpatient Days:
     0-25...........................         255         0.8        -0.1         0.7            -0.4            -0.2           0         3.2         4.9
    25-50...........................       1,350         0.3           0         0.3            -0.3               0           0         2.7         4.4
    50-65...........................       1,431        -0.1        -0.2        -0.3             0.4             0.1           0         1.9         3.7
    Over 65.........................         392        -0.8        -0.2          -1             0.5               0         0.1         1.2           3
FY 2009 Reclassifications by the
 Medicare Geographic Classification
 Review Board:
    All Reclassified Hospitals......         805           0           0           0               2            -0.1           0         2.1         3.8
    Non-Reclassified Hospitals......       2,723         0.2        -0.1           0            -0.7               0           0         2.4         4.2
    Urban Hospitals Reclassified....         445         0.2           0         0.2             1.5            -0.2           0         2.1         3.9
    Urban Nonreclassified, FY 2009..       2,075         0.3        -0.1         0.1            -0.7             0.1           0         2.5         4.3
    All Rural Hospitals Reclassified         360        -0.7           0        -0.7             3.3              -0           0         1.8         3.7
     Full Year FY 2009..............
    Rural Nonreclassified Hospitals          565        -1.5          -0        -1.6            -0.4            -0.1         0.3           1         2.8
     Full Year FY 2009..............

[[Page 23910]]

 
    All Section 401 Reclassified              29        -1.3        -0.2        -1.6             0.6               0           0         1.6         3.5
     Hospitals......................
    Other Reclassified Hospitals              61          -1        -0.2        -1.3             3.2            -0.2         0.1           1         2.8
     (Section 1886(d)(8)(B))........
Specialty Hospitals
    Cardiac specialty Hospitals.....          20        -2.2        -0.1        -2.4            -0.7             0.1           0           0         1.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the
  national total. Discharge data are from FY 2007, and hospital cost report data are from reporting periods beginning in FY 2006 and FY 2005.
\2\ This column displays the payment impact of the changes to the V26 GROUPER and the recalibration of the DRG weights based on FY 2007 MedPAR data in
  accordance with section 1886(d)(4)(C)(iii) of the Act.
\3\ This column displays the payment impact of updating the wage index data to the FY 2005 cost report data.
\4\ This column displays the combined payment impact of the changes in column 2 and column 3 and the budget neutrality factors for DRG and wage index
  changes in accordance with section 1886(d)(4)(C)(iii) of the Act and section 1886(d)(3)(E) of the Act.
\5\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
  the FY 2009 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2008. Reclassification for
  prior years has no bearing on the payment impacts shown here. This column reflects the geographic budget neutrality factor of 0.992333.
\6\ This column displays the effects of the rural floor and the imputed rural floor, including the proposal to apply the budget neutrality adjustment
  within State.
\7\ 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 threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with
  higher wage indexes.
\8\ This column shows changes in payments from FY 2008 to FY 2009, including the proposed FY 2009 -0.9 percent documentation and coding adjustment, but
  not the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all
  of the changes displayed in Columns 4, 5, 6, 7 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the
  FY 2009 update, and changes in hospitals' reclassification status in FY 2009 compared to FY 2008.
\9\ This column shows changes in payments from FY 2008 to FY 2009 including the proposed FY 2009 -0.9 percent documentation and coding adjustment and
  the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all of
  the changes displayed in Columns 4, 5, 6, 7, 8 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the
  FY 2008 update, and changes in hospitals' reclassification status in FY 2009 compared to FY 2008. The sum of these impacts may be different from the
  percentage changes shown here due to rounding and interactive effects.

C. Effects of the Proposed Changes to the MS-DRG Reclassifications 
and Relative Cost-Based Weights (Column 2)

    In Column 2 of Table I, we present the effects of the 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 FY2009 
DRG relative weights will be 100 percent cost-based and 100 percent 
MS-DRGs, thus completing our three year transition to cost-based 
relative weights and our two year transition to MS-DRGs. For FY 
2009, the MS-DRGs are calculated using the FY2007 MedPAR data 
grouped to the Version 26.0 (FY2009) DRGs. The proposed methods of 
calculating the relative weights and the reclassification changes to 
the GROUPER are described in more detail in section II.H. of the 
preamble to this proposed rule. In previous years, this column would 
also reflect the effects of the recalibration budget neutrality 
factor that is applied to the hospital-specific rates and the Puerto 
Rico-specific standardized amount. However, for this proposed rule, 
we show the effects of the recalibration budget neutrality factor of 
0.998700 in column 4. We note that, consistent with section 
1886(d)(4)(C)(iii) of the Act, we are applying a budget neutrality 
factor to the national standardized amounts to ensure that the 
overall payment impact of the DRG changes (combined with the wage 
index changes) is budget neutral. This proposed wage and 
recalibration budget neutrality factor of 0.99525 is applied to 
payments in Column 4 and not Column 2.
    The proposed changes to the relative weights and DRGs shown in 
column 2 are prior to any offset for budget neutrality. The ``All 
Hospitals'' line indicates that proposed changes in this column will 
increase payments by 0.1 percent. However, as stated earlier, the 
proposed changes shown in this column are combined with revisions to 
the wage index, and the budget neutrality adjustments made for these 
changes are shown in column 4. Thus, the impact after accounting 
only for budget neutrality for proposed changes to the DRG relative 
weights and classification is somewhat lower than the figures shown 
in this column (approximately 0.1 percent).

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

    Section 1886(d)(3)(E) of the Act requires that, beginning 
October 1, 1993, we annually update the wage data used to calculate 
the wage index. In accordance with this requirement, the wage index 
for FY 2009 is based on data submitted for hospital cost reporting 
periods beginning on or after October 1, 2004 and before October 1, 
2005. The estimated impact of the proposed wage data on hospital 
payments is isolated in Column 3 by holding the other payment 
parameters constant in this simulation. That is, Column 3 shows the 
percentage changes in payments when going from a model using the FY 
2008 wage index, based on FY 2004 wage data and having a 100-percent 
occupational mix adjustment applied, to a model using the FY 2009 
pre-reclassification wage index, also having a 100-percent 
occupational mix adjustment applied, based on FY 2005 wage data 
(while holding other payment parameters such as use of the version 
26.0 DRG grouper constant). The wage data collected on the FY 2005 
cost report include overhead costs for contract labor that were not 
collected on FY 2004 and earlier cost reports. The impacts below 
incorporate the effects of the FY 2005 wage data collected on 
hospital cost reports, including additional overhead costs for 
contract labor compared to the wage data from FY 2004 cost reports 
that were used to calculate the FY 2008 wage index.
    Column 3 shows the impacts of updating the wage data using FY 
2004 cost reports. Overall, the new wage data will lead to a -0.1 
percent change for all hospitals before application of the wage and 
DRG recalibration budget neutrality adjustment shown in column 4. 
Thus, the figures in this column are approximately 0.1 below what 
they otherwise would be if they also illustrated a budget neutrality 
adjustment solely for changes to the wage index. Among the regions, 
the largest increase is in the urban Pacific region, which 
experiences a 0.9 percent increase before applying an adjustment for 
budget neutrality. The largest decline from updating the wage data 
is seen in Puerto Rico (0.7 percent decrease).
    In looking at the wage data itself, the national average hourly 
wage increased 4.2 percent compared to FY 2008. Therefore, the only 
manner in which to maintain or exceed

[[Page 23911]]

the previous year's wage index was to match or exceed the national 
4.2 percent increase in average hourly wage. Of the 3,457 hospitals 
with wage data for both FYs 2008 and 2009, 1,707, or 49.4 percent, 
experienced an average hourly wage increase of 4.2 percent or more.
    The following chart compares the shifts in wage index values for 
hospitals for FY 2009 relative to FY 2008. Among urban hospitals, 32 
will experience an increase of more than 5 percent and less than 10 
percent and 5 will experience an increase of more than 10 percent. 
Among rural hospitals, none 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, 972 rural hospitals will 
experience increases or decreases of less than 5 percent, while 
2,420 urban hospitals will experience increases or decreases of less 
than 5 percent. Eighteen urban hospitals will experience decreases 
in their wage index values of more than 5 percent and less than 10 
percent. Ten urban hospitals will experience decreases in their wage 
index values of greater than 10 percent. No rural hospitals will 
experience decreases of more than 5 percent. These figures reflect 
changes in the wage index which is an adjustment to either 69.7 
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 would occur to the hospital's 
total payment.
    The following chart shows the projected impact for urban and 
rural hospitals.

------------------------------------------------------------------------
                                                   Number of hospitals
  Percentage change in area wage index values  -------------------------
                                                   Urban        Rural
------------------------------------------------------------------------
Increase more than 10 percent.................            5            0
Increase more than 5 percent and less than 10            32            0
 percent......................................
Increase or decrease less than 5 percent......        2,420          972
Decrease more than 5 percent and less than 10            18            0
 percent......................................
Decrease more than 10 percent.................           10            0
------------------------------------------------------------------------

E. Combined Effects of Proposed MS-DRG and Wage Index Changes 
(Column 4)

    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. As noted in the Addendum to this proposed 
rule, in determining the budget neutrality factor, we equated 
simulated aggregate payments for FY 2008 and FY 2009 using the FY 
2007 Medicare utilization data after applying the changes to the DRG 
relative weights and the wage index.
    We computed a wage and MS-DRG recalibration budget neutrality 
factor of 0.999525 (which is applied to the national standardized 
amounts) and a recalibration budget neutrality factor 0.998700 
(which is applied to the hospital-specific rates and the Puerto 
Rico-specific standardized amount). The 0.0 percent impact for all 
hospitals demonstrates that the proposed MS-DRG and wage changes, in 
combination with the budget neutrality factor, are budget neutral. 
In Table I, the combined overall impacts of the effects of both the 
MS-DRG reclassifications and the updated wage index are shown in 
Column 4. The estimated changes shown in this column reflect the 
combined effects of the changes in Columns 2 and 3 and the budget 
neutrality factors discussed previously.
    We estimate that the combined impact of the proposed changes to 
the relative weights and DRGs and the updated wage data with budget 
neutrality applied will increase payments to hospitals located in 
large urban areas (populations over 1 million) by approximately 0.3. 
These proposed changes would generally increase payments to 
hospitals in all urban areas (0.1 percent) and large teaching 
hospitals (0.2 percent). Rural hospitals will generally experience a 
decrease in payments (-1.1 percent). Among the rural hospital 
categories, rural hospitals with less than 50 beds will experience 
the greatest decline in payment (-2.3 percent) primarily due to the 
changes to MS-DRGs and the relative cost weights.

F. Effects of MGCRB Reclassifications (Column 5)

    Our impact analysis to this point has assumed hospitals are paid 
on the basis of their actual geographic location (with the exception 
of ongoing policies that provide that certain hospitals receive 
payments on other bases than where they are geographically located). 
The proposed changes in Column 5 reflect the per case payment impact 
of moving from this baseline to a simulation incorporating the MGCRB 
decisions for FY 2009 which affect hospitals' wage index area 
assignments.
    By February 28 of each year, the MGCRB makes reclassification 
determinations that will be effective for the next fiscal year, 
which begins on October 1. The MGCRB may approve a hospital's 
reclassification request for the purpose of using another area's 
wage index value. 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 2009 geographic reclassifications.
    The overall effect of geographic reclassification is required by 
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we 
are proposing to apply an adjustment of 0.992333 to ensure that the 
effects of the section 1886(d)(10) reclassifications are budget 
neutral. (See section II.A. of the Addendum to this proposed rule.) 
Geographic reclassification generally benefits hospitals in rural 
areas. We estimate that geographic reclassification will increase 
payments to rural hospitals by an average of 2.1 percent.

G. Effects of the Proposed Rural Floor and Imputed Rural Floor, 
Including the Proposed Application of Budget Neutrality at the 
State Level (Column 6)

    As discussed in section III.B. of the preamble of this FY 2009 
proposed rule, section 4410 of Pub. L. 105-33 established the rural 
floor by requiring that the wage index for a hospital in any urban 
area cannot be less than the area wage index determined for the 
state's rural area. 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. For FY 2009, we 
are proposing to apply the rural floor budget neutrality adjustment 
at the State level, which would redistribute payments within the 
State rather than across all other providers within the Nation.
    Furthermore, the FY 2005 IPPS final rule (69 FR 49109) 
established a temporary imputed rural floor for all urban States 
from FY 2005 to FY 2007. The rural floor requires that an urban wage 
index cannot be lower than the wage index for any rural hospital in 
that State. Therefore, an imputed rural floor was established for 
States that do not have rural areas or rural IPPS hospitals. In the 
FY 2008 IPPS final rule with comment period (72 FR 47321), we 
finalized our rule to extend the imputed rural floor for 1 
additional year. In this proposed rule, we are proposing to extend 
the imputed rural floor for an additional 3 years through FY 2011. 
Furthermore, consistent with our proposal to apply the rural floor 
budget neutrality adjustment at the State level, we are proposing to 
apply the imputed rural floor budget neutrality adjustment to the 
wage index at the State level.
    Column 6 shows the projected impact of the rural floor and the 
imputed rural floor, including the proposed application of the 
budget neutrality adjustment at the State level. The column compares 
the post-reclassification FY 2009 wage index of providers before the 
rural floor adjustment and the post-reclassification FY 2009 wage 
index of providers with the rural floor and

[[Page 23912]]

imputed rural 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 urban hospitals to which the adjustment is not 
made) had experienced a decrease in payments due to the budget 
neutrality adjustment applied nationally. However, under this 
proposal, States that have no hospitals receiving a rural floor wage 
index would no longer have a negative budget neutrality adjustment 
applied to their wage indices. Conversely, all hospitals in States 
with hospitals receiving a rural floor would 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. We project hospitals located in 
other urban areas (populations of 1 million or fewer) will 
experience a 0.1 percent increase in payments because the rural 
floor adjustment applies to urban hospitals. Rural New England 
hospitals can expect the greatest decrease in payment by 0.9 percent 
because hospitals in Vermont will receive a rural floor budget 
neutrality adjustment of 0.901 or a reduction of approximately 10 
percent, and hospitals in Connecticut will receive a rural floor 
budget neutrality adjustment of 0.9639 or a reduction of 
approximately 4 percent. New Jersey, which is the only State that 
benefits from the imputed rural floor, is expected to receive a 
rural floor budget neutrality adjustment of 0.987838 or a reduction 
of approximately 1.2 percent.
    The table that appears in section III B.2.b. of the preamble of 
this proposed rule shows how payments would change, at the State 
level, if we moved from our current policy of applying rural floor 
budget neutrality at the national level to our proposed policy to 
apply the rural floor budget neutrality within the State. The table 
shows that, under our current policy of applying budget neutrality 
at the national level, States that do not have any hospitals 
receiving the rural floor wage index would expect a decrease in 
payments because, in order to maintain budget neutrality nationally, 
these hospitals have to pay for the hospitals in other States that 
do receive a rural floor. For example, States such as Arizona, New 
York, and Rhode Island, which do not have hospitals receiving a 
rural floor, would expect to lose 0.2 percent in payments under a 
national rural floor budget neutrality adjustment. However, under 
our proposed policy to apply rural floor budget neutrality within 
each State, States that do not have hospitals receiving a floor 
would see an increase in payments (compared with our current policy 
of applying budget neutrality at the national level) because they 
would no longer have their wage indexes adjusted to maintain budget 
neutrality. However, all hospitals in States with hospitals 
receiving a rural floor would expect a decrease in their payments in 
order to achieve budget neutrality within their States (that is, the 
wage indices for hospitals in that State would be decreased in order 
to make the additional payments to hospitals in that State receiving 
the rural floor). Therefore, compared with our current policy of 
applying budget neutrality at the national level, States such as 
Arizona, New York, and Rhode Island could expect payment increases 
of 0.3 percent under a rural floor budget neutrality applied at the 
State level, while States such as California and Connecticut, which 
have several hospitals that benefit from the rural floor, could 
expect decreases in payments by 0.8 percent and 2.2 percent, 
respectively.

H. Effects of the Proposed Wage Index Adjustment for Out-Migration 
(Column 7)

    Section 1886(d)(13) of the Act, as added by section 505 of Pub. 
L. 108-173, provides for an increase in the wage index for hospitals 
located in certain counties that have a relatively high percentage 
of hospital employees who reside in the county, but work in a 
different area with a higher wage index. Hospitals located in 
counties that qualify for the payment adjustment are to receive an 
increase in the wage index that is equal to a weighted average of 
the difference between the wage index of the resident county, post-
reclassification and the higher wage index work area(s), weighted by 
the overall percentage of workers who are employed in an area with a 
higher wage index. With the out-migration adjustment, rural 
providers will experience a 0.1 percent increase in payments in FY 
2009 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.

I. Effects of All Proposed Changes With CMI Adjustment Prior to 
Estimated Growth (Column 8)

    Column 8 compares our estimate of payments per case between FY 
2008 and FY 2009 with all changes reflected in this proposed rule 
for FY 2009, including a -0.9 percent documentation and coding 
adjustment to the FY 2009 national standardized amounts to account 
for anticipated improvements in documentation and coding that are 
expected to increase case-mix. We generally apply an adjustment to 
the DRGs to ensure budget neutrality assuming constant utilization. 
However, in the FY 2008 IPPS final rule with comment period, we 
indicated that we believe that the adoption of MS-DRGs would lead to 
increases in case-mix as a result of improved documentation and 
coding. In the FY 2008 IPPS final rule with comment period, we had 
finalized a policy to apply a documentation and coding adjustment to 
the standardized amount of -1.2 percent for FY 2008, -1.8 percent 
for FY 2009, and -1.8 percent for FY 2010 to offset the expected 
increase in case-mix and achieve budget neutrality. However, in 
compliance with section 7 of Pub. L. 110-90, we reduced the 
documentation and coding adjustment to -0.6 percent for FY 2008. In 
accordance with section 7 of Pub. L. 110-90, for FY 2009, we are 
applying a documentation and coding adjustment of -0.9 percent to 
the FY 2009 national standardized amounts (in addition to the -0.6 
percent adjustment made for FY 2008). We are not proposing to apply 
the documentation and coding adjustment to the FY 2009 hospital-
specific rates and the FY 2009 Puerto Rico-specific standardized 
amount. However, we continue to believe that case-mix growth of an 
additional 1.8 percent compared to FY 2008 is likely to occur across 
all hospitals as a result of improvements in documentation and 
coding.
    Column 8 illustrates the total payment change for FY 2009 
compared to FY 2008, taking into account the -0.9 percent FY 2009 
documentation and coding adjustment but not the projected 1.8 
percent case-mix increase itself. Therefore, this column illustrates 
a total payment change that is less than what is anticipated to 
occur.

J. Effects of All Proposed Changes With CMI Adjustment and 
Estimated Growth (Column 9)

    Column 9 compares our estimate of payments per case between FY 
2008 and FY 2009, incorporating all changes reflected in this 
proposed rule for FY 2009 (including statutory changes). This column 
includes the FY 2009 documentation and coding adjustment of -0.9 
percent and the projected 1.8 percent increase in case-mix from 
improved documentation and coding (with the 1.8 percent case-mix 
increase assumed to occur equally across all hospitals).
    Column 9 reflects the impact of all FY 2009 changes relative to 
FY 2008, including those shown in Columns 2 through 7. The average 
increase for all hospitals is approximately 4.1 percent. This 
increase includes the effects of the 3.0 percent market basket 
update. It also reflects the 0.3 percentage point difference between 
the projected outlier payments in FY 2008 (5.1 percent of total DRG 
payments) and the current estimate of the percentage of actual 
outlier payments in FY 2008 (4.8 percent), as described in the 
introduction to this Appendix and the Addendum to this proposed 
rule. As a result, payments are projected to be 0.3 percentage 
points lower in FY 2008 than originally estimated, resulting in a 
0.3 percentage point greater increase for FY 2009 than would 
otherwise occur. In addition, the impact of expiration of section 
508 of Pub. L. 108-173 reclassification accounts for a 0.1 percent 
decrease in estimated payments. 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 product of the percentage changes described 
above.
    The overall change in payments per case for hospitals in FY 2009 
is proposed to increase by 4.1 percent. Hospitals in urban areas 
will experience an estimated 4.2 percent increase in payments per 
case compared to FY 2008. Hospitals in large urban areas will 
experience an estimated 4.4 percent increase and hospitals in other 
urban areas will experience an estimated 3.9 percent increase in 
payments per case in FY 2008. Hospital payments per case in rural 
areas are estimated to increase 3.3 percent. The increases that are 
larger than the national average for larger urban areas and smaller 
than the national average for other urban and rural areas are 
largely attributed to the differential impact of adopting MS-DRGs.

[[Page 23913]]

    Among urban census divisions, the largest estimated payment 
increases will be 5.2 percent in the Pacific region (generally 
attributed to MS-DRGs and wage data) and 5.0 percent in the Mountain 
region (mostly due to MS-DRGs). The smallest urban increase is 
estimated at 3.0 percent in the Middle Atlantic and New England 
regions.
    Among the rural regions in Column 9, the providers in the New 
England region experience the smallest increase in payments (2.3 
percent) primarily due to the State-specific rural floor budget 
neutrality adjustment. The South Atlantic and Pacific regions will 
have the highest increases among rural regions, with 3.7 percent and 
3.6 percent estimated increases, respectively. Again, increases in 
rural areas are generally less than the national average due to the 
adoption of MS-DRGs.
    Among special categories of rural hospitals in Column 9, the SCH 
and RRC providers will receive an estimated increase in payments of 
4.1 percent, and the MDH and RRCs will experience an estimated 
increase in payments by 2.8 percent.
    Urban hospitals reclassified for FY 2009 are anticipated to 
receive an increase of 3.9 percent, while urban hospitals that are 
not reclassified for FY 2009 are expected to receive an increase of 
4.3 percent. Rural hospitals reclassifying for FY 2009 are 
anticipated to receive a 3.7 percent payment increase and rural 
hospitals that are not reclassifying are estimated to receive a 
payment increase of 2.8 percent.

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

    For FY 2009, we are continuing 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 2009. We estimate the impact of these providers 
receiving the additional 25-percent payment increase to be 
approximately $2,300.

L. Impact Analysis of Table II

    Table II presents the projected impact of the proposed changes 
for FY 2009 for urban and rural hospitals and for the different 
categories of hospitals shown in Table I. It compares the estimated 
payments per case for FY 2008 with the proposed average estimated 
payments per case for FY 2009, as calculated under our models. Thus, 
this table presents, in terms of the average dollar amounts paid per 
discharge, the combined effects of the proposed changes presented in 
Table I. The proposed percentage changes shown in the last column of 
Table II equal the proposed percentage changes in average payments 
from Column 9 of Table I.

         Table II.--Impact Analysis of Proposed Changes for FY 2009 Operating Prospective Payment System
                                               [Payments per case]
----------------------------------------------------------------------------------------------------------------
                                                                                         Average
                                                                           Average FY  proposed FY  All proposed
                                                              Number of       2008         2009        FY 2009
                                                              hospitals   payment per  payment per     changes
                                                                            case \1\     case \1\
                                                                     (1)          (2)          (3)         (4)
----------------------------------------------------------------------------------------------------------------
All hospitals..............................................        3,528       $9,144       $9,519           4.1
By Geographic Location:
    Urban hospitals........................................        2,542        9,571        9,972           4.2
    Large urban areas (populations over 1 million).........        1,402       10,045       10,484           4.4
    Other urban areas (populations of 1 million or fewer)..        1,140        9,000        9,355           3.9
    Rural hospitals........................................          986        6,683        6,905           3.3
Bed Size (Urban):
    0-99 beds..............................................          643        7,283        7,533           3.4
    100-199 beds...........................................          829        8,103        8,428           4
    200-299 beds...........................................          483        8,985        9,363           4.2
    300-499 beds...........................................          411       10,046       10,482           4.3
    500 or more beds.......................................          176       11,875       12,382           4.3
Bed Size (Rural):
    0-49 beds..............................................          338        5,509        5,644           2.5
    50-99 beds.............................................          373        6,097        6,279           3
    100-149 beds...........................................          166        6,660        6,884           3.4
    150-199 beds...........................................           67        7,467        7,752           3.8
    200 or more beds.......................................           42        8,361        8,686           3.9
Urban by Region:
    New England............................................          121        9,935       10,230           3
    Middle Atlantic........................................          348       10,440       10,752           3
    South Atlantic.........................................          385        9,025        9,427           4.5
    East North Central.....................................          394        9,065        9,440           4.1
    East South Central.....................................          163        8,681        9,044           4.2
    West North Central.....................................          157        9,140        9,555           4.5
    West South Central.....................................          371        9,043        9,466           4.7
    Mountain...............................................          157        9,571       10,051           5
    Pacific................................................          393       11,614       12,219           5.2
    Puerto Rico............................................           53        4,706        4,857           3.2
Rural by Region:
    New England............................................           23        9,051        9,263           2.3
    Middle Atlantic........................................           70        6,912        7,124           3.1
    South Atlantic.........................................          172        6,529        6,773           3.7
    East North Central.....................................          121        6,872        7,093           3.2
    East South Central.....................................          176        6,263        6,474           3.4
    West North Central.....................................          113        6,886        7,119           3.4
    West South Central.....................................          200        6,088        6,276           3.1
    Mountain...............................................           75        6,802        7,010           3.1
    Pacific................................................           36        8,162        8,455           3.6
By Payment Classification:
    Urban hospitals........................................        2,584        9,549        9,948           4.2
    Large urban areas (populations over 1 million).........        1,424       10,026       10,464           4.4
    Other urban areas (populations of 1 million or fewer)..        1,160        8,975        9,328           3.9

[[Page 23914]]

 
    Rural areas............................................          944        6,716        6,941           3.3
Teaching Status:
    Non-teaching...........................................        2,485        7,716        8,023           4
    Fewer than 100 Residents...............................          805        9,193        9,577           4.2
    100 or more Residents..................................          238       13,392       13,951           4.2
Urban DSH:
    Non-DSH................................................          838        8,118        8,409           3.6
    100 or more beds.......................................        1,534       10,062       10,498           4.3
    Less than 100 beds.....................................          354        6,792        7,022           3.4
Rural DSH:
    SCH....................................................          389        6,093        6,293           3.3
    RRC....................................................          206        7,465        7,740           3.7
    100 or more beds.......................................           39        6,110        6,299           3.1
    Less than 100 beds.....................................          168        5,451        5,580           2.4
Urban teaching and DSH:
    Both teaching and DSH..................................          811       10,986       11,457           4.3
    Teaching and no DSH....................................          172        8,885        9,201           3.6
    No teaching and DSH....................................        1,077        8,283        8,644           4.4
    No teaching and no DSH.................................          524        7,796        8,083           3.7
Rural Hospital Types:
    RRC....................................................          197        7,783        8,100           4.1
    SCH....................................................          355        6,564        6,764           3
    MDH....................................................          156        5,757        5,975           3.8
    SCH and RRC............................................          102        7,901        8,223           4.1
    MDH and RRC............................................           12        7,303        7,510           2.8
Type of Ownership:
    Voluntary..............................................        2,027        9,252        9,625           4
    Proprietary............................................          827        8,424        8,772           4.1
    Government.............................................          587        9,440        9,853           4.4
Medicare Utilization as a Percent of Inpatient Days:
    0-25...................................................          255       13,112       13,751           4.9
    25-50..................................................        1,350       10,344       10,801           4.4
    50-65..................................................        1,431        7,950        8,245           3.7
    Over 65................................................          392        7,033        7,245           3
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board:
FY 2009 Reclassifications:
    All Reclassified Hospitals FY 2009.....................          805        8,803        9,141           3.8
    All Non-Reclassified Hospitals FY 2009.................        2,723        9,264        9,651           4.2
    Urban Reclassified Hospitals FY 2009:..................          445        9,547        9,921           3.9
    Urban Non-reclassified Hospitals FY 2009:..............        2,075        9,586        9,994           4.3
    Rural Reclassified Hospitals FY 2009:..................          360        7,240        7,505           3.7
    Rural Nonreclassified Hospitals FY 2009:...............          565        5,870        6,033           2.8
    All Section 401 Reclassified Hospitals:................           29        7,555        7,816           3.5
    Other Reclassified Hospitals (Section 1886(d)(8)(B))...           61        6,534        6,716           2.8
Specialty Hospitals:
    Cardiac Specialty Hospitals............................           20       10,894       11,085           1.8
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

VII. Effects of Other Proposed Policy Changes

    In addition to those policy changes discussed above that we are 
able to model using our IPPS payment simulation model, we are 
proposing to make various other changes in this proposed rule. 
Generally, we have limited or no specific data available with which 
to estimate the impacts of these proposed changes. Our estimates of 
the likely impacts associated with these other proposed changes are 
discussed below.

A. Effects of Proposed Policy on HACs, Including Infections

    In section II.F. of the preamble of this proposed rule, we 
discuss our implementation of section 5001(c) of Pub. L. 109-171, 
which requires the Secretary to identify conditions that (1) are 
high cost, high volume, or both, (2) result in the assignment of a 
case to a MS-DRG that has a 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. That is, the case will be paid as 
though the secondary diagnosis was not present. However, the statute 
also requires the Secretary to continue counting the condition as a 
secondary diagnosis that results in a higher IPPS payment when doing 
the budget neutrality calculations for MS-DRG reclassifications and 
recalibration. Therefore, we do our budget neutrality calculations 
as though the payment provision

[[Page 23915]]

did not apply but Medicare will make a lower payment to the hospital 
for the specific case that includes the secondary diagnosis. Thus, 
the provision will result in cost savings to the Medicare program.
    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. 
Therefore, if at least one nonselected secondary diagnosis that 
leads to the same higher payment is on the claim, the case will 
continue to be assigned to the higher paying DRG and there will be 
no savings to Medicare from the case. 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. 
Therefore, in only a small percentage of the cases will the 
beneficiary have only one secondary diagnosis that would lead to 
higher payment.
    The section 5001(c) payment provision will go into effect on 
October 1, 2008. Our savings estimate for the next 5 fiscal years 
from this provision has changed from our savings estimate published 
in the FY 2008 IPPS final rule with comment period because of the 
potential addition to the list of selected HACs for FY 2009 of the 
nine conditions considered in section II.F. of this proposed rule. 
We had estimated a savings of $20 million per year from this 
provision for the eight conditions we originally selected in the FY 
2008 IPPS final rule with comment period (72 FR 48168). We now 
estimate that this provision will save $50 million per year for the 
first 3 years beginning October 1, 2008. Beginning in FY 2012, we 
estimate a savings of $60 million per year as a result of this 
provision. Our savings estimates for the next 5 fiscal years are 
shown below:

------------------------------------------------------------------------
                                                                Savings
                            Year                                  (in
                                                               millions)
------------------------------------------------------------------------
FY 2009.....................................................         $50
FY 2010.....................................................          50
FY 2011.....................................................          50
FY 2012.....................................................          60
FY 2013.....................................................          60
------------------------------------------------------------------------

B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative 
Weights for LTCHs

    In section II.I. of the preamble to this proposed rule, we 
discuss the proposed MS-LTC-DRGs (proposed Version 26.0 of the 
GROUPER) and development of the proposed relative weights for use 
under the LTCH PPS for FY 2009. We also discuss that when we adopted 
the new severity adjusted MS-LTC-DRG patient classification system 
under the LTCH PPS in the FY 2008 IPPS final rule with comment, we 
implemented a 2-year transition, in which the MS-LTC-DRG relative 
weights for FY 2009 would be based completely on the MS-LTC-DRG 
patient classification system (and no longer based in part on the 
former LTC-DRG patient classification system). Consistent with the 
requirement at Sec.  412.517 established in the RY 2008 LTCH PPS 
final rule (72 FR 26880 through 26884), the proposed annual update 
to the classification and relative weights under the LTCH PPS for RY 
2009 was done in a budget neutral manner, such that estimated 
aggregate LTCH PPS payments would be unaffected; that is, they would 
be neither greater than nor less than the estimated aggregate LTCH 
PPS payments that would have been made without the MS-LTC-DRG 
classification and relative weight changes. To achieve budget 
neutrality under Sec.  412.517, in determining the proposed FY 2009 
MS-LTC-DRG relative weights, we applied a factor of 1.038266 in the 
first step of the budget neutrality process (normalization), and we 
applied a budget neutrality factor of 0.9965 after normalization 
(see section II.I.4. (step 7) of the preamble of this proposed 
rule). These proposed factors that were applied to maintain budget 
neutrality were based on the most recent available LTCH claims data 
(FY 2007 MedPAR files) for the 387 LTCHs in our database. Consistent 
with the budget neutrality requirement under Sec.  412.517, we 
estimate that with the proposed changes to the MS-LTC-DRG 
classifications and relative weights for FY 2009, there would be no 
change in aggregate LTCH PPS payments. In applying the budget 
neutrality adjustment described above, we assumed constant 
utilization.

C. Effects of Proposed Policy Change Relating to New Medical 
Service and Technology Add-On Payments

    In section II.J. of the preamble to this proposed rule, we 
discuss proposed add-on payments for new medical services and 
technologies. 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.J.4. of this 
proposed rule, we have yet to determine whether any of the four 
applications we received will meet the criteria for new technology 
add-on payments for FY 2009. Consequently, it is premature to 
estimate the potential payment impact in FY 2009 of any potential 
new technology add-on payments for FY 2009. There are no 
technologies receiving new technology add-on payment in FY 2008. 
Therefore, at this time, we estimate that Medicare's new technology 
add-on payments would remain unchanged in FY 2009 compared to FY 
2008. If any of the four applicants are found to be eligible for new 
technology add-on payments for FY 2009 in the final rule, we would 
discuss the estimated payment impact for FY 2009 in that final rule.

D. Effects of Proposed Policy Regarding Postacute Care Transfers to 
Home Health Services

    In section IV.A. of the preamble to this proposed rule, we noted 
that, under current regulations, the postacute care transfer policy 
applies to acute care discharges for which home health care (for a 
related condition) begins within 3 days of the discharge from an 
acute care hospital where the patient was discharged from the 
hospital prior to the geometric mean length of stay for a 
``qualified'' MS-DRG. In that section, we discussed the reasons why 
we believe that the 3-day timeframe is no longer an appropriate 
threshold under the postacute care transfer policy. We discussed our 
rationale for extending the timeframe from within 3 days to within 7 
days. Accordingly, we proposed to revise the timeframe in our 
regulations to within 7 days of discharge to home under a written 
plan for the provision of home health services, effective with 
discharges occurring on or after October 1, 2008.
    To estimate the impact of this proposal, we used acute care 
hospital claims from the FY 2005 MedPAR file and searched for claims 
with a discharge destination code of ``01'' (Discharged to Home or 
Self-Care (Routine Discharge)) or ``06'' (Discharged/Transferred to 
Home under Care of Organized Home Health Service Organization in 
Anticipation of Covered Skilled Care). We then matched the acute 
care hospital MedPAR claims with HHA final action claims for 2005, 
using beneficiary identification numbers. We then compared the 
hospital discharge date with the home health admission date and 
determined a distribution by the difference in these two dates. We 
found that, for those patients for whom home health services began 
within 60 days of hospital discharge, in 6.7 percent of the cases, 
the services began on days 4 through day 7 after the acute care 
hospital discharge. We estimate that applying the proposed change to 
the hospital postacute care transfer policy would reduce Medicare 
payments to acute care inpatient hospitals by approximately $330 
million over 5 years. For FY 2009, we estimate that Medicare 
payments would be reduced by approximately $50 million.

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

    In section IV.B. of the preamble of this proposed rule, we 
discuss the requirements for hospitals to report quality data in 
order for hospitals to receive the full annual hospital payment 
update for FY 2009 and FY 2010. There are an estimated 186 hospitals 
in this analysis that may not receive the full market basket update 
for FY 2009. Most of these hospitals are either small rural or small 
urban hospitals. However, at this time, information is not available 
to determine the hospitals that do not meet the requirements for the 
full hospital market increase for FY 2009.
    We also note that, for the FY 2009 payment update, hospitals 
must pass our validation requirement of a minimum of 80 percent 
reliability, based upon our chart-audit validation process, for the 
four quarters of data from FY 2007. These data were due to the QIO 
Clinical Warehouse by May 15, 2007 (fourth quarter CY 2006 
discharges), August 15, 2007 (first quarter CY 2007 discharges), 
November 15, 2007 (second quarter CY 2007 discharges), and February 
15, 2008 (third quarter CY 2007 discharges). We have continued our 
efforts to ensure that QIOs provide assistance to all hospitals that 
wish to submit data. In the preamble of this proposed rule, we are 
proposing to provide additional validation criteria to ensure that 
the quality data being sent to CMS are accurate. The requirement of 
5 charts per

[[Page 23916]]

hospital will result in approximately 21,500 charts per quarter 
total submitted to the agency. We reimburse hospitals for the cost 
of sending charts to the Clinical Data Abstraction Center (CDAC) at 
the rate of 12 cents per page for copying and approximately $4.00 
per chart for postage. Our experience shows that the average chart 
received at the CDAC is approximately 150 pages. Thus, the agency 
will have expenditures of approximately $597,600 per quarter to 
collect the charts. Given that we reimburse for the data collection 
effort, we believe that a requirement for five charts per hospital 
per quarter represents a minimal burden to the participating 
hospital.

F. Effects of Proposed Policy Change to Methodology for Computing 
Core Staffing Factors for Volume Decrease Adjustment for SCHs and 
MDHs

    In section IV.D. of the preamble of this proposed rule, we 
discuss a change to the methodology we would use to compute the 
average nursing staff factors (nursing hours per patient days) for 
the volume decrease adjustment for SCHs and MDHs. If certain 
requirements are met, this adjustment may be made if the hospital's 
total discharges decrease by more than 5 percent from one cost 
reporting period to the next. We do not believe this proposed change 
would have any significant impact on Medicare payments to these 
hospitals.

G. Effects of Proposed Clarification of Policy for Collection of 
Risk Adjustment Data From MA Organizations

    In section IV.H. of the preamble of this proposed rule, we 
discuss our proposed revision of our regulations to clarify that CMS 
has the authority to require MA organizations to submit encounter 
data for each item and service provided to an MA plan enrollee. The 
proposed revision also would clarify that CMS will determine the 
formats for submitting encounter data, which may be more abbreviated 
than those used for the Medicare fee-for-service claims data 
submission process. At this time, we have not yet determined an 
approach for submission of the encounter data. Therefore, we are not 
in a position to determine the extent to which the cost impact of 
submitting encounter data would differ from the current costs to MA 
organizations of submitting risk adjustment data.

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

    In section IV.I. of the preamble of this proposed rule, we are 
proposing to clarify our policy regarding the applicability of 
EMTALA to hospital inpatients. We are proposing to amend the 
regulations to state that when an individual covered by EMTALA was 
admitted as an inpatient and remains unstabilized with an emergency 
medical condition, a receiving hospital with specialized 
capabilities has an EMTALA obligation to accept that individual, 
assuming that the transfer of the individual is an appropriate 
transfer and the participating hospital with specialized 
capabilities has the capacity to treat the individual. In addition, 
we are proposing two changes relating to the requirements for on-
call physicians in hospital emergency departments. We are proposing 
to delete the provision relating to maintaining a list of on-call 
physicians from the regulations referring to EMTALA at Sec.  
489.24(j)(1) because a provision addressing the on-call physician 
list is already included in the regulations relating to provider 
agreements at Sec.  489.20(r)(2). We are proposing to incorporate 
the language of Sec.  489.24(j)(1) as replacement language for the 
existing Sec.  489.20(r)(2) and amend the regulatory language to 
make it more consistent with the statutory language found at section 
1866(a)(1)(I)(iii) of the Act, which refers to hospital CoPs and the 
requirement to maintain an on-call list. These proposed changes 
would make the regulations consistent with the statutory basis for 
maintaining an on-call list. In addition, we are proposing to amend 
our regulations to provide that hospitals may comply with the on-
call list requirement by participating in a formal community call 
plan so long as the plan includes a number of elements that are 
specified in the preamble to the proposed rule. Lastly, we are 
proposing to make a technical change to the regulations to conform 
them to the statutory language found in the Pandemic and All-Hazards 
Preparedness Act. These proposals do not include any substantive new 
requirements. Although hospitals choosing to participate in a 
community call arrangement will be required to devise a formal 
community call plan, such a plan would increase a hospital's 
flexibility in meeting its on-call requirements. We are estimating 
no impact on Medicare expenditures and no significant impact on 
hospitals with emergency departments.

I. Effects of Implementation of Rural Community Hospital 
Demonstration Program

    In section IV.K. of the preamble to this proposed rule, we 
discuss our implementation of section 410A of Pub. L. 108-173 that 
required the Secretary to establish a demonstration that will modify 
reimbursement for inpatient services for up to 15 small rural 
hospitals. Section 410A(c)(2) requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration 
program under this section was not implemented.'' There are 
currently nine hospitals participating in the demonstration. We are 
currently conducting a solicitation for up to six additional 
hospitals to participate in the demonstration program.
    As discussed in section IV.K. of the preamble to this proposed 
rule, we are satisfying this requirement by adjusting national IPPS 
rates by a factor that is sufficient to account for the added costs 
of this demonstration. We estimate that the average additional 
annual payment for FY 2009 that would be made to each participating 
hospital under the demonstration would be approximately $2,134,123. 
We based this estimate on the recent historical experience of the 
difference between inpatient cost and payment for hospitals that are 
participating in the demonstration. As an estimate for the 15 
hospitals that may participate, the total annual impact of the 
demonstration program for FY 2009 is projected to be $32,011,849. 
(In the final rule, we should know the exact number of hospitals 
participating in the demonstration program and would revise our 
estimates accordingly.) The adjustment factor to the Federal rate 
used in calculating Medicare inpatient prospective payments as a 
result of the demonstration is 0.999903.

J. Effects of Proposed Policy Changes Relating to Payments to 
Hospitals-Within-Hospitals

    In section VI.F. of the preamble of this proposed rule, we 
discuss our proposed policy change to allow a HwH that cannot meet 
the criteria in regulations for a separate governing body solely 
because it is a State hospital occupying space with another State 
hospital or located on the same campus as another State hospital and 
both hospitals are under the same governing authority, or the 
governing authority of a third entity that controls both State 
hospitals, to nevertheless qualify for an exclusion from the IPPS if 
the hospital meets other applicable criteria for HwHs in the 
regulations and the specified proposed criteria in this proposed 
rule. We are only aware of one hospital that would be allowed 
qualify for exclusion from the IPPS under the proposed criteria and 
to expand its bed size under the proposed provisions. Because any 
expansion would occur at some point in the future, we are unable to 
quantify the impact of this proposed change.

K. Effects of Proposed Policy Changes Relating to Requirements for 
Disclosure of Physician Ownership in Hospitals

    In section VII. of the preamble of this proposed rule, we 
discuss our proposals concerning (1) the definition of a physician-
owned hospital; (2) the requirement that physician-owned hospitals 
disclose the ownership to patients; and (3) the requirement that all 
hospitals and CAHs must furnish written notice to their patients at 
the beginning of their hospital stay or outpatient visit if a 
physician is not present in the hospital 24 hours per day, 7 days 
per week, and that the notice must indicate how the hospital will 
meet the medical needs of any patient who develops an emergency 
medical condition at a time when there is no physician present in 
the hospital. The definition and the above requirements were 
implemented in the FY 2008 IPPS final rule with comment period (72 
FR 47387 and 47391).
    In this proposed rule, we are proposing to revise the definition 
of a physician-owned hospital at Sec.  489.3 to include hospitals 
that have an ownership or investment interests by a physician and/or 
by an immediate family member of a physician. (The existing 
definition refers to an ownership or investment interest by a 
physician only, and not to an ownership or investment interest by an 
immediate family member.) We are also proposing to except from the 
definition of physician-owned hospital those hospitals that do not 
have at least one physician owner/investor or immediate family 
member

[[Page 23917]]

owner/investor who refers patients to the hospital. We believe that 
the proposed changes to the definition of physician-owned hospital 
would result in no more than a de minimis increase in the number of 
hospitals that are subject to the disclosure requirements applicable 
to physician-owned hospitals. We believe that there would be very 
few hospitals that would now meet the definition of physician-owned 
hospital, if we adopt our proposal to include immediate family 
members within the group of owners or investors that cause a 
hospital to be considered physician-owned, that did not already meet 
the definition. That is, we believe there are very few hospitals for 
which an immediate family member of a physician, but not the 
physician himself or herself, or any other physician, has an 
ownership or investment interest. Moreover, to the extent that such 
hospitals exist, that is, hospitals that have no physician owner/
investors but which have owners/investors who are immediate family 
members of one or more physicians, such hospitals would not be 
subject to the disclosure requirement if we adopt our proposed 
exception to the definition of a physician-owned hospital for those 
hospitals that do not have at least one referring physician whose 
immediate family member is an owner/investor. Also, if we adopt this 
proposed exception to the definition of physician-owned hospital, 
the number of hospitals that now are subject to the disclosure 
requirement may be reduced slightly as we understand that there are 
some hospitals that have no referring physician owner/investors but 
rather have physician owner/investors who have retired from the 
practice of medicine. Thus, if both our proposed changes to the 
definition of physician-owned hospital are adopted, the net result 
may be no change, or a minimal increase or decrease in the number of 
hospitals that are subject to the disclosure requirement. Finally, 
if our proposal to change the definition of physician-owned hospital 
is adopted to encompass immediate family members, some hospitals 
that already meet the definition based on the presence of physician 
owner/investors may have to amend their list of physician owner/
investors to add immediate family members, which we believe would be 
a minimal burden.
    We are proposing to clarify that the list of the hospital's 
owners or investors who are physicians or immediate family members 
of physicians must be provided to the patient at the time the 
request for the list is made by or on behalf of the patient. We note 
that hospitals are already currently required to furnish the list of 
physician owners or investors and, thus, we believe that the impact 
of stipulating a timeframe for furnishing the list is negligible.
    We are proposing to require all hospitals to require that all 
physician owners who also are members of the hospital's medical 
staff to agree, as a condition of continued medical staff membership 
or admitting privileges, to disclose, in writing, to all patients 
they refer to the hospital any ownership or investment interest that 
is held by themselves or by an immediate family member (as defined 
in Sec.  411.351). Disclosure would be required at the time the 
referral is made. Both hospitals and physicians would participate in 
the disclosure process. We believe this proposal would have a small 
effect on physician-owned hospitals to the extent that it may 
require them to change their bylaws or make similar changes.
    We do not anticipate that our proposals in section VII. of the 
preamble of this proposed rule would have a significant economic 
impact on a substantial number of physicians, other health care 
providers and suppliers, or the Medicare or Medicaid programs and 
their beneficiaries. Specifically, we believe that this proposed 
rule would affect mostly hospitals, physicians, and beneficiaries. 
The proposed changes concerning both the definition of a physician-
owned hospital and the disclosure of physician ownership in 
hospitals are consistent with the physician self-referral statute 
and regulations as well as the current practices of most hospitals. 
Thus, our proposed requirement that the list of physician owners be 
provided to the patient at the time the request for the list is made 
by or on behalf of the patient would present a negligible economic 
impact on the hospital. Similarly, the cost borne by individual 
physicians to implement these provisions would be limited to a one-
time cost associated with developing a disclosure notice that would 
be shared with patients at the time the referral is made in addition 
to the negligible time associated with providing the list to the 
patient and maintaining a copy of the notice in the patient's 
medical record.
    We are also proposing to provide authority for CMS to terminate 
the Medicare provider agreement of any hospital that fails to 
furnish the required written notice that a physician is not 
available 24 hours per day, 7 days per week and to describe how the 
hospital will meet the medical needs of any patient who develops an 
emergency medical condition at a time when there is no physician 
present in the hospital. We believe that the cost borne by hospitals 
to implement this proposal would be limited to a one-time cost 
associated with completing minor revisions to the hospital's 
policies and procedures to comply with the requirements of its 
Medicare provider agreement. Most hospitals have standard procedures 
to satisfy CMS by correcting deficiencies (such as the failure to 
furnish notice of physician ownership in the hospital to patients) 
before action is taken by CMS to terminate the Medicare provider 
agreement.
    Overall, we believe that beneficiaries would be positively 
impacted by these provisions. Specifically, disclosure of physician 
ownership or investment interests equips patients to make informed 
decisions about where they elect to receive care. Our proposals make 
no significant changes that have the potential to impede patient 
access to health care facilities and services. In fact, we believe 
that our proposals would help minimize anti-competitive behavior 
that can affect the decision as to where a beneficiary receives 
health care services and possibly the quality of the services 
furnished.

L. Effects of Proposed Changes Relating to Physician Self-Referral 
Provisions

    In section VIII. of the preamble of this proposed rule, we 
discuss our proposals pertaining to physician self-referral 
provisions, including: stand in the shoes, period of disallowance, 
and reporting of financial relationships between hospitals and 
physicians. We do not anticipate that our proposals would have a 
significant impact on physicians, other health care providers and 
suppliers, or the Medicare or Medicaid programs and their 
beneficiaries.
    With respect to the proposals to modify the physician ``stand in 
the shoes'' provisions, we do not anticipate that entities that 
include one or more physician organizations would find it necessary 
to restructure their organizational relationships. We believe that 
if either of our alternative approaches is adopted, compliance with 
the ``stand in the shoes'' provisions would be made easier by 
simplifying the required analysis of arrangements in which a 
physician organization is interposed between the referring physician 
and the entity furnishing DHS. In addition to our proposals 
concerning the physician ``stand in the shoes'' provisions, we are 
making an entity ``stand in the shoes'' proposal, whereby an entity 
that furnishes DHS would be deemed to stand in the shoes of an 
organization in which it has a 100-percent ownership interest and 
would be deemed to have the same compensation arrangements with the 
same parties and on the same terms as does the organization that it 
owns. We believe that the entity stand in the shoes proposal may 
result in more financial relationships between entities and 
physicians being subject to the physician self-referral provisions, 
but we are unable to quantify at this time the possible increase or 
determine the effect of the proposal on the referral patterns or 
organization structures of DHS entities and their wholly-owned 
organizations. Rather, we welcome public comments on these issues.
    Our proposal pertaining to the period of disallowance is a 
codification of what we believe is existing law and reflects what we 
believe most entities furnishing DHS are already following. 
Therefore, we do not anticipate a significant economic impact on the 
industry.

M. Effects of Proposed Changes Relating to Reporting of Financial 
Relationships Between Hospitals and Physicians

    As discussed in section IX. of the preamble to this proposed 
rule, we are proposing to require that 500 hospitals furnish 
information concerning their financial relationships with their 
physicians. The financial relationships include ownership and 
investment interests and compensation arrangements. We are proposing 
that this information be submitted in a collection of information 
instrument that CMS has developed--the ``DFRR,'' which is included 
in Appendix C to this proposed rule. We are unable to quantify the 
number of physicians who have ownership and investment interests and 
compensation arrangements with hospitals. Even if we assume that the 
500 hospitals have a substantial number of financial relationships 
with physicians, we believe that, in general, the economic impact on 
these hospitals would not be substantial. Because we are proposing 
that the DFRR be completed by hospitals and that the

[[Page 23918]]

physician information requested in the DFRR will be on file at the 
hospital, we believe there should be negligible, if any, impact upon 
physicians or other health care providers or suppliers. 
Specifically, we believe that the cost to complete the DFRR for each 
hospital would be approximately $1,550, and the total cost burden 
for the industry would be approximately $775,000.
    We expect that this proposed rule may result in savings to the 
Medicare program by minimizing anti-competitive business 
arrangements as well as financial incentives that encourage 
overutilization. In addition, to the extent that we determine that 
any arrangements are noncompliant with the physician self-referral 
statute and regulations, there may be monies returned to the 
Medicare Trust Fund. We cannot gauge with any certainty the extent 
of these savings to the Medicare program at this time. Finally, we 
do not anticipate any financial burden on beneficiaries or impact on 
beneficiary access to medically necessary services because the 
completion of the DFRR would be conducted by hospitals.

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 (see Sec.  412.340). Under the hold-harmless 
methodology, unless a hospital elected payment based on 100 percent 
of the capital Federal rate, hospitals were paid 85 percent of 
reasonable costs for old capital costs (100 percent for SCHs) plus 
an amount for new capital costs based on a proportion of the capital 
Federal rate (see Sec.  412.344). As we state in section V. of the 
preamble of this proposed rule, with the 10-year transition period 
ending with hospital cost reporting periods beginning on or after 
October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective 
payment system payments for most hospitals are based solely on the 
capital Federal rate. Therefore, we no longer include information on 
obligated capital costs or projections of old capital costs and new 
capital costs, which were factors needed to calculate payments 
during the transition period, for our impact analysis.
    The basic methodology for determining a capital PPS payment is 
set forth at Sec.  412.312. The basic methodology for calculating 
capital IPPS payments in FY 2009 would be as follows: (Standard 
Federal Rate) x (DRG weight) x (GAF) x (COLA for hospitals located 
in Alaska and Hawaii) x (1 + Disproportionate Share Adjustment 
Factor + IME Adjustment Factor, if applicable).
    We note that, in accordance with Sec.  412.322(c), the IME 
adjustment factor for FY 2009 is equal to half of the current 
adjustment, as discussed in section V.B.2. of the preamble of this 
proposed rule. In addition, hospitals may also receive outlier 
payments for those cases that qualify under the threshold 
established for each fiscal year.
    The data used in developing the impact analysis presented below 
are taken from the December 2007 update of the FY 2007 MedPAR file 
and the December 2007 update of the Provider-Specific File that is 
used for payment purposes. Although the analyses of the proposed 
changes to the capital prospective payment system do not incorporate 
cost data, we used the December 2007 update of the most recently 
available hospital cost report data (FYs 2005 and 2006) 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 III. of the Addendum to this proposed rule, as we 
established for FY 2008, we are proposing to adjust the national 
capital rate to account for improvements in documentation and coding 
under the MS-DRGs in FY 2009. (As discussed in section III.A.6. of 
the Addendum to this proposed rule, we are not proposing to adjust 
the Puerto Rico specific capital rate to account for improvements in 
documentation and coding under the MS-DRGs in FY 2009.) Furthermore, 
due to the interdependent nature of the IPPS, it is very difficult 
to precisely quantify the impact associated with each proposed 
change. In addition, we draw upon various sources for the data used 
to categorize hospitals in the tables. In some cases (for instance, 
the number of beds), there is a fair degree of variation in the data 
from different sources. We have attempted to construct these 
variables with the best available sources overall. However, for 
individual hospitals, some miscategorizations are possible.
    Using cases from the December 2007 update of the FY 2007 MedPAR 
file, we simulated payments under the capital PPS for FY 2008 and FY 
2009 for a comparison of total payments per case. Any short-term, 
acute care hospitals not paid under the general IPPS (Indian Health 
Service hospitals and hospitals in Maryland) are excluded from the 
simulations.
    As we explain in section III.A. of the Addendum to this proposed 
rule, payments are no longer made under the regular exceptions 
provision under Sec. Sec.  412.348(b) through (e). Therefore, we no 
longer use the actuarial capital cost model (described in Appendix B 
of the August 1, 2001 proposed rule (66 FR 40099)). We modeled 
payments for each hospital by multiplying the capital Federal rate 
by the GAF and the hospital's case-mix. We then added estimated 
payments for indirect medical education (which are reduced by 50 
percent in FY 2009 in accordance with Sec.  412.322(c), as discussed 
in section V.B.2. of the preamble of this proposed rule), 
disproportionate share, and outliers, if applicable. For purposes of 
this impact analysis, the model includes the following assumptions:
    <bullet> We estimate that the Medicare case-mix index will 
increase by 1.0 percent in both FYs 2008 and 2009. (We note that 
this does not reflect the expected growth in case-mix due to 
improvement in documentation and coding under the MS-DRGs, as 
discussed below.)
    <bullet> We estimate that the Medicare discharges will be 13.2 
million in FY 2008 and 13.3 million in FY 2009 for an approximately 
0.4 percent increase from FY 2008 to FY 2009.
    <bullet> 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 VIII. of the 
preamble and section III.A.2.1. of the Addendum to this proposed 
rule, the proposed FY-2009 update is 0.7 percent.
    <bullet> In addition to the proposed FY 2009 update factor, the 
proposed FY 2009 capital Federal rate was calculated based on a 
proposed GAF/DRG budget neutrality factor of 1.0007, a proposed 
outlier adjustment factor of 0.9427, and a proposed exceptions 
adjustment factor of 0.9998.
    <bullet> For FY 2009, as discussed in section III.A. of the 
Addendum to this proposed rule, the proposed FY 2009 national 
capital rate was further adjusted by a factor to account for 
anticipated improvements in documentation and coding that are 
expected to increase case-mix under the MS-DRGs. In the FY 2008 IPPS 
final rule with comment period (72 FR 47186), we established 
adjustments to the IPPS rates based on the Office of the Actuary 
projected case-mix growth resulting from improved documentation and 
coding of 1.2 percent for FY 2008, 1.8 percent for FY 2009, and 1.8 
percent for FY 2010. However, we reduced the documentation and 
coding adjustment to -0.6 percent for FY 2008, and for FY 2009, we 
are proposing to apply an adjustment of 0.9 percent, consistent with 
section 7 of Pub. L. 110-90. As noted above and as discussed in 
section III.A.6. of the Addendum to this proposed rule, we are not 
proposing to adjust the Puerto Rico-specific capital rate to account 
for improvements in documentation and coding under the MS-DRGs in FY 
2009.

B. Results

    We used the actuarial model described above to estimate the 
potential impact of our proposed changes for FY 2009 on total 
capital payments per case, using a universe of 3,528 hospitals. As 
described above, the individual hospital payment parameters are 
taken from the best available data, including the December 2007 
update of the FY 2007 MedPAR file, the December 2007 update to the 
PSF, and the most recent cost report data from the December 2007 
update of HCRIS. In Table III, we present a comparison of total 
payments per case for FY 2008 compared to proposed FY 2009 based on 
the proposed FY 2009 payment policies. Column 2 shows estimates of 
payments per case under our model for FY 2008. Column 3 shows 
estimates of payments per case under our model for FY 2009. Column 4 
shows the total percentage change in payments from FY 2008 to FY 
2009. The change represented in Column 4 includes the proposed 0.7 
percent update to the capital Federal rate, other changes in the 
adjustments to the capital Federal rate (for example, the 50 percent 
reduction to the teaching adjustment for FY

[[Page 23919]]

2009), and the additional 0.9 percent reduction to the national 
capital rate to account for improvements in documentation and coding 
(or other changes in coding that do not reflect real changes in 
case-mix) for implementation of the MS-DRGs. Consistent with the 
impact analysis for the proposed policy changes under the IPPS for 
operating costs in section VI. of this Appendix, for purposes of 
this impact analysis, we also assume a 1.8 percent increase in case-
mix growth for FY 2009, as determined by the Office of the Actuary, 
because we believe the adoption of the MS-DRG will result in case-
mix growth due to documentation and coding changes that do not 
reflect real changes in patient severity of illness. 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 2009 can be expected to remain about the same as 
capital payments per case in FY 2008. The proposed capital rate for 
FY 2009 would decrease 1.14 percent as compared to the FY 2008 
capital rate, and the proposed changes to the GAFs are expected to 
result in a slight decrease (0.3 percent) in capital payments. In 
addition, the 50 percent reduction to the teaching adjustment in FY 
2009 will also result in a decrease in capital payments from FY 2008 
as compared to FY 2009. Countering these factors is the projected 
case-mix growth as a result of improved documentation and coding 
(discussed above) as well as an estimated increase in outlier 
payments in FY 2008 as compared to FY 2009. The net result of these 
changes is an estimated 0.0 percent change in capital payments per 
discharge from FY 2008 to FY 2009 for all hospitals (as shown below 
in Table III).
    The results of our comparisons by geographic location and by 
region are consistent with the results we expected with the decrease 
to the teaching adjustment in FY 2009 (Sec.  412.522(c)). The 
geographic comparison shows that all urban hospitals are expected to 
experience no change in capital IPPS payments per case in FY 2009 as 
compared to FY 2008, while hospitals in large urban areas are 
expected to experience a slight decrease (0.3 percent) in capital 
IPPS payments per case in FY 2009 as compared to FY 2008. Capital 
IPPS payments per case for rural hospitals are expected to increase 
0.5 percent. These differences in payments per case by geographic 
location are mostly due to the decrease in the teaching adjustment. 
Because teaching hospitals generally tend to be located in urban or 
large urban areas, we would expect that the 50 percent decrease in 
the teaching adjustment for FY 2009 would have a more significant 
impact on hospitals in those areas than those hospitals located in 
rural areas.
    Most regions are estimated to experience an increase in total 
capital payments per case from FY 2008 to FY 2009. These increases 
vary by region and range from a 1.9 percent increase in the Pacific 
urban and West South Central urban regions to a 0.1 percent increase 
in the East North Central urban region. Two urban regions are 
projected to experience a relatively larger decrease in capital 
payments, with the difference mostly due to proposed changes in the 
GAFs and the 50 percent reduction in the teaching adjustment for FY 
2009: -2.7 percent in the Middle Atlantic urban region and -3.6 
percent in the New England urban region. The East North Central 
urban region is also expected to experience a decrease of 0.1 
percent in capital payments in FY 2009 as compared to FY 2008, 
mostly due to proposed changes in the GAFs. There are two rural 
regions that expected to experience a decrease in total capital 
payments per case: A -4.5 percent decrease in the New England rural 
region and a -1.0 percent decrease in the Middle Atlantic rural 
region. Again, for these two rural regions, the projected decrease 
in capital payments is mostly due to proposed changes in the GAF, as 
well as a smaller than average increase in changes payments due to 
the adoption of the MS-DRGs.
    By type of ownership, voluntary and government hospitals are 
estimated to experience a decrease of 0.2 percent and 0.8 percent, 
respectively. The projected decrease in capital payments per case is 
primarily due to the 50 percent teaching adjustment reduction for FY 
2009. Proprietary hospitals are estimated to experience an increase 
in capital payments per case of 1.6 percent. This estimated increase 
in capital payments is mostly due to a smaller than average decrease 
in payments resulting from the 50 percent teaching adjustment 
reduction for FY 2009.
    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 2009. 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 2009, we show the average capital payments per case for 
reclassified hospitals for FY 2008. Urban reclassified hospitals are 
expected to have the largest decrease in capital payments of 0.4 
percent, while rural reclassified hospitals are expected to have the 
largest increase in capital payments of 1.0 percent. Urban 
nonreclassified hospitals are not expected to experience any change 
in capital payment from FY 2008 to FY 2009, while rural 
nonreclassified hospitals are expected to experience a slight 
decrease in capital payments of 0.3 percent. The projected changes 
in capital payments for rural hospitals are mainly due to the 
proposed changes to the GAF (including the proposal to apply the 
rural floor budget neutrality at a State level). The projected 
changes in capital payments for urban hospitals are mainly due to 
the 50 percent reduction in the teaching adjustment in FY 2009.

                            Table III.--Comparison of Total Capital Payments Per Case
                                 [FY 2008 payments compared to FY 2009 payments]
----------------------------------------------------------------------------------------------------------------
                                                                            Average FY   Average FY
                                                               Number of       2008         2009
                                                               hospitals    payments/    payments/      Change
                                                                               case         case
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...........................................        3,528          757          757          0.0
    Large urban areas (populations over 1 million)..........        1,402          834          831         -0.3
    Other urban areas (populations of 1 million or fewer)...        1,140          752          754          0.3
    Rural areas.............................................          986          528          531          0.5
    Urban hospitals.........................................        2,542          796          796          0.0
        0-99 beds...........................................          643          632          642          1.6
        100-199 beds........................................          829          684          692          1.1
        200-299 beds........................................          483          752          758          0.8
        300-499 beds........................................          411          829          827         -0.3
        500 or more beds....................................          176          973          957         -1.7
    Rural hospitals.........................................          986          528          531          0.5
        0-49 beds...........................................          338          429          427         -0.5
        50-99 beds..........................................          373          485          487          0.4
        100-149 beds........................................          166          532          537          1.0
        150-199 beds........................................           67          586          595          1.4
        200 or more beds....................................           42          652          652          0.0
By Region:

[[Page 23920]]

 
    Urban by Region.........................................        2,542          796          796          0.0
        New England.........................................          121          835          805         -3.6
        Middle Atlantic.....................................          348          858          835         -2.7
        South Atlantic......................................          385          755          763          1.1
        East North Central..................................          394          777          770         -0.9
        East South Central..................................          163          719          727          1.2
        West North Central..................................          157          777          779          0.2
        West South Central..................................          371          747          761          1.9
        Mountain............................................          157          807          822          1.8
        Pacific.............................................          393          925          943          1.9
        Puerto Rico.........................................           53          367          368          0.3
    Rural by Region.........................................          986          528          531          0.5
        New England.........................................           23          706          675         -4.5
        Middle Atlantic.....................................           70          543          537         -1.0
        South Atlantic......................................          172          516          524          1.5
        East North Central..................................          121          555          555          0.1
        East South Central..................................          176          480          484          0.9
        West North Central..................................          113          560          567          1.1
        West South Central..................................          200          479          483          0.8
        Mountain............................................           75          533          539          1.2
        Pacific.............................................           36          650          660          1.6
By Payment Classification:
    All hospitals...........................................        3,528          757          757          0.0
    Large urban areas (populations over 1 million)..........        1,424          832          830         -0.3
    Other urban areas (populations of 1 million or fewer)...        1,160          750          752          0.3
    Rural areas.............................................          944          528          531          0.6
    Teaching Status:
        Non-teaching........................................        2,484          643          657          2.1
        Fewer than 100 Residents............................          805          765          769          0.5
        100 or more Residents...............................          238        1,085        1,037         -4.4
        Urban DSH:
            100 or more beds................................        1,534          823          820         -0.3
            Less than 100 beds..............................          354          567          573          1.2
        Rural DSH:
            Sole Community (SCH/EACH).......................          389          467          469          0.4
            Referral Center (RRC/EACH)......................          206          584          589          0.8
            Other Rural:
                100 or more beds............................           39          489          493          0.8
                Less than 100 beds..........................          168          438          438          0.1
    Urban teaching and DSH:
        Both teaching and DSH...............................          811          896          881         -1.6
        Teaching and no DSH.................................          172          784          777         -0.8
        No teaching and DSH.................................        1,077          683          700          2.5
        No teaching and no DSH..............................          524          702          716          2.0
    Rural Hospital Types:
        Non special status hospitals                                2,459          800          799         -0.1
        RRC/EACH............................................           63          700          714          2.0
        SCH/EACH............................................           36          654          659          0.8
        Medicare-dependent hospitals (MDH)..................           11          457          456         -0.2
        SCH, RRC and EACH...................................           15          751          776          3.4
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board:
    FY 2009 Reclassifications:
        All Urban Reclassified..............................          445          802          799         -0.4
        All Urban Non-Reclassified..........................        2,075          796          796          0.0
        All Rural Reclassified..............................          360          573          579          1.0
        All Rural Non-Reclassified..........................          565          459          458         -0.3
        Other Reclassified Hospitals (Section 1886(d)(8)(B))           54          535          538          0.5
    Type of Ownership:
        Voluntary...........................................        2,027          770          769         -0.2
        Proprietary.........................................          827          699          710          1.6
        Government..........................................          587          752          746         -0.8
    Medicare Utilization as a Percent of Inpatient Days:
        0-25................................................          255          998          971         -2.8
        25-50...............................................        1,350          847          843         -0.5
        50-65...............................................        1,431          671          677          0.9
        Over 65.............................................          392          598          601          0.5
----------------------------------------------------------------------------------------------------------------


[[Page 23921]]

IX. Alternatives Considered

    This proposed rule contains a range of proposed policies. The 
preamble of this proposed rule provides descriptions of the 
statutory provisions that are addressed, identifies those proposed 
policies when discretion has been exercised, and presents rationale 
for our decisions and, where relevant, alternatives that were 
considered.

X. Overall Conclusion

    The changes we are proposing in this proposed rule will affect 
all classes of hospitals. Some hospitals are expected to experience 
significant gains and others less significant gains, but overall 
hospitals are projected to experience positive updates in IPPS 
payments in FY 2009. Table I of section VI. of this Appendix 
demonstrates the estimated distributional impact of the IPPS budget 
neutrality requirements for proposed MS-DRG and wage index changes, 
and for the wage index reclassifications under the MGCRB. Table I 
also shows an overall increase of 4.1 percent in operating payments. 
We estimate operating payments to increase by $3.96 billion. This 
accounts for the projected savings associated with the postacute 
care transfer policy proposal and the HACs policy, which each have 
an estimated savings of $50 million. In addition, this estimate 
includes the hospital reporting of quality data program costs ($2.39 
million) and all proposed operating payment policies as described in 
section VII. of this Appendix. Capital payments are estimated to 
increase by 0.0 percent per case, as shown in Table III of section 
VIII. of this Appendix. Therefore, we project that the increase in 
capital payments in FY 2009 compared to FY 2008 is negligible ($6 
million). The proposed operating and capital payments should result 
in a net increase of $3.967 billion to IPPS providers. The 
discussions presented in the previous pages, in combination with the 
rest of this proposed rule, constitute a regulatory impact analysis.

XI. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf), in Table IV below, we 
have prepared an accounting statement showing the classification of 
the expenditures associated with the provisions of this proposed 
rule. This table provides our best estimate of the increase in 
Medicare payments 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 IV.--Accounting Statement: Classification of Estimated
                  Expenditures From FY 2008 to FY 2009
------------------------------------------------------------------------
                Category                            Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers.........  $3.967 Billion.
From Whom to Whom......................  Federal Government to IPPS
                                          Medicare Providers.
                                        --------------------------------
    Total..............................  $3.967 Billion.
------------------------------------------------------------------------

XII. Executive Order 12866

    In accordance with the provisions of Executive Order 12866, the 
Office of Management and Budget reviewed this proposed rule.

Appendix B: Recommendation of Update Factors for Operating Cost Rates 
of Payment for Inpatient Hospital Services

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 and high quality care. Under section 1886(e)(5)(B) 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 rate-of-increase limits for hospitals and 
hospital units 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 2009

    Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 
5001(a) of Pub. L. 109-171, sets the FY 2009 percentage increase in 
the operating cost standardized amount equal to the rate-of-increase 
in the hospital market basket for IPPS hospitals in all areas, 
subject to the hospital submitting quality information under rules 
established by the Secretary in accordance with 1886(b)(3)(B)(viii) 
of the Act. For hospitals that do not provide these data, the update 
is equal to the market basket percentage increase less 2.0 
percentage points. Consistent with current law, based on Global 
Insight, Inc.'s first quarter 2008 forecast of the FY 2009 market 
basket increase, we are estimating that the FY 2009 update to the 
standardized amount will be 3.0 percent (that is, the current 
estimate of the market basket rate-of-increase) for hospitals in all 
areas, provided the hospital submits quality data in accordance with 
our rules. For hospitals that do not submit quality data, we are 
estimating that the update to the standardized amount will be 1.0 
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 2009, we are applying 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 3.0 percent.
    Section 1886(b)(3)(B)(iv) of the Act sets the FY 2009 percentage 
increase in the hospital-specific rates applicable to SCHs and MDHs 
equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act 
(that is, the same update factor as for all other hospitals subject 
to the IPPS, or the rate-of-increase in the market basket). 
Therefore, the update to the hospital-specific rates applicable to 
SCHs and MDHs is estimated to be 3.0 or 1.0 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 
Sec.  403.752(a) of the regulations, RNHCIs are paid under Sec.  
413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to 
update the percentage increase in the rate-of-increase limits. 
Section 1886(j)(3)(C) of the Act addresses the increase factor for 
the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 
106-113, as amended by section 307(b) of Pub. L. 106-554, provides 
the statutory authority for updating payment rates under the LTCH 
PPS. As discussed below, for cost reporting periods beginning on or 
after October 1, 2006, LTCHs that are not defined as new under Sec.  
412.23(e)(4), and that had not elected to be paid under 100 percent 
of the Federal rate are paid 100 percent of the adjusted Federal PPS 
rate. Therefore, because no portion of LTCHs' prospective payments 
will be based on reasonable cost concepts for cost reporting periods 
beginning on or after October 1, 2006, we are not proposing a rate-
of-increase percentage to the reasonable cost portion for FY 2009 
for LTCHs to be used under Sec.  413.40. In addition, section 124 of 
Pub. L. 106-113 provides the statutory authority for updating all 
aspects of the payment rates for IPFs. Under this broad authority, 
IPFs that are not defined as new under Sec.  412.426(c) are paid 
under a blended methodology for cost reporting periods beginning on 
or after January 1, 2005, and before January 1, 2008. For cost 
reporting periods beginning on or after January 1, 2008, existing 
IPFs are paid based on 100 percent of the Federal per diem rate. 
Therefore, because no portion of the existing IPFs prospective 
payments will be based on reasonable cost concepts for cost 
reporting periods beginning on or after

[[Page 23922]]

January 1, 2008, we are not proposing a rate-of-increase percentage 
to the reasonable cost portion for FY 2009 for IPFs to be used under 
Sec.  412.426(c). New IPFs are paid based on 100 percent of the 
Federal per diem payment amount.
    Currently, children's hospitals, cancer hospitals, and RNHCIs 
are the remaining three types of hospitals still reimbursed under 
the reasonable cost methodology. We are providing our current 
estimate of the FY 2009 IPPS operating market basket percentage 
increase (3.0 percent) to update the target limits for children's 
hospitals, cancer hospitals, and RNHCIs.
    Effective for cost reporting periods beginning on or after 
October 1, 2002, LTCHs have been paid under the LTCH PPS. 
Additionally, for cost reporting periods beginning on or after 
October 1, 2006, no portion of a LTCH's PPS payments can be based on 
reasonable cost concepts. Consequently, there is no need to propose 
to update the target limit under Sec.  413.40 effective October 1, 
2008, for LTCHs.
    In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), 
we proposed an update of 2.6 percent to the LTCH PPS Federal rate 
for RY 2009, which is based on a proposed market basket increase of 
3.5 percent and a proposed adjustment of 0.9 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. The 
proposed market basket of 3.5 percent used in determining this 
proposed update factor is based on our proposal in the LTCH proposed 
rule to extend the LTCH RY 2009 by 3 months (a total of 15 months 
instead of 12 months) through September 30, 2009. (A full discussion 
of the reasons for this proposed extension of RY 2009 can be found 
in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).) 
However, if we were not proposing to extend the 2009 LTCH PPS rate 
year by 3 months, we would have proposed a market basket update of 
3.1 percent for a 12-month RY 2009 offset by the proposed adjustment 
of 0.9 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. For cost reporting periods beginning on or after January 
1, 2005, and before January 1, 2008, existing IPFs (those not 
defined as ``new'' under Sec.  412.426(c)) are paid based on a blend 
of the reasonable cost-based PPS payments and the Federal per diem 
base rate. For cost reporting periods beginning on or after January 
1, 2008, existing IPFs are paid based on 100 percent of the Federal 
per diem rate. Consequently, there is no need to propose to update 
the target limit under Sec.  412.426(c) effective October 1, 2008, 
for IPFs.
    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). Section 1886(j)(3)(C) of the Act, as amended by 
section 115 of Pub. L. 110-173 sets the FY 2009 IRF PPS update 
factor equal to 0 percent. Thus, we are not applying an update 
(market basket) to the IRF PPS rates for FY 2009.

III. Secretary's Recommendation

    MedPAC is recommending an inpatient hospital update equal to the 
market basket rate of increase for FY 2009. MedPAC's rationale for 
this update recommendation is described in more detail below. Based 
on the FY 2009 President's Budget, we are recommending an update to 
the standardized amount of 0 percent. We are recommending that this 
same update factor apply to SCHs and MDHs.
    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 2009, we are applying 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 3.0 percent.
    In addition to making a recommendation for IPPS hospitals, in 
accordance with section 1886(e)(4)(A) of the Act, we are also 
recommending update factors for all other types of hospitals. 
Consistent with the President's Budget, we are recommending an 
update based on the IPPS market basket increase for children's 
hospitals, cancer hospitals, and RNHCIs of 0 percent. As mentioned 
above, for cost reporting periods beginning on or after January 1, 
2008, existing IPFs are paid based on 100 percent of the Federal per 
diem rate (and are no longer paid a blend of the reasonable cost-
based PPS payments and the Federal per diem base rate). 
Consequently, we are no longer recommending an update factor for the 
portion of the payment that is based on reasonable costs. Consistent 
with the President's Budget, based on Global Insight, Inc.'s first 
quarter 2008 forecast of the RPL market basket increase, we are 
recommending an update to the IPF PPS Federal rate for RY 2009 of 
3.2 percent for the Federal per diem payment amount.
    In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), 
we proposed an update of 2.6 percent to the LTCH PPS Federal rate 
for RY 2009, which is based on a proposed market basket increase of 
3.5 percent and a proposed adjustment of 0.9 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. The 
proposed market basket of 3.5 percent used in determining this 
proposed update factor is based on our proposal in the LTCH proposed 
rule to extend the LTCH RY 2009 by 3 months (a total of 15 months 
instead of 12 months) through September 30, 2009. (A full discussion 
on the reasons for this proposed extension of RY 2009 can be found 
in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).) 
However, if we were not proposing to extend the 2009 LTCH PPS rate 
year by 3 months, we would have proposed a market basket update for 
a 12 month RY 2009 of 3.1 percent in determining the proposed update 
factor for RY 2009 offset by the proposed adjustment of 0.9 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.
    Finally, consistent with the President's FY 2009 Budget, we are 
recommending a zero percent update to the IRF PPS Federal rate for 
FY 2009. This recommendation is consistent with the zero percent 
increase factor specified in section 1886(j)(3)(C) of the Act, as 
amended by section 115 of Pub. L. 110-173.

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating 
Payments in Traditional Medicare

    In its March 2008 Report to Congress, MedPAC assessed the 
adequacy of current payments and costs, and the relationship between 
payments and an appropriate cost base, utilizing an established 
methodology used by MedPAC in the past several years.
    MedPAC recommended an update to the hospital inpatient rates 
equal to the increase in the hospital market basket in FY 2009, 
concurrent with implementation of a quality incentive program. 
Similar to last year, MedPAC also recommended that CMS put pressure 
on hospitals to control their costs rather than accommodate the 
current rate of cost growth, which is, in part, caused by a lack of 
pressure from private payers.
    MedPAC noted that indicators of payment adequacy are almost 
uniformly positive. MedPAC expects Medicare margins to remain low in 
2008. At the same time though, MedPAC's analysis finds that 
hospitals with low non-Medicare profit margins have below average 
standardized costs and most of these facilities have positive 
overall Medicare margins.
    Response: Similar to our response last year, we agree with 
MedPAC that hospitals should control costs rather than accommodate 
the current rate of growth. An update equal to less than the market 
basket will motivate hospitals to control their costs, consistent 
with MedPAC's recommendation. 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.
    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 proposing to continue to use 
separate updates for operating and capital payments. The proposed 
update to the

[[Page 23923]]

capital rate is discussed in section III of the Addendum to this 
proposed rule.

Appendix C--Disclosure of Financial Relationship Report (DFRR) Form

Disclosure of Financial Relationship Report (DFRR)

Requirement

    Completion of the Disclosure of Financial Relationship Report 
(DFRR or Report) is required under section 1877(f) of the Social 
Security Act. The Report must be completed, certified by the 
appropriate officer of the hospital, and received by CMS within 60 
days of the date that appears on the cover letter or e-mail 
transmission. Pursuant to 42 CFR 411.361(f), failure to timely 
submit the requested information concerning an entity's ownership, 
investment, and compensation arrangements may result in civil 
monetary penalties of up to $10,000 for each day beyond the deadline 
established for disclosure.
    Please be advised that the results from the DFRR may be shared 
with other Federal agencies and with Congressional committees, as 
permitted or mandated by law. We intend to protect from public 
disclosure, to the fullest extent permitted by Exemptions 4 and 6 of 
the Freedom of Information Act, 5 U.S.C. 552(b)(4) and (6), any 
confidential business information and any individual-specific 
information collected. We note that CMS is prevented by the Trade 
Secrets Act, 18 U.S.C. 1905, from releasing confidential business 
information, except as authorized by law.
    Information collected from each hospital will be analyzed 
separately to determine whether the financial relationships are in 
compliance with the physician self-referral laws and implementing 
regulations. At this time, we do not plan to aggregate data.

Exception to Mandatory Reporting

    An entity that furnishes 20 or fewer Part A and/or Part B 
services during a calendar year is excepted from this reporting 
requirement pursuant to 42 CFR 411.361(b). If you believe that the 
hospital qualifies for this exception:
    <bullet> The Chief Executive Officer, Chief Financial Officer, 
or a comparable officer of the Hospital must certify in writing that 
the hospital furnishes 20 or fewer Part A and/or Part B services 
during a calendar year.
    <bullet> The certification statement must read as follows: ``I, 
(insert name), hereby certify that, to the best of my knowledge and 
belief, (insert name of Hospital) furnishes 20 or fewer Part A and/
or Part B services during a calendar year. Therefore the hospital is 
relying on the exception in 42 CFR 411.361(b) and will not be 
reporting financial relationship data concerning the facility.'' The 
certification statement must be signed and dated, and include the 
title of the signatory.
    <bullet> If the hospital or entity qualifies for the exception 
at 42 CFR 411.361(b), please mail the original and one copy of the 
signed certification statement to: Physician Self-Referral, Centers 
for Medicare & Medicaid Services, 7500 Security Boulevard, Mailstop 
C4-25-02, Baltimore, Maryland 21244-1850. In addition, we request, 
but do not require, that you e-mail a PDF or other electronically 
scanned version of the document to <a href="/cdn-cgi/l/email-protection#afe7e0fcffe6fbeee3ebe6fcece3e0fcfafdeaefccc2dc81c7c7dc81c8c0d9"><span class="__cf_email__" data-cfemail="e6aea9b5b6afb2a7aaa2afb5a5aaa9b5b3b4a3a6858b95c88e8e95c8818990">[email protected]</span></a>. 
In the subject line, please include the title ``Exception to 
Disclosure Report.''

General Instructions for DFRR

    <bullet> The requested disclosures on Worksheets 1 through 6 
pertain only to hospitals with physician ownership or investment. 
For purposes of this Report, ownership is synonymous with 
investment.
    <bullet> For any question pertaining to the financial 
relationship between a physician and the Hospital or entity or 
individual, ``physician'' shall include each immediate family member 
of the physician, as defined in 42 CFR 411.351.
    <bullet> The terms, ``physician-owner'' and ``physician-
investor'' are used interchangeably throughout this report.
    <bullet> Please provide the physician's last name, first name, 
and Medicare National Provider Identifier (NPI). Only for those 
physicians who have not yet received an NPI, may the physician's 
Unique Physician Identification Number (UPIN) be submitted instead. 
We will not accept a hospital created identifier (for example, 
Physician 1, Physician 2, etc.).
    <bullet> Where supporting documentation or an explanation is 
requested, please include the name of the physician-owner or 
physician-investor, and his/her NPI.
    <bullet> Supplemental documents should be provided only when 
specifically requested on a worksheet. Supporting documentation 
should be organized and clearly labeled to reference the relevant 
worksheet. Please include only information that responds to the 
question asked; extraneous information should not be included. For 
example, if only a few pages of a large document are responsive to a 
question, please only submit those relevant pages.
    <bullet> If a particular question does not apply to the 
hospital, please type ``N/A.''
    <bullet> If sufficient rows are not provided, please save the 
Excel spreadsheet, insert the necessary number of additional rows, 
and print a copy of the revised Excel spreadsheet.
    <bullet> Upon completion of the entire DFRR, please verify all 
information presented (including the totals for the respective 
fields or columns) and return an original and one copy to: Physician 
Self-Referral, Centers for Medicare & Medicaid Services, 7500 
Security Boulevard, Mailstop C4-25-02, Baltimore, Maryland 21244-
1850. CMS also requests, but does not require, that a PDF or other 
electronically scanned version of the DFRR and accompanying 
documentation be sent to <a href="/cdn-cgi/l/email-protection#7c34332f2c35283d3038352f3f30332f292e393c1f110f5214140f521b130a"><span class="__cf_email__" data-cfemail="7f37302c2f362b3e333b362c3c33302c2a2d3a3f1c120c5117170c51181009">[email protected]</span></a>.
    <bullet> Please enter all date fields in the following format: 
MM/DD/YY. For example, ``March 31, 2006'' must be entered as 
follows: 03/31/06.

Report Contents

    The attached report consists of the following spreadsheets:
    <bullet> Cover Sheet--(Certification Page)
    <bullet> Worksheet 1--Hospital Characteristics
    <bullet> Worksheet 2--Direct Ownership in Hospital
    <bullet> Worksheet 3--Indirect Ownership in Hospital
    <bullet> Worksheet 4--Payments Made to Hospital by Direct Owners
    <bullet> Worksheet 5--Payments Made to Hospital by Indirect 
Owners
    <bullet> Worksheet 6--Investment Reconciliation
    <bullet> Worksheet 7--Compensation Arrangements--Rentals, 
Personal Service Arrangements, and Recruitment (See 42 CFR 411.357)
    <bullet> Worksheet 8--Other Types of Compensation Arrangements 
(See 42 CFR 411.357)

Key Terms

    1. Additional Purchases: Stocks purchased after initial or 
starting investment. Report the total cost and number of additional 
shares of stock purchased.
    2. Assessments: Any cost or fee required and paid by any 
investor of the hospital. These fees usually do not involve any 
basis or change in the owner's investment in the facility.
    3. Back-up Guarantee: Physician-owner's risk of loss or 
liability related to the ownership of his or her stock is guaranteed 
by another entity. If the borrower has problems in repayment, the 
payment is guaranteed by a third party.
    4. Basis of Stock/Shares: The cost of the stock at the end of 
the cost reporting period(s) ending in 2006.
    5. Capital Calls: Each investor is asked/required to put 
additional capital in the company. Depending on the structure of the 
call, if no additional shares are issued, the basis (cost) of the 
investor's stock will increase, or if additional shares are issued, 
the number of the investor's shares will increase.
    6. Compilation of Financial Statements: A compilation presents 
information in the form of financial statements that are the 
representation of management without expressing assurances.
    7. Direct Ownership or Investment Interest: Direct ownership or 
investment interest is defined at 42 CFR 411.354(a)(2).
    8. Disproportionate Guarantee by Physician Investor: Physician 
investor's risk of loss or liability related to the ownership of 
his/her stock is guaranteed by the corporate investor in a 
disproportionate percentage to the percentage of stock owned by that 
physician investor (i.e.: Physician investor owns 40% of the stock 
of a hospital, but assumes risk of loss or liability equal to 20%.)
    9. Fair Market Value: Fair market value is defined at 42 CFR 
411.351.
    10. Hospital: Hospital is synonymous with operating entity (that 
is, the corporation or legal entity through which the hospital 
operates).
    11. Immediate family member: An immediate family member means: 
Husband or wife; birth or adoptive parent, child, or sibling; 
stepparent, stepchild, stepbrother, or stepsister; father-in-law, 
mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-
in-law; grandparent or grandchild; and spouse of a grandparent or 
grandchild. 42 CFR 411.351.
    12. Indirect Ownership or Investment Interest: An indirect 
ownership or investment interest is defined at 42 CFR 411.354(b)(5).

[[Page 23924]]

    13. Internally prepared: Internally prepared financial 
statements are prepared by employees of the hospital, and are used 
mostly to monitor the hospital's performance.
    14. Loan Guarantees: A situation when the borrower's liability 
is collateralized by a third party.
    15. NPI: Medicare National Provider Identifier.
    16. Other Capital Assessments: Report only if shares of stock 
are involved. Fees assessed should not be reported.
    17. Relinquishments or Sales: For each share of stock that is 
sold during the cost reporting period(s) in 2006, report the dollar 
amount of the sale and the number of shares sold.
    18. Reporting Period: The reporting period refers to any cost 
reporting period(s) ending in 2006.
    19. Return of Capital Dividends: A distribution that is not paid 
out of the earnings and profits of the company. This distribution 
reduces the basis of the stock.
    20. Review of Financial Statements: A review of financial 
statements is an engagement that results in an accountant's opinion 
that expresses less assurance than that of a certified audit, but 
more than a compilation. Typically this involves limited auditing, 
testing, analytical procedures, and/or inquiries.
    21. Stock/share: These terms are used interchangeably throughout 
the worksheets.
    22. Stock Dividends: Stock dividends are distributions made by a 
corporation of its own stock.

Worksheet 1--Hospital Characteristics

    <bullet> Please include month, date, and year for the beginning 
and end of your cost reporting period(s).

Worksheet 2--Direct Ownership in Hospital

    <bullet> Identify the class of stock (if applicable) and list 
all owners of that class within the same grouping on the Worksheet.
    <bullet> If the direct owner is the physician, enter ``Self'' in 
Column B.
    <bullet> If the direct owner is not the physician, please write 
the individual's name in Column A and in Column B indicate his/her 
relationship to the physician and give the physician's name.
    <bullet> The basis of the stock/shares is the cost of the stock 
at the end of the cost reporting period(s) ending in 2006. This 
amount should equal Worksheet 6, Column B, Line 18.
    <bullet> One hundred percent of ownership should be identified 
for each individual class of stock.

Worksheet 3--Indirect Ownership in Hospital

    <bullet> Report only indirect ownership interests of physicians 
and immediate family members on this Worksheet.
    <bullet> In Column A, identify each entity with ownership in the 
hospital and identify the type of entity in Column B. The entity's 
percentage of direct ownership should be listed in Column C.
    <bullet> List each investor-owner of the group entity in Column 
D. Indicate if the investor-owner is a physician. If the investor-
owner is an immediate family member, please indicate the 
relationship to, and name of the physician to whom the investor-
owner is related.
    <bullet> Column E should indicate each investor-owner's 
percentage ownership in the entity at the end of the cost reporting 
period(s) in 2006, with the number of shares owned (if applicable) 
listed in Column F. Each type of share owned (if applicable) should 
be listed individually with the type of stock labeled in Column G.
    <bullet> To calculate the percent of indirect ownership in 
Column H for each investor-owner of the entity, multiply the 
percentage in Column C by the percentage in Column E.

Worksheet 4--Payments Made to Hospital by Direct Owners

    <bullet> Report only payments to the hospital by direct 
physician-owners and immediate family member owners on this 
Worksheet.
    <bullet> Complete one line for each payment made by a physician-
owner related to his or her investment interest, including, but not 
limited to: Initial investments, assessments, capital calls, and 
loan guarantees. If necessary, please insert additional lines.
    <bullet> In Column B, indicate ``Self'' if the physician is the 
direct owner. If the direct owner is not the physician, please list 
the direct owner's name in Column A and in Column B, indicate the 
immediate family member's relationship to the physician and give the 
physician's name.
    <bullet> Do not group payments under one physician name, but 
rather use a separate line for each type of payment made by a 
physician.

Worksheet 5--Payments Made to Hospital by Indirect Owners

    <bullet> Report only payments made by indirect physician-owners 
and immediate family member owners on this Worksheet.
    <bullet> Complete one line for each payment made by an entity 
related to an investment interest, including, but not limited to: 
Initial investments, assessments, capital calls, and loan 
guarantees. If necessary, please insert additional lines.
    <bullet> List the name of the indirect ownership entity in 
Column A. In Column B, list the names of individuals that compose 
that entity, placing only one person per line and indicating his or 
her status, i.e. ``Self'' for physician, or ``IFM'' for immediate 
family member.
    <bullet> For immediate family members, enter the relationship to 
and name of, the physician family member in Column C.
    <bullet> Do not group payments under one entity name, but rather 
use a separate line for each type of payment made by an entity.

Worksheet 6--Investment Reconciliation

    <bullet> Please complete a separate Worksheet for each 
physician-owner or immediate family member owner.
    <bullet> Please provide the owner's Social Security Number (SSN) 
or NPI as appropriate.
    <bullet> If a physician owns more than one class of stock/
equity, a separate worksheet must be completed for each class of 
stock/equity.
    <bullet> Line 10, Column A--The begin date must be the start of 
the cost reporting period(s) that end(s) in 2006. That is, for a 
cost reporting period of July 1, 2005 to June 30, 2006, the begin 
date is 07/01/05.
    <bullet> Line 10, Columns B, C, and D must reflect the 
physician-owner's total investment for the class of stock/equity 
described, as of the beginning of the period being evaluated (all 
cost period(s) ending in 2006).
    <bullet> Lines 11 through 17, Columns B, C, and D must reflect 
any and all changes to the physician-owner's stock/equity during the 
period being evaluated, so that line 18 reflects the owner's total 
investment at the end of the period.
    <bullet> Line 17 must reflect all other capital assessments that 
occurred during the cost reporting period(s) ending in 2006.
    <bullet> Line 18, Column A--The end date must be the end date of 
the cost reporting period(s) that end(s) in 2006. That is, for a 
cost reporting period of July 1, 2005 to June 30, 2006, the end date 
is 06/30/06.
    <bullet> Line 18, Column B--The amount entered here should be 
equal to the amount listed on Worksheet 2, Column C for each class 
of stock for each physician owner.

Worksheet 7--Compensation Arrangements--Rentals, Personal Service 
Arrangements, and Recruitment (See 42 CFR 411.357)

    <bullet> For all physicians who had one or more of the 
compensation arrangements listed in columns A through D list the 
physician's complete name in the first column, the physician's NPI, 
and insert either a Y or N as to whether the physician is an owner/
investor of the hospital. In addition, please insert the applicable 
number of compensation arrangements in each respective column.
    <bullet> For those compensation arrangements listed in columns A 
through D, include not just those that you believe fit within an 
exception in 42 CFR 411.357, but those that are implicated by the 
referenced exception.
    <bullet> The information requested in columns A and B must 
include compensation arrangements that occur in either direction 
(i.e., rentals to/from physicians).
    <bullet> Please indicate in the appropriate column the number of 
compensation arrangements that pertain to the physician for the 
reporting period(s) ending in 2006.
    <bullet> Note that each Column A-D that is filled in with a 
number requires the submission of supporting documentation for each 
compensation arrangement. With the exception of uniform personal 
service arrangements, please submit a copy of the written 
agreement(s) that were in effect during the reporting period(s) 
ending in 2006.
    <bullet> Personal Service Arrangements (PSA--Column C)
    [cir] For each physician listed, please indicate the number of 
PSAs in effect for the cost reporting period(s) ending in 2006.
    [cir] In the next column indicate if the physician used a 
uniform PSA prepared by the hospital. We consider a PSA to be 
uniform if all of the elements present in the arrangements are 
materially the same. Only one copy of the uniform PSA should be 
included in the supplemental materials. The

[[Page 23925]]

one copy will satisfy the supporting documentation requirement for 
all physicians who entered into a uniform PSA with the hospital.
    [cir] Indicate whether or not the hospital has a signed copy of 
this agreement on file for this physician in the next sub-column 
with a Y or N.
    [cir] If the physician had a non-uniform PSA in effect for the 
cost reporting period(s) ending in 2006, please indicate this on the 
Worksheet and provide a copy of the PSA with the supplemental 
materials for this Worksheet.

Worksheet 8--Other Types of Compensation Arrangements (See 42 CFR 
411.357)

    <bullet> This Worksheet addresses other compensation 
arrangements exceptions that are found at 42 CFR 411.357.
    <bullet> Please note that you may be required to furnish an 
explanation or additional documentation depending on the answer to 
each question.
    <bullet> Submit only the information that is necessary to answer 
the question by removing extraneous documentation where possible.

Questions

    Questions regarding these instructions may be directed to: <a href="/cdn-cgi/l/email-protection#d296948080ff83a7b7a1a6bbbdbca192b1bfa1fcbabaa1fcb5bda4"><span class="__cf_email__" data-cfemail="20646672720d7155455354494f4e5360434d530e4848530e474f56">[email protected]</span></a>.
BILLING CODE 4120-01-P
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[FR Doc. 08-1135 Filed 4-14-08; 9:19 am]
BILLING CODE 4120-01-C


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