23528 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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. 

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-ofincrease 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23529 

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 diagnosisrelated group 

MS–LTC–DRG Medicare severity long-term 

care diagnosis-related group 

NAICS North American Industrial 

Classification System 

NCD National coverage determination 


jlentini on PROD1PC65 with PROPOSALS2
23530 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 HospitalSpecific Rates 

3. Application of the Documentation and 

Coding Adjustment to Puerto RicoSpecific 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 CardioverterDefibrillators (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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23531 

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. CardioWestTM Temporary Total Artificial 

Heart System (CardioWestTM TAH–t) 

b. Emphasys Medical Zephyr

Endobronchial Valve (Zephyr EBV) 

c. Oxiplex

d. TherOx Downstream 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 


jlentini on PROD1PC65 with PROPOSALS2
23532 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 CapitalRelated 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-toCharge 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 CapitalRelated 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 HospitalsWithin-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 laborrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
23534 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 hospitalspecific 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 hospitalspecific 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 

§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 capitalrelated 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 selfreferral 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—

• Proposed changes to MS–DRG 

reclassifications based on our yearly 

review. 

• Proposed application of the 

documentation and coding adjustment 

to hospital-specific rates resulting from 

implementation of the MS–DRG system. 

• Proposed changes to address the 

RTI reporting recommendations on 

charge compression. 

• 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 hospitalacquired 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: 

• 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. 

• Changes to the CBSA designations. 

• The methodology for computing the 

proposed FY 2009 wage index. 

• The proposed FY 2009 wage index 

update, using wage data from cost 

reporting periods that began during FY 

2006. 

• Analysis and implementation of the 

proposed FY 2009 occupational mix 

adjustment to the wage index. 

• Proposed revisions to the wage 

index based on hospital redesignations 

and reclassifications. 

• 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. 

• The timetable for reviewing and 

verifying the wage data used to compute 

the proposed FY 2009 wage index. 

• 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: 

• Proposed changes to the postacute 

care transfer policy as it relates to 

transfers to home with the provision of 

home health services. 

• The reporting of hospital quality 

data as a condition for receiving the full 

annual payment update increase. 

• Proposed changes in the collection 

of Medicare Advantage (MA) encounter 

data that are used for computing the risk 

payment adjustment made to MA 

organizations. 

• Discussion of the report to Congress 

on the Medicare value-based purchasing 


jlentini on PROD1PC65 with PROPOSALS2
23536 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

plan and current testing and further 

development of the plan. 

• Proposed changes to the 

methodology for determining core staff 

values for the volume decrease payment 

adjustment for SCHs and MDHs. 

• The proposed updated national and 

regional case-mix values and discharges 

for purposes of determining RRC status. 

• The statutorily-required IME 

adjustment factor for FY 2009 and 

technical changes to the GME payment 

policies. 

• Proposed changes to policies on 

hospital emergency services under 

EMTALA to address EMTALA 

Technical Advisory Group (TAG) 

recommendations. 

• Solicitation of public comments on 

Medicare policies relating to incentives 

for avoidable readmissions to hospitals. 

• 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 hospitalswithin-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 physicianowned 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 rateof-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: 

• A single average standardized 

amount for all areas for hospital 

inpatient services paid under the IPPS 

for operating costs (and hospital-specific 

rates applicable to SCHs and MDHs). 

• Target rate-of-increase limits to the 

allowable operating costs of hospital 

inpatient services furnished by hospitals 

and hospital units excluded from the 

IPPS. 

12. 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23537 

1Medicare Payment Advisory Commission: 

Report to the Congress, Physician-Owned Specialty 

Hospitals, March 25, page viii. 

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, PhysicianOwned 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). 

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 


jlentini on PROD1PC65 with PROPOSALS2
23538 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 midOctober 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 costbased 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 costbased 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 costweighting methodology for FY 2009. 

We believe that revisions to the DRG 

system to better recognize severity of 


jlentini on PROD1PC65 with PROPOSALS2
23540 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 HospitalSpecific 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 hospitalspecific 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 hospitalspecific 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 hospitalspecific 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23541 

examine our FY 2008 claims data for 

hospitals paid based on the hospitalspecific 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 hospitalspecific 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 Ricospecific 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 Ricospecific 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 casemix 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 


jlentini on PROD1PC65 with PROPOSALS2
23542 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

(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 costbased relative weights, we decided to 

transition cost-based weights over 3 

years by blending them with chargebased weights beginning in FY 2007. In 

FY 2008, we continued our transition by 

blending the relative weights with onethird charge-based weights and twothirds 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 costbased 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 ‘‘RadiologyDiagnostics’’. 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 regressionbased 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 regressionbased 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/ 


jlentini on PROD1PC65 with PROPOSALS2
23544 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 regressionadjusted CCRs. Although RTI 

recommended adopting regressionbased 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 passthrough device category in the OPPS. 

(There are no such existing criteria for 

devices under the IPPS.) The provisions 

of the regulations under § 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 §§ 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: 

• 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). 

• A material or supply furnished 

incident to a service (for example, a 

suture, customized surgical kit, or clip, 

other than a radiological site marker). 

• 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 passthrough payment purposes and do not 

include additional criteria that are used 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 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 §§ 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: 

• 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). 

• 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). 

• Material that may be used to replace 

human skin (for example, a biological or 

synthetic material). 

• 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 passthrough payment under the OPPS at 

§ 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 nonroutine 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 


jlentini on PROD1PC65 with PROPOSALS2
23546 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 passthrough 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 


jlentini on PROD1PC65 with PROPOSALS2
23548 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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. 

3Centers 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 

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 deaths4

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

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. 

Service: MS–DRG Assignment*

(Examples below with CC/MCC indicate a single secondary diagnosis only) 

Present on admission (status 

of secondary 

diagnosis) 

Average payment (based 

on 50th percentile) 

Principal Diagnosis .................................................................................................................................................. ........................ $5,347.98 

• Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC—MS–DRG 066.

Principal Diagnosis .................................................................................................................................................. Y 6,177.43 

• Intracranial hemorrhage or cerebral infarction (stroke) with CC—MS–DRG 065.

Example Secondary Diagnosis 

• Dislocation of patella-open due to a fall (code 836.4 (CC)).

Principal Diagnosis .................................................................................................................................................. N 5,347.98 

• Intracranial hemorrhage or cerebral infarction (stroke) with CC—MS–DRG 065.

Example Secondary Diagnosis 

• Dislocation of patella-open due to a fall (code 836.4 (CC)).

Principal Diagnosis .................................................................................................................................................. Y 8,030.28 

• Intracranial hemorrhage or cerebral infarction (stroke) with MCC—MS–DRG 064.

Example Secondary Diagnosis 

• Stage III pressure ulcer (code 707.23 (MCC)).

Principal Diagnosis .................................................................................................................................................. N 5,347.98 

• Intracranial hemorrhage or cerebral infarction (stroke) with MCC—MS–DRG 064.

Example Secondary Diagnosis 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23549 

6For 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. 

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 evidencebased 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. 

• 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. 

• 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. 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23550 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.000</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23551 

BILLING CODE 4120–01–C 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.001</GPH>
23552 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• 707.20 (Pressure ulcer, unspecified 

stage). 

• 707.21 (Pressure ulcer stage I). 

• 707.22 (Pressure ulcer stage II). 

• 707.23 (Pressure ulcer stage III). 

• 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: 

• 707.00 (Decubitus ulcer, 

unspecified site). 

• 707.01 (Decubitus ulcer, elbow). 

• 707.09 (Decubitus ulcer, other site). 

The following codes would no longer be 

an MCC: 

• 707.02 (Decubitus ulcer, upper 

back). 

• 707.03 (Decubitus ulcer, lower 

back). 

• 707.04 (Decubitus ulcer, hip). 

• 707.05 (Decubitus ulcer, buttock). 

• 707.06 (Decubitus ulcer, ankle). 

• 707.07 (Decubitus ulcer, heel). 

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: 

• HAC Candidate—We are seeking 

public comment on all HAC candidates. 

• 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. 

• CC/MCC—We are seeking public 

comment on the statutory criterion that 

an ICD–9–CM diagnosis code(s) clearly 

identifies the HAC candidate. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23553 

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 lowrisk profile for surgical site infections. 

The following elective surgical 

procedures are under consideration: 

• Total Knee Replacement (81.54): 

ICD–9–CM codes 996.66 (CC) and 

998.59 (CC) 

• Laparoscopic Gastric Bypass (44.38) 

and Laparoscopic Gastroenterostomy 

(44.39): ICD–9–CM code 998.59 (CC) 

• 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 

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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.002</GPH> EP30AP08.003</GPH>
23554 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 communityacquired 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 

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: 

• Diabetic Ketoacidosis: ICD–9–CM 

codes 250.10–250.13 (CC) 

• Nonketotic Hyperosmolar Coma: 

ICD–9–CM code 251.0 (CC) 

• Diabetic Coma: ICD–9–CM codes 

250.30–250.33 (CC) 

• 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 evidencebased guidelines. Based on the public 

comments we receive, we may select 

some combination of these glycemic 

control-related conditions as HACs. 

d. Iatrogenic Pneumothorax 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.004</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23555 

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 evidencebased guidelines. Based on the public 

comments we receive, we may select 

iatrogenic pneumothorax as an HAC. 

e. Delirium 

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 evidencebased guidelines. Based upon the public 

comments we receive, we may select 

delirium as an HAC. 

f. Ventilator-Associated Pneumonia 

(VAP) 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.005</GPH> EP30AP08.006</GPH>
23556 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

7American 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. 

8Ramirez 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. 

9Safdar et al.: The Pathogenesis of VentilatorAssociated Pneumonia: Its Relevance to Developing 

Effective Strategies for Prevention. Respiratory 

Care, June 2005, Vol. 50, No. 6, pp.725–741. 

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 evidencebased 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

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. 

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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.007</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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) 

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 

evidenceπbased 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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.008</GPH> EP30AP08.009</GPH>
23558 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

10 Jensen, A.G. Importance of Focus Identification 

in the Treatment of Staphylococcus aureus 

Bacteremia. 2002. Vol. 52, pp. 29–36. 

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 catheterassociated infections are only one cause 

of septicemia. Therefore, catheteroriented evidence-based guidelines 

would not cover all cases of 

Staphylococcus aureus Septicemia.10

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) 

We discussed Clostridium difficileassociated 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) 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.010</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23559 

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. 

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. 

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 careassociated MRSA); (2) http:// 

www.cdc.gov/ncidod/dhqp/ 

ar_mrsa_ca_public.html (communityacquired 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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.011</GPH>
23560 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• Risk adjustment could be applied to 

make the HAC payment provision more 

precise. 

• Rates of HACs could be collected to 

obtain a more robust longitudinal 

measure of a hospital’s incidence of 

these conditions. 

• POA information could be used in 

various ways to decrease the incidence 

of preventable HACs. 

• The adoption of ICD–10–PCS could 

facilitate more precise identification of 

HACs. 

• 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. 

• 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-theart 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 casemix 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 careassociated conditions could potentially 

be applied to Medicare payment settings 

other than IPPS hospitals. Other 


jlentini on PROD1PC65 with PROPOSALS2
23562 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 notfor-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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 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 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 midyear 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 


jlentini on PROD1PC65 with PROPOSALS2
23564 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• ‘‘0’’ for without mention of 

intractable epilepsy. 

• ‘‘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): 

• Patients with a primary diagnosis of 

epilepsy with intractability specified 

(codes 345.01 through 345.91). 

• Patients with a primary diagnosis of 

epilepsy without intractability specified 

(codes 345.00 through 345.90). 

• 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23565 

MS–DRG Number of 

cases 

Average length 

of stay 

Average 

charges 

MS–DRG 100—All Cases ......................................................................................................... 16,142 6 .34 $27,623 

MS–DRG 100—Cases with Intractable Epilepsy with vEEG (Codes 345.01, 345.11, 345.41, 

345.51, 345.61, 345.71, 345.81, 345.91) .............................................................................. 69 6 .6 26,990 

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 345.01, 345.11, 345.41, 

345.51, 345.61, 345.71, 345.81, 345.91) .............................................................................. 879 5 .0 19,227 

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 CardioverterDefibrillators (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 cardioverterdefibrillator (AICD) generator 

replacements and defibrillator lead 

replacements. The new MS–DRG 245 

(AICD lead and generator procedures) 

contains the following codes: 

• 00.52, Implantation or replacement 

of transvenous lead [electrode] into left 

ventricular coronary venous system. 

• 00.54, Implantation or replacement 

of cardiac resynchronization 

defibrillator pulse generator device only 

[CRT–D]. 

• 37.95, Implantation of automatic 

cardioverter/defibrillator leads(s) only. 

• 37.96, Implantation of automatic 

cardioverter/defibrillator pulse 

generator only. 

• 37.97, Replacement of automatic 

cardioverter/defibrillator leads(s) only. 

• 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. 


jlentini on PROD1PC65 with PROPOSALS2
23566 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

MS–DRG Number of 

cases 

Average 

length of stay 

Average 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23567 

MS–DRG Number of 

cases 

Average 

length of stay 

Average 

charges 

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: 

• 81.51, Total hip replacement. 

• 81.52, Partial hip replacement. 

• 81.54, Total knee replacement. 

• 81.56, Total ankle replacement. 

• 84.26, Foot reattachment. 

• 84.27, Lower leg or ankle 

reattachment. 

• 84.28, Thigh reattachment. 

CMS DRG 545 included the following 

procedure code assignments: 

• 00.70, Revision of hip replacement, 

both acetabular and femoral 

components. 

• 00.71, Revision of hip replacement, 

acetabular component. 

• 00.72, Revision of hip replacement, 

femoral component. 

• 00.73, Revision of hip replacement, 

acetabular liner and/or femoral head 

only. 

• 00.80, Revision of knee replacement, 

total (all components). 

• 00.81, Revision of knee replacement, 

tibial component. 

• 00.82, Revision of knee replacement, 

femoral component. 

• 00.83, Revision of knee replacement, 

patellar component. 

• 00.84, Revision of knee replacement, 

tibial insert (liner). 

• 81.53, Revision of hip replacement, 

not otherwise specified 

• 81.55, Revision of knee 

replacement, not otherwise specified 

Further, we created a number of new 

ICD–9–CM procedure codes effective 

October 1, 2005, that better distinguish 

the many different types of joint 

replacement procedures that are 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 


jlentini on PROD1PC65 with PROPOSALS2
23568 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

• 00.73, Revision of hip replacement, 

acetabular liner and/or femoral head 

only. 

• 00.85, Resurfacing hip, total, 

acetabulum and femoral head. 

• 00.86, Resurfacing hip, partial, 

femoral head. 

• 00.87, Resurfacing hip, partial, 

acetabulum. 

• 81.51, Total hip replacement. 

• 81.52, Partial hip replacement. 

• 81.53, Revision of hip replacement, 

not otherwise specified. 

Complex Hip Replacements 

• 00.70, Revision of hip replacement, 

both acetabular and femoral 

components. 

• 00.71, Revision of hip replacement, 

acetabular component. 

• 00.72, Revision of hip replacement, 

femoral component. 

Routine Knee Replacements and Ankle 

Procedures 

• 00.83, Revision of knee 

replacement, patellar component. 

• 00.84, Revision of knee 

replacement, tibial insert (liner). 

• 81.54, Revision of knee 

replacement, not otherwise specified. 

• 81.55, Revision of knee 

replacement, not otherwise specified. 

• 81.56, Total ankle replacement. 

Complex Knee Replacements and Other 

Reattachments 

• 00.80, Revision of knee 

replacement, total (all components). 

• 00.81, Revision of knee 

replacement, tibial component. 

• 00.82, Revision of knee 

replacement, femoral component. 

• 84.26, Foot reattachment. 

• 84.27, Lower leg or ankle 

reattachment. 

• 84.28, Thigh reattachment. 

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: 

• 00.70, Revision of hip replacement, 

both acetabular and femoral 

components. 

• 00.80, Revision of knee 

replacement, total (all components). 

• 00.85, Resurfacing hip, total, 

acetabulum and femoral head. 

• 00.86, Resurfacing hip, partial, 

femoral head. 

• 00.87, Resurfacing hip, partial, 

acetabulum. 

• 81.51, Total hip replacement. 

• 81.52, Partial hip replacement. 

• 81.54, Total knee replacement. 

• 81.56, Total ankle replacement. 

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: 

• MS–DRG 466 (Revision of Hip or 

Knee Replacement with MCC) 

• MS–DRG 467 (Revision of Hip or 

Knee Replacement with CC) 

• MS–DRG 468 (Revision of Hip or 

Knee Replacement without CC/MCC) 

• MS–DRG 469 (Major Joint 

Replacement or Reattachment of Lower 

Extremity with MCC) 

• 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: 

• Is the per-case underpayment 

amount significant enough to affect 

admission vs. referral decisions on a 

case-by-case basis? 

• 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: 

• Create subgroups if they meet the 

five existing criteria, with cost 

difference between subgroups ($1,350) 

substituted for charge difference 

between subgroups ($4,000); 

• 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: b At least $1,000 cost difference per 

case between subgroups; or b At least $1 million overall cost 

should be shifted to cases with a CC (or 

MCC) within the base DRG for payment 

weight calculations. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• 00.83 Revision of knee replacement, 

patellar component 

• 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: 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23570 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• MS–DRGs 463, 463, and 465 

(Wound Debridement and Skin Graft 

Excluding Hand, for MusculoskeletalConnective Tissue Disease with MCC, 

with CC, without CC/MCC, 

respectively). 

• MS–DRGs 480, 481, and 482 (Hip 

and Femur Procedures Except Major 

Joint with MCC, with CC, without CC/ 

MCC, respectively). 

• MS–DRGs 485, 486, and 487 (Knee 

Procedures with Principal Diagnosis of 

Infection and with MCC, with CC, and 

without CC/MCC, respectively). 

• MS–DRGs 488 and 489 (Knee 

Procedures without Principal Diagnosis 

of Infection and with CC/MCC and 

without CC/MCC, respectively). 

• 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). 

• 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: 

• 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)). 

• 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 

• 170.7 (Malignant neoplasm of long 

bones of lower limb). 

• 171.3 (Malignant neoplasm of soft 

tissue, lower limb, including hip). 

• 711.05 (Pyogenic arthritis, pelvic 

region and thigh). 

• 711.06 (Pyogenic arthritis, lower 

leg). 

• 730.05 (Acute osteomyelitis, pelvic 

region and thigh). 

• 730.06 (Acute osteomyelitis, lower 

leg). 

• 730.15 (Chronic osteomyelitis, 

pelvic region and thigh). 

• 730.16 (Chronic osteomyelitis, 

lower leg). 

• 730.25 (Unspecified osteomyelitis, 

pelvic region and thigh). 

• 730.26 (Unspecified osteomyelitis, 

lower leg). 

• 996.66 (Infection and inflammatory 

reaction due to internal joint 

prosthesis). 

• 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) 

• 170.7 (Malignant neoplasm of long 

bones of lower limb). 

• 171.3 (Malignant neoplasm of soft 

tissue, lower limb, including hip). 

• 198.5 (Secondary malignant 

neoplasm of bone and bone marrow) .* 

• 711.05 (Pyogenic arthritis, pelvic 

region and thigh). 

• 711.06 (Pyogenic arthritis, lower 

leg). 

• 730.05 (Acute osteomyelitis, pelvic 

region and thigh). 

• 730.06 (Acute osteomyelitis, lower 

leg). 

• 730.15 (Chronic osteomyelitis, 

pelvic region and thigh). 

• 730.16 (Chronic osteomyelitis, 

lower leg). 

• 730.25 (Unspecified osteomyelitis, 

pelvic region and thigh). 

• 730.26 (Unspecified osteomyelitis, 

lower leg). 

• 736.30 (Acquired deformities of 

hip, unspecified deformity). 

• 736.39 (Other acquired deformities 

of hip) .* 

• 736.6 (Other acquired deformities 

of knee) .* 

• 736.89 (Other acquired deformities 

of other parts of limbs). * 

• 996.66 (Infection and inflammatory 

reaction due to internal joint 

prosthesis). * 

• 996.67 (Infection and inflammatory 

reaction due to other internal 

orthopedic device, implant, and graft). * 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

• 170.7 (Malignant neoplasm of long 

bones of lower limb). 

• 171.3 (Malignant neoplasm of soft 

tissue, lower limb, including hip). 

• 711.05 (Pyogenic arthritis, pelvic 

region and thigh). 

• 711.06 (Pyogenic arthritis, lower 

leg). 

• 730.05 (Acute osteomyelitis, pelvic 

region and thigh). 

• 730.06 (Acute osteomyelitis, lower 

leg). 

• 730.15 (Chronic osteomyelitis, 

pelvic region and thigh). 

• 730.16 (Chronic osteomyelitis, 

lower leg). 

• 730.25 (Unspecified osteomyelitis, 

pelvic region and thigh). 

• 730.26 (Unspecified osteomyelitis, 

lower leg). 

• 996.66 (Infection and inflammatory 

reaction due to internal joint 

prosthesis). 

• 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: 

• 038.0 (Streptococcal septicemia). 

• 038.10 (Staphylococcal septicemia, 

unspecified). 

• 038.11 (Staphylococcal aureus 

septicemia). 

• 038.19 (Other staphylococcal 

septicemia). 

• 038.2 (Pneumococcal septicemia 

[streptococcus pneumonia septicemia]). 

• 038.3 (Septicemia due anaerobes). 

• 038.40 (Septicemia due to gramnegative organisms). 

• 038.41 (Hemophilus influenzae [H. 

Influenzae]). 

• 038.42 (Escherichia coli [E. Coli]). 

• 038.43 (Pseudomonas). 

• 038.44 (Serratia). 

• 038.49 (Other septicemia due to 

gram-negative organisms). 

• 038.8 (Other specified septicemias). 

• 038.9 (Unspecified septicemia). 

• 995.91 (Sepsis). 

• 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. 

MS–DRG Number of 

cases 

Average 

length of stay 

Average 

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 


jlentini on PROD1PC65 with PROPOSALS2
23572 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

MS–DRG Number of 

cases 

Average 

length of stay 

Average 

charges 

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

Stage 1 Total cases Average 

length of stay 

Average 

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

Stage 2 Total cases Average 

length of stay 

Average 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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. 

MS–DRGs Number of 

cases 

Average 

length of stay 

Average 

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 


jlentini on PROD1PC65 with PROPOSALS2
23574 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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) 

• MS–DRG 870 (Septicemia with 

Mechanical Ventilation 96+ Hours). 

• MS–DRG 871 (Septicemia without 

Mechanical Ventilation 96+ Hours with 

MCC). 

• 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: 

• Proposed Revised MS–DRG 870 

(Septicemia or Severe Sepsis with 

Mechanical Ventilation 96+ Hours). 

• Proposed Revised MS–DRG 871 

(Septicemia or Severe Sepsis without 

Mechanical Ventilation 96+ Hours with 

MCC). 

• 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. 

• 958.90 (Compartment syndrome, 

unspecified). 

• 958.91 (Traumatic compartment 

syndrome of upper extremity). 

• 958.92 (Traumatic compartment 

syndrome of lower extremity). 

• 958.93 (Traumatic compartment 

syndrome of abdomen). 

• 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: 

• Significant head trauma. 

• Significant chest trauma. 

• Significant abdominal trauma. 

• Significant kidney trauma. 

• Significant trauma of the urinary 

system. 

• Significant trauma of the pelvis or 

spine. 

• Significant trauma of the upper 

limb. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 lowerweighted 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 higherordered surgical class has a lower 


jlentini on PROD1PC65 with PROPOSALS2
23576 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

12See 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. 

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: 

• Chronic and acute manifestations of 

the same condition should not be 

considered CCs for one another. 

• Specific and nonspecific (that is, 

not otherwise specified (NOS)) 

diagnosis codes for the same condition 

should not be considered CCs for one 

another. 

• Codes for the same condition that 

cannot coexist, such as partial/total, 

unilateral/bilateral, obstructed/ 

unobstructed, and benign/malignant, 

should not be considered CCs for one 

another. 

• Codes for the same condition in 

anatomically proximal sites should not 

be considered CCs for one another. 

• Closely related conditions should 

not be considered CCs for one another. 

The creation of the CC Exclusions List 

was a major project involving hundreds 

of codes. We have continued to review 

the remaining CCs to identify additional 

exclusions and to remove diagnoses 

from the master list that have been 

shown not to meet the definition of a 

CC.12

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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23577 

SUMMARY OF ADDITIONS TO THE MS–DRG MCC LIST.—TABLE 6I.1—Continued 

Code Description 

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-Stra ̈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. 


jlentini on PROD1PC65 with PROPOSALS2
23578 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

SUMMARY OF ADDITIONS TO THE MS–DRG CC LIST.—TABLE 6J.1—Continued 

Code Description 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23579 

13The 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). 

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: 

• 60.0, Incision of prostate. 

• 60.12, Open biopsy of prostate. 

• 60.15, Biopsy of periprostatic 

tissue. 

• 60.18, Other diagnostic procedures 

on prostate and periprostatic tissue. 

• 60.21, Transurethral prostatectomy. 

• 60.29, Other transurethral 

prostatectomy. 

• 60.61, Local excision of lesion of 

prostate. 

• 60.69, Prostatectomy, not elsewhere 

classified. 

• 60.81, Incision of periprostatic 

tissue. 

• 60.82, Excision of periprostatic 

tissue. 

• 60.93, Repair of prostate. 

• 60.94, Control of (postoperative) 

hemorrhage of prostate. 

• 60.95, Transurethral balloon 

dilation of the prostatic urethra. 

• 60.96, Transurethral destruction of 

prostate tissue by microwave 

thermotherapy. 

• 60.97, Other transurethral 

destruction of prostate tissue by other 

thermotherapy. 

• 60.99, Other operations on prostate. 

All remaining O.R. procedures are 

assigned to MS–DRGs 981 through 983 

and 987 through 989, with MS–DRGs 

987 through 989 assigned to those 

discharges in which the only procedures 

performed are nonextensive procedures 

that are unrelated to the principal 

diagnosis.13

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 


jlentini on PROD1PC65 with PROPOSALS2
23580 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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, CoChairperson, ICD–9–CM Coordination 

and Maintenance Committee, NCHS, 

Room 2402, 3311 Toledo Road, 

Hyattsville, MD 20782. Comments may 

be sent by E-mail to: dfp4@cdc.gov. 

Questions and comments concerning 

the procedure codes should be 

addressed to: Patricia E. Brooks, CoChairperson, ICD–9–CM Coordination 

and Maintenance Committee, CMS, 

Center for Medicare Management, 

Hospital and Ambulatory Policy Group, 

Division of Acute Care, C4–08–06, 7500 

Security Boulevard, Baltimore, MD 

21244–1850. Comments may be sent by 

E-mail to: 

patricia.brooks2@cms.hhs.gov. 

The ICD–9–CM code changes that 

have been approved will become 

effective October 1, 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 addon 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 costbased 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 


jlentini on PROD1PC65 with PROPOSALS2
23582 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• 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. 

• 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 Medicareapproved 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.) 

• Organ acquisition costs for kidney, 

heart, heart-lung, liver, lung, pancreas, 

and intestinal (or multivisceral organs) 

transplants continue to be paid on a 

reasonable cost basis. Because these 

acquisition costs are paid separately 

from the prospective payment rate, it is 

necessary to subtract the acquisition 

charges from the total charges on each 

transplant bill that showed acquisition 

charges before computing the average 

cost for each DRG and before 

eliminating statistical outliers. 

• Claims with total charges or total 

length of stay less than or equal to zero 

were deleted. Claims that had an 

amount in the total charge field that 

differed by more than $10.00 from the 

sum of the routine day charges, 

intensive care charges, pharmacy 

charges, special equipment charges, 

therapy services charges, operating 

room charges, cardiology charges, 

laboratory charges, radiology charges, 

other service charges, labor and delivery 

charges, inhalation therapy charges, 

emergency room charges, blood charges, 

and anesthesia charges were also 

deleted. 

• At least 96.1 percent of the 

providers in the MedPAR file had 

charges for 10 of the 15 cost centers. 

Claims for providers that did not have 

charges greater than zero for at least 10 

of the 15 cost centers were deleted. 

• Statistical outliers were eliminated 

by removing all cases that were beyond 

3.0 standard deviations from the mean 

of the log distribution of both the total 

charges per case and the total charges 

per day for each 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 costof-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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23583 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.012</GPH>
23584 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.013</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23585 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.014</GPH>
23586 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.015</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23587 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.016</GPH>
23588 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.017</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 Medicarespecific 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 chargebased 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 twothirds 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 O.R. Procedure Except Sterilization and/ 

or D&C.

FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

789 ................ Neonates, Died or Transferred to Another Acute Care Facility FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

790 ................ Extreme Immaturity or Respiratory Distress Syndrome, 

Neonate.

FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

791 ................ Prematurity with Major Problems ................................................ FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

792 ................ Prematurity without Major Problems ........................................... FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

793 ................ Full-Term Neonate with Major Problems .................................... FY 2008 FR weight (adjusted by percent change in average 

weight of the cases in other MS–DRGs). 

794 ................ Neonate with Other Significant Problems ................................... FY 2008 FR weight (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). 


jlentini on PROD1PC65 with PROPOSALS2
23590 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

I. Proposed Medicare Severity LongTerm 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 longterm 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 

§ 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 § 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: 

• Principal diagnosis. 

• Up to eight additional diagnoses. 

• Up to six procedures performed. 

• Age. 

• Sex. 

• 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: 

• 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.) 

• Cases including surgical procedures 

not covered under Medicare. (For 

example, organ transplant in a 

nonapproved transplant center.) 

• 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 hospitalspecific 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 § 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 (§ 412.60(e)) and the 

LTCH PPS (§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23592 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

§ 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 lowvolume 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). 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 (§ 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 allinclusive 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 ventilatordependent 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 


jlentini on PROD1PC65 with PROPOSALS2
23594 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 (§ 412.529 and § 412.503). 

The average adjusted charge reflects the 

average intensity of the health care 

services delivered by a particular LTCH 

and the average cost level of that LTCH. 

The resulting ratio is multiplied by that 

LTCH’s case-mix index to determine the 

standardized charge for the case. 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 lowvolume 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 lowvolume 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 lowvolume quintile (as described below). 

After sorting the 290 proposed lowvolume 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 lowvolume 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 lowvolume 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 lowvolume 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 26.0) 

Proposed MS–LTC–DRG description (version 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. 


jlentini on PROD1PC65 with PROPOSALS2
23596 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

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.*** 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23597 

PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

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. 


jlentini on PROD1PC65 with PROPOSALS2
23598 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

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.*** 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23599 

PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

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. 


jlentini on PROD1PC65 with PROPOSALS2
23600 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

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 allinclusive rate LTCHs and LTCHs that 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 412.529(a) in conjunction 

with § 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 fivesixths 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 § 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 hospitalspecific relative charge values above are 

multiplied by these hospital-specific 

case-mix indexes. These hospitalspecific 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 


jlentini on PROD1PC65 with PROPOSALS2
23602 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 novolume 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 crosswalked (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 novolume MS–LTC–DRG the proposed 

relative weight of the proposed crosswalked 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 crosswalk 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 novolume 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23603 

PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009 

Proposed 

MS–LTC–DRG 

(Version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

Proposed 

cross-walked 

MS–LTC–DRG 

9 ..................................... Bone marrow transplant ........................................................................................................................ 823 

13 ................................... Tracheostomy for face, mouth & neck diagnoses w/o CC/MCC .......................................................... 12 

20 ................................... Intracranial vascular procedures w PDX hemorrhage w MCC ............................................................. 31 

21 ................................... Intracranial vascular procedures w PDX hemorrhage w CC ................................................................ 32 

22 ................................... Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC .................................................... 32 

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 MCC ................................................................ 70 

62 ................................... Acute ischemic stroke w use of thrombolytic agent w CC ................................................................... 71 

63 ................................... Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC ....................................................... 72 

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 device ............................................................... 146 

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 CC/MCC ......................................................... 133 

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 cath w MCC ....................................................... 237 

217 ................................. Cardiac valve & oth maj cardiothoracic proc w card cath w CC .......................................................... 238 

218 ................................. Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC .............................................. 238 

219 ................................. Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC .................................................... 237 

220 ................................. Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC ....................................................... 238 

221 ................................. Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC ........................................... 238 

222 ................................. Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC ........................................................... 242 

223 ................................. Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC ........................................................ 243 

224 ................................. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC ........................................................ 242 

225 ................................. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC ..................................................... 243 

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 AMI w/o MCC ....................................................... 250 

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/MCC .............................................................. 373 

345 ................................. Minor small & large bowel procedures w CC ....................................................................................... 344 

346 ................................. Minor small & large bowel procedures w/o CC/MCC ........................................................................... 344 


jlentini on PROD1PC65 with PROPOSALS2
23604 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(Version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

Proposed 

cross-walked 

MS–LTC–DRG 

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/MCC ................................................................ 354 

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 c.d.e. w MCC .......................................................... 409 

410 ................................. Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC ................................................. 409 

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 CC/MCC ...................................................... 415 

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 CC/MCC ......................................................... 424 

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+ fusions w/o CC/MCC ............................................. 457 

460 ................................. Spinal fusion except cervical w/o MCC ................................................................................................ 459 

461 ................................. Bilateral or multiple major joint procs of lower extremity w MCC ......................................................... 480 

462 ................................. Bilateral or multiple major joint procs of lower extremity w/o MCC ...................................................... 482 

473 ................................. Cervical spinal fusion w/o CC/MCC ...................................................................................................... 472 

479 ................................. Biopsies of musculoskeletal system & connective tissue w/o CC/MCC .............................................. 478 

483 ................................. Major joint & limb reattachment proc of upper extremity w CC/MCC .................................................. 480 

484 ................................. Major joint & limb reattachment proc of upper extremity w/o CC/MCC ............................................... 482 

491 ................................. Back & neck procedures except spinal fusion w/o CC/MCC ............................................................... 490 

499 ................................. Local excision & removal int fix devices of hip & femur w/o CC/MCC ................................................ 498 

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 proc w/o CC/MCC .................................................. 511 

517 ................................. Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC ............................................................. 516 

538 ................................. Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC .................................................... 537 

583 ................................. Mastectomy for malignancy w/o CC/MCC ............................................................................................ 582 

585 ................................. Breast biopsy, local excision & other breast procedures w/o CC/MCC ............................................... 584 

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 CC/MCC ............................................................. 626 

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 malignancy w CC/MCC .............................................. 717 

716 ................................. Other male reproductive system O.R. proc for malignancy w/o CC/MCC ........................................... 717 

718 ................................. Other male reproductive system O.R. proc exc malignancy w/o CC/MCC .......................................... 717 

724 ................................. Malignancy, male reproductive system w/o CC/MCC .......................................................................... 723 

734 ................................. Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC .................................................. 717 

735 ................................. Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC ............................................... 717 

736 ................................. Uterine & adnexa proc for ovarian or adnexal malignancy w MCC ..................................................... 754 

737 ................................. Uterine & adnexa proc for ovarian or adnexal malignancy w CC ........................................................ 755 

738 ................................. Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC ............................................ 756 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23605 

PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009—Continued 

Proposed 

MS–LTC–DRG 

(Version 26.0) 

Proposed MS–LTC–DRG description (version 26.0) 

Proposed 

cross-walked 

MS–LTC–DRG 

740 ................................. Uterine, adnexa proc for non-ovarian/adnexal malig w CC .................................................................. 739 

741 ................................. Uterine, adnexa proc for non-ovarian/adnexal malig w/o CC/MCC ..................................................... 739 

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/o CC/MCC ......................................................... 744 

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 CC/MCC ...................................................... 749 

760 ................................. Menstrual & other female reproductive system disorders w CC/MCC ................................................. 744 

761 ................................. Menstrual & other female reproductive system disorders w/o CC/MCC .............................................. 744 

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. procedure ................................................................... 744 

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. procedure ................................................................ 744 

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 facility ................................................................ 781 

790 ................................. Extreme immaturity or respiratory distress syndrome, neonate ........................................................... 781 

791 ................................. Prematurity w major problems .............................................................................................................. 781 

792 ................................. Prematurity w/o major problems ........................................................................................................... 781 

793 ................................. Full term neonate w major problems .................................................................................................... 781 

794 ................................. Neonate w other significant problems ................................................................................................... 781 

795 ................................. Normal newborn .................................................................................................................................... 781 

799 ................................. Splenectomy w MCC ............................................................................................................................. 800 

801 ................................. Splenectomy w/o CC/MCC ................................................................................................................... 800 

803 ................................. Other O.R. proc of the blood & blood forming organs w CC ............................................................... 802 

804 ................................. Other O.R. proc of the blood & blood forming organs w/o CC/MCC ................................................... 802 

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/MCC ........................................................... 824 

825 ................................. Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC .................................................... 824 

828 ................................. Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC ................................................. 827 

830 ................................. Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC .............................................. 829 

837 ................................. Chemo w acute leukemia as sdx or w high dose chemo agent w MCC ............................................. 829 

838 ................................. Chemo w acute leukemia as sdx or w high dose chemo agent w CC ................................................ 829 

839 ................................. Chemo w acute leukemia as sdx or w high dose chemo agent w/o CC/MCC .................................... 829 

848 ................................. Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC ......................................... 847 

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 significant trauma ................................................... 482 

959 ................................. Other O.R. procedures for multiple significant trauma w/o CC/MCC ................................................... 958 

986 ................................. Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC ............................................. 985 

To illustrate this methodology for 

determining the proposed relative 

weights for the proposed 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); 


jlentini on PROD1PC65 with PROPOSALS2
23606 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 novolume 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 threelevel 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 caseweighted 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, 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 caseweighted 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 lowvolume 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 lowvolume 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 lowvolume 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 crosswalk 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 novolume 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 baseMS–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 caseweighted 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 caseweighted 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 


jlentini on PROD1PC65 with PROPOSALS2
23608 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 § 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 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

(§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23610 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 412.88, if 

the costs of the discharge (determined 

by applying CCRs as described in 

§ 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 claimspayment 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 highquality, 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 CTI@cms.hhs.gov 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 AddOn 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—


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23611 

• Provide, before publication of a 

proposed rule, for public input 

regarding whether a new service or 

technology represents an advance in 

medical technology that substantially 

improves the diagnosis or treatment of 

Medicare beneficiaries; 

• Make public and periodically 

update a list of the services and 

technologies for which applications for 

add-on payments are pending; 

• Accept comments, 

recommendations, and data from the 

public regarding whether a service or 

technology represents a substantial 

clinical improvement; and 

• Provide, before publication of a 

proposed rule, for a meeting at which 

organizations representing hospitals, 

physicians, manufacturers, and any 

other interested party may present 

comments, recommendations, and data 

regarding whether a new medical 

service or technology represents a 

substantial clinical improvement to the 

clinical staff of CMS. 

In order to provide an opportunity for 

public input regarding add-on payments 

for new medical services and 

technologies for FY 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 addon 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. CardioWestTM Temporary Total 

Artificial Heart System (CardioWestTM

TAH–t) 

SynCardia Systems, Inc. submitted an 

application for approval of the 

CardioWestTM temporary Total Artificial 

Heart system (TAH–t) 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. 


jlentini on PROD1PC65 with PROPOSALS2
23612 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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/viewdraft

decisionmemo.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 caseweighted 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 nonTAH–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 FDAapproved 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 

Endobronchial Valve (Zephyr EBV) 

Emphasys Medical submitted an 

application for new technology add-on 

payments for FY 2009 for the Emphasys 

Medical Zephyr Endobronchial Valve 

(Zephyr EBV). The Zephyr 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 

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 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 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 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 

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 

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 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 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 caseweighted 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 caseweighted threshold amount, the 

applicant maintains that the Zephyr 

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 EBV 

meets the cost criterion. 

The applicant asserts that the 

Zephyr 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 


jlentini on PROD1PC65 with PROPOSALS2
23614 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

14Strange, 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. 

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 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 onesided Wilcoxon rank sum test). 

However, the data also showed that 

patients who received the Zephyr 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. 

While CMS recognizes that the 

Zephyr 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 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 EBV. We welcome comments 

from the public on both the patient 

population who would be eligible for 

the technology, and whether the 

Zephyr 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 

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 

FzioMed, Inc. submitted an 

application for new technology add-on 

payments for FY 2009 for Oxiplex. 

Oxiplex 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 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 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 may be 

substantially similar to adhesion 

barriers that have been on the market for 

several years. We also note that 

Oxiplex has been marketed as an 

adhesion barrier in other countries 

outside of the United States. The 

manufacturer maintains that Oxiplex 

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 caseweighted 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 would meet 

the cost criterion. We invite public 

comment on whether Oxiplex meets 

the cost criterion. 

The manufacturer maintains that 

Oxiplex 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23615 

Surgery Syndrome (FBSS) following 

surgery.’’ The manufacturer also claims 

that the Oxiplex gel reduces leg and 

back pain after discectomy, 

laminectomy, and laminotomy. The 

manufacturer also asserts that the use of 

Oxiplex is consistent with fewer 

revision surgeries. (During the FDA 

Investigational Device Exemption (IDE) 

trial, one Oxiplex patient required 

revision surgery compared to six control 

patients.) However, as we noted 

previously in this section, we are 

concerned that Oxiplex 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 

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 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 System 

TherOx, Inc. submitted an application 

for new technology add-on payments for 

FY 2009 for the TherOx Downstream 

System (Downstream System). The 

Downstream 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 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 laboratorybased 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 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 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 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 caseweighted 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 System would meet the 

cost criterion. We invite public 

comment on whether Downstream 

System meets the cost criterion. 

The applicant asserts that the 

Downstream 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 


jlentini on PROD1PC65 with PROPOSALS2
23616 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

15Oneill, 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. 

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 AMIHOT15 and AMIHOT II trials 

did not attempt to measure differences 

in heart failure outcomes nor mortality 

outcomes. 

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 § 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, 

§ 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, 

§ 412.87(b)(3) of our existing regulations 

provides that, to be eligible for the addon 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, § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 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 § 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 § 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 § 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 § 412.87 to set July 1 of 

each year as the deadline by which IPPS 

new medical service or technology addon 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 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23618 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• Problems associated with the 

definition of labor markets for the wage 

index adjustment. 

• The modification or elimination of 

geographic reclassifications and other 

adjustments. 

• The use of Bureau of Labor of 

Statistics data or other data or 

methodologies to calculate relative 

wages for each geographic area. 

• Minimizing variations in wage 

index adjustments between and within 

MSAs and statewide rural areas. 

• The feasibility of applying all 

components of CMS’ proposal to other 

settings. 

• Methods to minimize the volatility 

of wage index adjustments while 

maintaining the principle of budget 

neutrality. 

• The effect that the implementation 

of the proposal would have on health 

care providers on each region of the 

country. 

• Methods for implementing the 

proposal(s) including methods to phase 

in such implementations. 

• 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—

• Uses wage data from all employers 

and industry-specific occupational 

weights; 

• Is adjusted for geographic 

differences in the ratio of benefits to 

wages; 

• Is adjusted at the county level and 

smoothes large differences between 

counties; and 

• 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: 

• 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. 

• 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. 

• 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. 

• 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. 

• 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. 

• MedPAC recommends a phased 

implementation for its recommended 

wage index in order to cushion the 

effect of large wage index changes on 

individual hospitals. 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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. 


jlentini on PROD1PC65 with PROPOSALS2
23620 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 wagerelated 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

State 

Current policy 

application of national rural floor 

and imputed floor 

budget neutrality 

Proposed policy 

application of rural 

floor and imputed 

floor budget 

neutrality within 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23621 

FY 2009 IPPS ESTIMATED PAYMENTS WITH PROPOSED WITHIN-STATE RURAL FLOOR AND IMPUTED FLOOR BUDGET

NEUTRALITY—Continued 

State 

Current policy 

application of national rural floor 

and imputed floor 

budget neutrality 

Proposed policy 

application of rural 

floor and imputed 

floor budget 

neutrality within 

each state 

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 


jlentini on PROD1PC65 with PROPOSALS2
23622 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.018</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 Statespecific 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 withinState 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 


jlentini on PROD1PC65 with PROPOSALS2
23624 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

wage index (69 FR 49029). We are 

proposing to codify this longstanding 

policy into our regulations at 

§ 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: 

• 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; 

• New Brunswick, New Jersey, 

located in the Edison, New Jersey 

Metropolitan Division, qualifies as a 

new principal city of the New YorkNorthern New Jersey-Long Island, New 

York, New Jersey, Pennsylvania CBSA. 

The new title for the Metropolitan 

Division is Edison-New Brunswick, 

New Jersey CBSA; 

• Summerville, South Carolina 

qualifies as a new principal city of the 

Charleston-North Charleston, South 

Carolina CBSA. The new title is 

Charleston-North CharlestonSummerville, South Carolina; 

• Winter Haven, Florida qualifies as 

a new principal city of the Lakeland, 

Florida CBSA. The new title is 

Lakeland-Winter Haven, Florida; 

• Bradenton, Florida replaces 

Sarasota, Florida as the most populous 

principal city of the Sarasota-BradentonVenice, Florida CBSA. The new title is 

Bradenton-Sarasota-Venice, Florida. The 

new CBSA code is 14600; 

• 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; 

• North Myrtle Beach, South 

Carolina replaces Conway, South 

Carolina as the second most populous 

principal city of the Myrtle BeachConway-North Myrtle Beach, South 

Carolina CBSA. The new title is Myrtle 

Beach-North Myrtle Beach-Conway, 

South Carolina; 

• Pasco, Washington replaces 

Richland, Washington as the second 

most populous principal city of the 

Kennewick-Richland-Pasco, Washington 

CBSA. The new title is KennewickPasco-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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 


jlentini on PROD1PC65 with PROPOSALS2
23626 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30ap08.019</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23627 

BILLING CODE 4120–01–C 


jlentini on PROD1PC65 with PROPOSALS2EP30ap08.020</GPH>
23628 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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): 

• Salaries and hours from short-term, 

acute care hospitals (including paid 

lunch hours and hours associated with 

military leave and jury duty). 

• Home office costs and hours. 

• Certain contract labor costs and 

hours (which includes direct patient 

care, certain top management, 

pharmacy, laboratory, and nonteaching 

physician Part A services, and certain 

contract indirect patient care services 

(as discussed in the FY 2008 final rule 

with comment period (72 FR 47315). 

• Wage-related costs, including 

pensions and other deferred 

compensation costs. We note that, 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 


jlentini on PROD1PC65 with PROPOSALS2
23630 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 wagerelated 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 wagerelated costs by the above excluded area 

hours ratio. Finally, we subtract the 

computed overhead salaries, wagerelated 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

After Before Adjustment 

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 


jlentini on PROD1PC65 with PROPOSALS2
23632 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

Occupational mix nursing subcategory Average 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• If including the wage data for the 

redesignated hospitals would reduce the 

wage index value for the area to which 

the hospitals are redesignated by 1 

percentage point or less, the area wage 

index value determined exclusive of the 

wage data for the redesignated hospitals 

applies to the redesignated hospitals. 

• If including the wage data for the 

redesignated hospitals reduces the wage 

index value for the area to which the 

hospitals are redesignated by more than 

1 percentage point, the area wage index 

determined inclusive of the wage data 

for the redesignated hospitals (the 

combined wage index value) applies to 

the redesignated hospitals. 

• If including the wage data for the 

redesignated hospitals increases the 

wage index value for the urban area to 

which the hospitals are redesignated, 

both the area and the redesignated 

hospitals receive the combined wage 

index value. Otherwise, the hospitals 

located in the urban area receive a wage 

index excluding the wage data of 

hospitals redesignated into the area. 

Rural areas whose wage index values 

would be reduced by excluding the 

wage data for hospitals that have been 

redesignated to another area continue to 

have their wage index values calculated 

as if no redesignation had occurred 

(otherwise, redesignated rural hospitals 

are excluded from the calculation of the 

rural wage index). The wage index value 

for a redesignated rural hospital cannot 

be reduced below the wage index value 

for the rural areas of the State in which 

the hospital is located. 

CMS has also adopted the following 

policies: 

• The wage data for a reclassified 

urban hospital is included in both the 

wage index calculation of the area to 

which the hospital is reclassified 

(subject to the rules described above) 

and the wage index calculation of the 

urban area where the hospital is 

physically located. 

• In cases where urban hospitals have 

reclassified to rural areas 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): 

• 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. 

• 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 (§ 412.230(d)(2)(v)). 

• 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 (§ 412.64(b)(3)(ii)). 

• ‘‘Fallback’’ Reclassifications—A 

hospital will automatically be given its 

most recently approved reclassification 


jlentini on PROD1PC65 with PROPOSALS2
23634 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

(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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23635 

RURAL COUNTIES CONTAINING HOSPITALS REDESIGNATED AS URBAN UNDER SECTION 1886(D)(8)(B) OF THE ACT—

Continued 

[Based on CBSAs and Census 2000 Data] 

Rural county CBSA 

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 § 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 

(§ 412.230(b)(1)); and the hospital must 

show that its average hourly wage is at 

least 106 percent of the average hourly 

wage of all other hospitals in the area in 

which the hospital is located 

(§ 412.230(d)(1)(iii)(C)). 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 

(§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23636 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 postreclassified 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 outmigration 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 outmigration 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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’ earlyDecember 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: 

• 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. 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23638 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 prospectiveonly 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 wagerelated 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 laborrelated 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 laborrelated share lower than the laborrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 Ricospecific 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 (§ 412.4) 

1. Background 

Existing regulations at § 412.4(a) 

define discharges under the IPPS as 

situations in which a patient is formally 

released from an acute care hospital or 

dies in the hospital. Section 412.4(b) 

defines transfers from one acute care 

hospital to another. Section 412.4(c) 

establishes the conditions under which 

we consider a discharge to be a transfer 

for purposes of our postacute care 

transfer policy. In transfer situations, 

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 (§ 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 § 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: 

• The DRG had a geometric mean 

length of stay of at least 3 days; 

• The DRG had at least 2,050 

postacute care transfer cases; and 

• At least 5.5 percent of the cases in 

the DRG were discharged to postacute 

care prior to the geometric mean length 

of stay for the DRG. 

In addition, if the DRG was one of a 

paired set of DRGs based on the 

presence or absence of a CC or major 

cardiovascular condition (MCV), both 

paired DRGs would be included if either 

one met the three criteria above. 

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 § 412.4 further 

specify that if a DRG did not exist in 

Version 23.0 of the DRG Definitions 

Manual or a DRG included in Version 

23.0 of the DRG Definitions Manual is 

revised, the DRG will be a qualifying 

DRG if it meets the following criteria 

based on the version of the DRG 

Definitions Manual in use when the 

new or revised DRG first became 

effective, using the most recent 

complete year of MedPAR data: 

• The total number of discharges to 

postacute care in the DRG must equal or 

exceed the 55th percentile for all DRGs; 

and 

• The proportion of short-stay 

discharges to postacute care to total 

discharges in the DRG exceeds the 55th 

percentile for all DRGs. A short-stay 

discharge is a discharge before the 

geometric mean length of stay for the 

DRG. 

A DRG also is a qualifying DRG if it 

is paired with another DRG based on the 

presence or absence of a CC or MCV that 

meets either of the above two criteria. 

The MS–DRGs that we 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 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23640 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 § 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 § 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 

§ 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 

§ 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 §§ 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: 

• A hospital or hospital unit that is 

not a subsection 1886(d) hospital. 

(Section 1886(d)(1)(B) of the Act 

identifies the hospitals and hospital 

units that are excluded from the term 

‘‘subsection (d) hospital’’ as psychiatric 

hospitals and units, rehabilitation 

hospitals and units, children’s hospitals, 

long-term care hospitals, and cancer 

hospitals.) 

• A SNF (as defined at section1819(a) 

of the Act). 

• Home health services provided by a 

home health agency, if the services 

relate to the condition or diagnosis for 

which the individual received inpatient 

hospital services, and if the home health 

services are provided within an 

appropriate period (as determined by 

the Secretary). In the 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 412.4(c)(3) to 

extend the timeframe to within 7 days 

of discharge to home under a written 


jlentini on PROD1PC65 with PROPOSALS2
23642 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

(§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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) 

• Was aspirin given to the patient 

upon arrival to the hospital? 

• Was aspirin prescribed when the 

patient was discharged? 

• Was a beta blocker given to the 

patient upon arrival to the hospital? 

• Was a beta blocker prescribed when 

the patient was discharged? 

• Was an Angiotensin Converting 

Enzyme (ACE) Inhibitor given for the 

patient with heart failure? 

Heart Failure (HF) 

• Did the patient get an assessment of 

his or her heart function? 

• Was an Angiotensin Converting 

Enzyme (ACE) Inhibitor given to the 

patient? 

Pneumonia (PN) 

• Was an antibiotic given to the 

patient in a timely way? 

• Had the patient received a 

pneumococcal vaccination? 

• Was the patient’s oxygen level 

assessed? 

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 


jlentini on PROD1PC65 with PROPOSALS2
23644 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

16 Institute of Medicine, ‘‘Performance 

Measurement: Accelerating Improvement,’’

December 1, 2005, available at: www.iom.edu/CMS/ 

3809/19805/31310.aspx. 

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

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 Infarction). ............................................. • Aspirin at arrival.* 

• 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.** 

• Percutaneous Coronary Intervention (PCI) received within 120 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) ....................................................................................... • Initial antibiotic received within 4 hours of hospital arrival * 

• Oxygenation assessment.* 

• Pneumococcal vaccination status.* 

• Blood culture performed before first antibiotic received in hospital.** 

• Adult smoking cessation advice/counseling.** 

• Appropriate initial antibiotic selection.** 

• Influenza vaccination status.** 

Surgical Care Improvement Project (SCIP)—named SIP for discharges 

prior to July 2006 (3Q06).

• Prophylactic antibiotic received within 1 hour prior to surgical incision.** 

• Prophylactic antibiotics discontinued within 24 hours after surgery 

end time.** 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23645 

Topic Quality measure 

• SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered 

for surgery patients.*** 

• SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery.*** 

• SCIP Infection 2: Prophylactic antibiotic selection for surgical patients.*** 

Mortality Measures (Medicare patients) ................................................... • Acute Myocardial Infarction 30-day mortality Medicare patients*** 

• Heart Failure 30-day mortality Medicare patients.*** 

Patients’ Experience of Care. ................................................................... HCAHPS patient survey.*** 

*Measure included in 10 measure starter set. 

**Measure included in 21 measure expanded set. 

***Measure added in CY 2007 OPPS/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: 

• PN 30-day mortality measure 

(Medicare patients) 

• SCIP Infection 4: Cardiac Surgery 

Patients with Controlled 6AM 

Postoperative 

Serum Glucose 

• SCIP Infection 6: Surgery Patients 

with Appropriate Hair Removal 

• SCIP Infection 7: Colorectal Patients 

with Immediate Postoperative 

Normothermia 

• SCIP Cardiovascular 2: Surgery 

Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker 

During the Perioperative Period 

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: 

• SCIP Infection 4: Cardiac Surgery 

Patients with Controlled 6AM 

Postoperative 

Serum Glucose 

• 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 Infarction) .............................................. • Aspirin at arrival*. 

• 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**. 

• Primary Percutaneous Coronary Intervention (PCI) received within 

120 minutes of hospital arrival**. 

• Adult smoking cessation advice/counseling**. 

Heart Failure (HF) .................................................................................... • Left ventricular function assessment*. 


jlentini on PROD1PC65 with PROPOSALS2
23646 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

Topic Quality measure 

• 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) ....................................................................................... • Initial antibiotic received within 4 hours of hospital arrival*. 

• Oxygenation assessment*. 

• Pneumococcal vaccination status*. 

• Blood culture performed before first antibiotic received in hospital**. 

• Adult smoking cessation advice/counseling**. 

• Appropriate initial antibiotic selection**. 

• Influenza vaccination status**. 

Surgical Care Improvement Project (SCIP)—named SIP for discharges 

prior to July 2006 (3Q06).

• Prophylactic antibiotic received within 1 hour prior to surgical 

incision**. 

• Prophylactic antibiotics discontinued within 24 hours after surgery 

end time**. 

• SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered 

for surgery patients***. 

• SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery***. 

• SCIP Infection 2: Prophylactic antibiotic selection for surgical 

patients***. 

• SCIP–Infection 4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose*****. 

• SCIP Infection 6: Surgery Patients with Appropriate Hair 

Removal*****. 

Mortality Measures (Medicare patients) ................................................... • Acute Myocardial Infarction 30-day mortality Medicare patients***. 

• Heart Failure 30-day mortality Medicare patients***. 

• Pneumonia 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. 

  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: 

• Which of the measures or measure 

sets should be included in the FY 2009 

RHQDAPU program or in subsequent 

years? 

• What challenges for data collection 

and reporting are posed by the 

identified measures and measure sets? 

• What improvements could be made 

to data collection or reporting that might 

offset or otherwise address those 

challenges? 

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, 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 chartabstracted 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: 

• 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? 

• Are there reasons to consider 

retiring a measure other than high 

overall performance? 

• 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: 

• 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. 

• 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: 

• AMI—Timing of Receipt of Primary 

Percutaneous Coronary Intervention 

(PCI); and 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23648 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• Failure to Rescue 

• Pressure Ulcer Prevalence and 

Incidence by Severity (Joint 

Commission developed measure; all 

patient data from chart abstraction) 

• Patient Falls Prevalence 

• 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: 

• Pneumonia (PN) 30-Day Risk 

Standardized Readmission Measure 

(Medicare patients) 

• Heart Attack (AMI) 30-Day Risk 

Standardized Readmission Measure 

(Medicare patients) 

• 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. 

• VTE–1: VTE Prophylaxis 

• VTE–2: VTE Prophylaxis in the ICU 

• VTE–4: Patients with overlap in 

anticoagulation therapy 

• VTE–5/6: (as combined measure) 

Patients with UFH dosages who have 

platelet count monitoring and 

adjustment of medication per protocol 

or nomogram 

• VTE–7: Discharge instructions to 

address: follow-up monitoring, 

compliance, dietary restrictions and 

adverse drug reactions/interactions 

• 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. 

• STK–1 DVT Prophylaxis 

• STK–2 Discharged on 

Antithrombotic Therapy 

• STK–3 Patients with Atrial 

Fibrillation Receiving Anticoagulation 

Therapy 

• STK–5 Antithrombotic Medication 

By End of Hospital Day Two 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• Patient Safety Indicator (PSI) 4—

Death among surgical patients with 

treatable serious complications 

• PSI 6—Iatrogenic pneumothorax, 

adult 

• PSI 14—Postoperative wound 

dehiscence 

• PSI 15—Accidental puncture or 

laceration 

• Inpatient Quality Indicator (IQI) 4 

and 11—Abdominal aortic aneurysm 

(AAA) mortality rate (with or without 

volume) 

• IQI 19—Hip fracture morality rate 

• IQI Mortality for selected medical 

conditions (composite) 

• IQI Mortality for selected surgical 

procedures (composite) 

• 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: 

• Participation in a Systematic 

Database for Cardiac Surgery 

• Pre-Operative Beta Blockade 

• Prolonged Intubation 

• Deep Sternal Wound Infection Rate 

• Stroke/CVA 

• Post-Operative Renal Insufficiency 

• Surgical Reexploration 

• Anti-Platelet Medication at 

Discharge 

• Beta Blockade Therapy at Discharge 

• Anti-Lipid Treatment at Discharge 

• Risk-Adjusted Operative Mortality 

for CABG 

• Risk-Adjusted Operative Mortality 

for Aortic Valve Replacement 

• Risk-Adjusted Operative Mortality 

for Mitral Valve Replacement/Repair 

• Risk-Adjusted Mortality for Mitral 

Valve Replacement and CABG Surgery 

• 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 Infarction) .............................................. • AMI–1 Aspirin at arrival *. 

• AMI–2 Aspirin prescribed at discharge *. 

• AMI–3 Angiotensin Converting Enzyme Inhibitor (ACE–I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction *. 

• AMI 6 Beta blocker at arrival *. 

• AMI–5 Beta blocker prescribed at discharge *. 

• AMI–7a Fibrinolytic (thrombolytic) agent received within 30 minutes 

of hospital arrival**. 

• AMI–4 Adult smoking cessation advice/counseling**. 

• AMI–8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI). 

Heart Failure (HF) .................................................................................... • HF–2 Left ventricular function assessment *. 


jlentini on PROD1PC65 with PROPOSALS2
23650 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

Topic Quality measure 

• HF–3 Angiotensin Converting Enzyme Inhibitor (ACE–I) or 

Angiotensin II Receptor Blocker (ARB) for left ventricular systolic 

dysfunction *. 

• HF–1 Discharge instructions**. 

• HF–4 Adult smoking cessation advice/counseling**. 

Pneumonia (PN) ....................................................................................... • PN–2 Pneumococcal vaccination status *. 

• PN–3b Blood culture performed before first antibiotic received in 

hospital**. 

• PN–4 Adult smoking cessation advice/counseling**. 

• PN–6 Appropriate initial antibiotic selection**. 

• PN–7 Influenza vaccination status**. 

• PN–5c Timing of receipt of initial antibiotic following hospital 

arrival******. 

Surgical Care Improvement Project (SCIP)—named SIP for discharges 

prior to July 2006 (3Q06).

• SCIP–1 Prophylactic antibiotic received within 1 hour prior to surgical 

incision**. 

• SCIP–3 Prophylactic antibiotics discontinued within 24 hours after 

surgery end time**. 

• SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered 

for surgery patients***. 

• SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery***. 

• SCIP Infection 2: Prophylactic antibiotic selection for surgical 

patients***. 

• SCIP–Infection 4: Cardiac Surgery Patients with Controlled 6AM 

Postoperative Serum Glucose*****. 

• SCIP Infection 6: Surgery Patients with Appropriate Hair 

Removal*****. 

• SCIP Cardiovascular 2: Surgery Patients on a Beta Blocker Prior to 

Arrival Who Received a Beta Blocker During the Perioperative 

Period******. 

Mortality Measures (Medicare patients) ................................................... • MORT–30–AMI Acute Myocardial Infarction 30-day mortality Medicare patients***. 

• MORT–30–HF Heart Failure 30-day mortality Medicare patients***. 

• MORT–30–PN Pneumonia 30-day mortality Medicare patients . 

Patients’ Experience of Care .................................................................... • HCAHPS patient survey** *. 

Readmission Measures (Medicare patients) ............................................ • Heart Attack (AMI) 30-Day Risk Standardized Readmission Measure 

(Medicare patients)******. 

• Heart Failure (HF) 30-Day Risk Standardized Readmission Measure 

(Medicare patients)******. 

• Pneumonia (PN) 30-Day Risk Standardized Readmission Measure 

(Medicare patients) ******. 

Inpatient Stroke Care ............................................................................... • STK–1 DVT Prophylaxis******. 

• STK–2 Discharged on Antithrombotic Therapy******. 

• STK–3 Patients with Atrial Fibrillation Receiving Anticoagulation 

Therapy******. 

• STK–5 Antithrombotic Medication By End of Hospital Day Two******. 

• STK–7 Dysphasia Screening******. 

Venous Thromboembolic Care ................................................................. • VTE–1: VTE Prophylaxis******. 

• VTE–2: VTE Prophylaxis in the ICU******. 

• VTE–4: Patients with overlap in anticoagulation therapy******. 

• VTE–5/6: (as combined measure) patients with UFH dosages who 

have platelet count monitoring and adjustment of medication per protocol or nomagram******. 

• VTE–7: Discharge instructions to address: followup monitoring, compliance, dietary restrictions, and adverse drug reactions/ 

interactions******. 

• VTE–8: Incidence of preventable VTE******. 

AHRQ Patient Safety Indicators ............................................................... • Death among surgical patients with treatable serious 

complications******. 

• Iatrogenic pneumothorax, adult******. 

• Postoperative wound dehiscence******. 

• Accidental puncture or laceration******. 

AHRQ Inpatient Quality Indicators (IQI) ................................................... • Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) ******. 

• Hip fracture morality rate******. 

AHRQ IQI Composite Measures .............................................................. • Mortality for selected surgical procedures (composite) ******. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23651 

Topic Quality measure 

• Complication/patient safety for selected indicators (composite) ******. 

• Mortality for selected medical conditions (composite) ******. 

Nursing Sensitive Measures ..................................................................... • Failure to Rescue******. 

• Pressure Ulcer Prevalence and Incidence by Severity ******. 

• Patient Falls Prevalence******. 

• Patient Falls with Injury******. 

Cardiac Surgery Measures ....................................................................... • Participation in a Systematic Database for Cardiac Surgery ******. 

• Pre-operative Beta Blockade******. 

• Prolonged Intubation******. 

• Deep Sternal Wound Infection Rate******. 

• Stroke/CVA******. 

• Postoperative Renal Insufficiency******. 

• Surgical Reexploration******. 

• Anti-platelet Medication at Discharge******. 

• Beta Blockade Therapy at Discharge******. 

• Anti-lipid Treatment at Discharge******. 

• Risk-Adjusted Operative Mortality for CABG******. 

• Risk-Adjusted Operative Mortality for Aortic Valve Replacement******. 

• Risk-Adjusted Operative Mortality for Mitral Valve Replacement/ 

Repair******. 

• Risk-Adjusted Mortality for Mitral Valve Replacement and CABG 

Surgery******. 

• 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: 

IPPS payment year 

Number of 

RHQDAPU 

program 

quality 

measures 

Topics covered 

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 


jlentini on PROD1PC65 with PROPOSALS2
23652 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• Which of the measures or measure 

sets should be included in the 

RHQDAPU program for FY 2011 or in 

subsequent years? 

• What challenges for data collection 

and reporting are posed by the 

identified measures and measure sets? 

What improvements could be made to 

data collection or reporting that might 

offset or otherwise address those 

challenges? 

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, including Timeliness ............ Median Time from ED Arrival to 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)—named SIP for discharges 

prior to July 2006 (3Q06).

SCIP Infection 8—Short Half-life Prophylactic Administered 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 (‘‘Never Events’’) ................... Surgery performed on the wrong 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23653 

POSSIBLE MEASURES AND MEASURE SETS FOR THE RHQDAPU PROGRAM FOR FY 2011 AND SUBSEQUENT YEARS—

Continued 

Topic Quality measure 

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 Conditions (HACs) ........................... Catheter-Associated Urinary 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 


jlentini on PROD1PC65 with PROPOSALS2
23654 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• 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. 

• 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. 

• 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 highcost 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: 

• Use of registry-collected clinical 

data for which there is broad existing 

hospital participation as previously 

described with the STS registry. 

• 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: 

• 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/PaperworkReduction

Actof1995/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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23655 

patient characteristics that will help 

CMS capture information related to 

resource utilization; expected costs as 

well as clinical outcomes; and postdischarge 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. 

• 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. 

• 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: 

• American College of Cardiology 

(ACC) data registry for Cardiac 

Measures. 

• ACC data registry for ICD. 

• ACC data registry for Carotid Stents. 

• Vascular Surgery Registry for 

Vascular Surgical Procedures. 

• 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—

• Register with QualityNet, before 

participating hospitals initially begin 

reporting data, regardless of the method 

used for submitting data. 

› Identify a QualityNet 

Administrator who follows the 

registration process located on the 

QualityNet Web site 

(www.qualitynet.org). 

› 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. 

› 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 Core Measures Performance 

Measurement System, or another thirdparty 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. 

• 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. 

• 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). 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23656 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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%2F

QnetTier2&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: 

• 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. 

• 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: 

› AMI. We are proposing that a 

hospital that has five or fewer AMI 

discharges (both Medicare and nonMedicare 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. 

› HCAHPS. We are proposing that a 

hospital that has five or fewer HCAHPSeligible 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. 

› HF. We are proposing that a 

hospital that has five or fewer HF 

discharges (both Medicare and nonMedicare 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. 

› PN. We are proposing that a 

hospital that has five or fewer PN 

discharges (both Medicare and nonMedicare 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. 

› SCIP. We are proposing that a 

hospital that has five or fewer SCIP 

discharges (both Medicare and nonMedicare 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: 

• 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. 

• 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: 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 twostep 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: 

• The 21-measure expanded set will 

be validated using 4th quarter CY 2006 

(4Q06) through 3rd quarter CY 2007 

(3Q07) discharges. 

• SCIP VTE-1, VTE-2, and SCIP 

Infection 2 will be validated using 2nd 

quarter CY 2007 and 3rd quarter CY 

2007 discharges. 

• SCIP Infection 4 and SCIP Infection 

6 must be submitted starting with 1st 

quarter CY 2008 discharges but will not 

be validated. 

• HCAHPS data must continuously be 

submitted and will be reviewed as 

discussed above. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23658 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• 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. 

Topic Quality measure validated from 4th quarter 2007 through 3rd quarter 

2008 discharges 

Heart Attack (Acute Myocardial Infarction) .............................................. Aspirin at arrival 

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 (SCIP)—named SIP for discharges 

prior to July 2006 (3Q06).

Prophylactic antibiotic received within 1 hour prior 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 

• 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: 

• Pneumonia antibiotic prophylaxis 

timing within 4 hours will be validated 

using data from 4th quarter 2007 

through 3rd quarter 2008 discharges. 

• Percutaneous Coronary Intervention 

(PCI) Timing within 120 minutes will be 

validated using data from 4th quarter 

2007 through 3rd quarter 2008 

discharges. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23659 

the reliability and validity of the 

methodology. We specifically request 

input concerning the following: 

• 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? 

• 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? 

• 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? 

• 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—

• Submit to CMS, via QualityNet, a 

Reconsideration Request form (available 

on the QualityNet Web site) containing 

the following information: 

Æ Hospital Medicare ID number. 

Æ Hospital Name. 

Æ CMS-identified reason for failure 

(as provided in the CMS notification of 

failure letter to the hospital). 

Æ 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.) 

Æ CEO contact information, including 

name, e-mail address, telephone 

number, and mailing address (must 

include physical address, not just the 

post office box). 

Æ QualityNet System Administrator 

contact information, including name, email address, telephone number, and 

mailing address (must include physical 

address, not just the post office box). 

• The request must be signed by the 

hospital’s CEO. 

• Following receipt of a request for 

reconsideration, CMS will—

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
23660 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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/HospitalVBPPlanRTCFINAL

SUBMITTED2007.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 (§§ 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: 

• The Federal rate applicable to the 

hospital; 

• The updated hospital-specific rate 

based on FY 1982 costs per discharge; 

• The updated hospital-specific rate 

based on FY 1987 costs per discharge; 

or 

• The updated hospital-specific rate 

based on FY 1996 costs per discharge. 

For purposes of payment to SCHs for 

which the FY 1996 hospital-specific rate 

yields the greatest aggregate payment, 

payments for discharges during FYs 

2001, 2002, and 2003 were based on a 

blend of the FY 1996 hospital-specific 

rate and the greater of the Federal rate 

or the updated FY 1982 or FY 1987 


jlentini on PROD1PC65 with PROPOSALS2
23662 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 hospitalspecific 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 hospitalspecific 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 hospitalspecific 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 bedsize 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 bedsize 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 


jlentini on PROD1PC65 with PROPOSALS2
23664 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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

Number of beds 

Census Region 

New 

England 

Middle 

Atlantic 

South 

Atlantic 

East North 

Central 

East South 

Central 

West North 

Central 

West 

South 

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

Number of beds 

Census Region 

New 

England 

Middle 

Atlantic 

South 

Atlantic 

East North 

Central 

East South 

Central 

West North 

Central 

West 

South 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23665 

PAID NURSING HOURS PER PATIENT DAY—Continued 

Number of beds 

Census Region 

New 

England 

Middle 

Atlantic 

South 

Atlantic 

East North 

Central 

East South 

Central 

West North 

Central 

West 

South 

Central 

Mountain Pacific 

(1) (2) (3) (4) (5) (6) (7) (8) (9) 

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) 

(§ 412.96) 

Under the authority of section 

1886(d)(5)(C)(i) of the Act, the 

regulations at § 412.96 set forth the 

criteria that a hospital must meet in 

order to qualify under the IPPS 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 

(§ 412.96(b)(1)(ii)). A rural hospital that 

does not meet the bed size requirement 

can qualify as an RRC if the hospital 

meets two mandatory prerequisites (a 

minimum CMI and a minimum number 

of discharges), and at least one of three 

optional criteria (relating to specialty 

composition of medical staff, source of 

inpatients, or referral volume) 

(§ 412.96(c)(1) through (c)(5) and the 

September 30, 1988 Federal Register (53 

FR 38513)). With respect to the two 

mandatory prerequisites, a hospital may 

be classified as an RRC if—

• The hospital’s CMI is at least equal 

to the lower of the median CMI for 

urban hospitals in its census region, 

excluding hospitals with approved 

teaching programs, or the median CMI 

for all urban hospitals nationally; and 

• The hospital’s number of discharges 

is at least 5,000 per year, or, if fewer, the 

median number of discharges for urban 

hospitals in the census region in which 

the hospital is located. (The number of 

discharges criterion for an osteopathic 

hospital is at least 3,000 discharges per 

year, as specified in section 

1886(d)(5)(C)(i) of the Act.) 

1. Case-Mix Index 

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 

§ 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 

§ 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—

• 1.4285; or 

• The median CMI value (not 

transfer-adjusted) for urban hospitals 

(excluding hospitals with approved 

teaching programs as identified in 

§ 413.75) calculated by CMS for the 

census region in which the hospital is 

located. 

The proposed median CMI values by 

region are set forth in the following 

table: 

Region Case-mix 

index 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 


jlentini on PROD1PC65 with PROPOSALS2
23666 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

Region Case-mix 

index value 

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—

• 5,000 (3,000 for an osteopathic 

hospital); or 

• The median number of discharges 

for urban hospitals in the census region 

in which the hospital is located, as 

indicated in the following table. 

Region Number of 

discharges 

1. New England (CT, ME, MA, NH, RI, VT) .................................................................................................................................... 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 (§ 412.105) 

1. Background 

Section 1886(d)(5)(B) of the Act 

provides for an additional payment 

amount under the IPPS for hospitals 

that have residents in an approved 

graduate medical education (GME) 

program in order to reflect the higher 

indirect patient care costs of teaching 

hospitals relative to nonteaching 

hospitals. The regulations regarding the 

calculation of this additional payment, 

known as the indirect medical 

education (IME) adjustment, are located 

at § 412.105. 

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} .405 ¥ 1]. The 

formula is traditionally described in 

terms of a certain percentage increase in 

payment for every 10-percent increase 

in the resident-to-bed ratio. 

Section 502(a) of Pub. L. 108–173 

modified the formula multiplier (c) to be 

used in the calculation of the IME 

adjustment. Prior to the enactment of 

Pub. L. 108–173, the formula multiplier 

was fixed at 1.35 for discharges 

occurring during FY 2003 and 

thereafter. In the FY 2005 IPPS final 

rule, we announced the schedule of 

formula multipliers to be used in the 

calculation of the IME adjustment and 

incorporated the schedule in our 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23667 

regulations at § 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: 

• For discharges occurring on or after 

April 1, 2004, and before October 1, 

2004, the formula multiplier is 1.47. 

• For discharges occurring during FY 

2005, the formula multiplier is 1.42. 

• For discharges occurring during FY 

2006, the formula multiplier is 1.37. 

• For discharges occurring during FY 

2007, the formula multiplier is 1.32. 

• 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 (§ 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 hospitalspecific 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 §§ 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 § 413.75(b) and § 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 § 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 § 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 

‘‘§ 413.75(d).’’ The correct citation to the 

rolling average requirements for direct 

GME is § 413.79(d). We are proposing to 

correct the cross-reference under 

§ 413.79(f)(6)(iv) to read ‘‘paragraph (d) 

of this section’’. 

H. Payments to Medicare Advantage 

Organizations: Collection of Risk 

Adjustment Data (§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23668 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

adjustment models in order to reflect 

patterns of diagnoses and expenditures 

in the MA program. 

Specifically, we are proposing to 

revise § 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 

§§ 422.310(b), (c), (d)(3), and (g) to 

clarify that the term ‘‘services’’ includes 

items and services. 

We are proposing to revise 

§ 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 

§ 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 §§ 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 § 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 § 422.310(f) to 

clarify that risk adjustment data are 

used not only to adjust payments to 

plans described at §§ 422.301(a)(1), 

(a)(2), and (a)(3) (which refer to 

coordinated care plans and private feefor-service plans), but also to adjust 

payments for ESRD enrollees and 

payments to MSA plans and Religious 

Fraternal Benefit society plans, as 

described at § 422.301(c). 

Under § 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 § 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 (§ 489.24) 

1. Background 

Sections 1866(a)(1)(I), 1866(a)(1)(N), 

and 1867 of the Act impose specific 

obligations on certain Medicareparticipating 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• 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 § 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). 

• 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 

§ 489.24(f) that makes explicit the 

current policy that all Medicareparticipating 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). 

• 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). 

• 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). 

• That CMS strike the language in the 

Interpretive Guidelines (CMS State 

Operations Manual, Appendix V) that 

addresses telehealth/telemedicine 

(relating to the regulations at 

§ 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) 


jlentini on PROD1PC65 with PROPOSALS2
23670 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 § 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 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 oncall 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 § 489.24(j)(1) to 

the regulations implementing provider 

agreements at § 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 § 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 § 489.20(r)(2). We are 

proposing to incorporate the language of 

§ 489.24(j)(1) as replacement language 

for the existing § 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 § 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 § 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 

§ 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 

§ 489.24(j) to provide that hospitals may 

comply with the on-call list requirement 

specified at § 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 


jlentini on PROD1PC65 with PROPOSALS2
23672 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 oncall for cases requiring specialized 

interventional cardiac care, while 

Hospital B could be designated as oncall 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 oncall 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: 

• 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. 

• The community call plan would 

define the specific geographic area to 

which the plan applies. 

• The community call plan would be 

signed by an appropriate representative 

of each hospital participating in the 

plan. 

• The community call plan would 

ensure that any local and regional EMS 

system protocol formally includes 

information on community on-call 

arrangements. 

• 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. 

• 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. 

• There would be an annual 

reassessment of the community call 

plan by the participating hospitals. 

Proposed revised § 489.24(j) would 

read ‘‘Availability of on-call physicians. 

In accordance with the on-call list 

requirements specified in § 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 oncall 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 § 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 § 489.24(a)(2) to 

include the aforementioned language to 

conform the regulation text to the 

statutory language. Proposed revised 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23673 

17Medicare Payment Advisory Commission: 

Report to Congress: Promoting Greater Efficiency in 

Medicare. June 2007, Chapter 5, page 103. 

18Coleman, 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. 

19Coleman, 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. 

20Coleman, 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: 

Continued 

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 afterhospital care, and more active 

involvement of patients and caregivers 

in decision making. 

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 patientπspecific 

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 


jlentini on PROD1PC65 with PROPOSALS2
23674 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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. 

23Lappe, 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. 

24Naylor, 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. 

26Weinberg 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. 

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 evidencebased 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: 

• Better, safer care during the 

hospitalization. 

• Improved communication among 

providers and with the patient and 

caregivers. 

• Care planning that begins with 

assessment at admission. 

• Clear discharge instructions, with 

specific attention to medication 

management. 

• Shared accountability for care 

coordination, with attention to 

transitions and hand-offs. 

• Discharge to a proper setting of 

care. 

• Better, safer care in the post-acute 

setting of care. 

• Appropriate use of palliative care 

and honest planning for the likely 

course. 

• Timely physician follow up visits. 

• 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 costefficiency 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: PerformanceBased Payment Adjustment 

The second approach presented for 

comment is adjustment to hospital MS–

DRG payments using a performancebased 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/ 

HospitalVBPPlan

RTCFINALSUBMITTED2007.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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 hospitalspecific, 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—

• Is located in a rural area (as defined 

in section 1886(d)(2)(D) of the Act) or is 

treated as being located in a rural area 

under section 1886(d)(8)(E) of the Act; 

• Has fewer than 51 beds (excluding 

beds in a distinct part psychiatric or 

rehabilitation unit) as reported in its 

most recent cost report; 

• Provides 24-hour emergency care 

services; and 

• Is not designated or eligible for 

designation as a CAH. 

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 


jlentini on PROD1PC65 with PROPOSALS2
23676 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 capitalrelated 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 capitalrelated costs from a reasonable costbased 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 § 412.312. For the purpose of 

calculating payments for each discharge, 

the standard Federal rate is adjusted as 

follows: 

(Standard Federal Rate) × (DRG 

Weight) × (Geographic Adjustment 

Factor (GAF)) × (Large Urban Add-on, if 

applicable) × (COLA for hospitals 

located in Alaska and Hawaii) × (1 + 

Capital DSH Adjustment Factor + 

Capital IME Adjustment Factor, if 

applicable). 

Hospitals also may receive outlier 

payments for those cases that qualify 

under the threshold established for each 

fiscal year as specified in § 412.312(c) of 

the regulations. 

1. Exception Payments 

The regulations at § 412.348(f) 

provide that a hospital may request an 

additional payment if the hospital 

incurs unanticipated capital 

expenditures in excess of $5 million due 

to extraordinary circumstances beyond 

the hospital’s control. This policy was 

originally established for hospitals 

during the 10-year transition period, but 

as we discussed in the FY 2003 IPPS 

final rule (67 FR 50102), we revised the 

regulations at § 412.312 to specify that 

payments for extraordinary 

circumstances are also made for cost 

reporting periods after the transition 

period (that is, cost reporting periods 

beginning on or after October 1, 2001). 

Additional information on the exception 

payment for extraordinary 

circumstances in § 412.348(f) can be 

found in the FY 2005 IPPS final rule (69 

FR 49185 and 49186). 

During the transition period, under 

§§ 412.348(b) through (e), eligible 

hospitals could receive regular 

exception payments. These exception 

payments guaranteed a hospital a 

minimum payment percentage of its 

Medicare allowable capital-related costs 

depending on the class of the hospital 

(§ 412.348(c)), but were available only 

during the 10-year transition period. 

After the end of the transition period, 

eligible hospitals can no longer receive 

this exception payment. However, even 

after the transition period, eligible 

hospitals receive additional payments 

under the special exceptions provisions 

at § 412.348(g), which guarantees all 

eligible hospitals a minimum payment 

of 70 percent of 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 § 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, § 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 § 412.304(c)(2) to provide 

that, for cost reporting periods 

beginning on or after October 1, 2002, a 

new hospital (defined under 

§ 412.300(b)) is paid 85 percent of its 

Medicare allowable capital-related costs 

through its first 2 years of operation, 

unless the new hospital elects to receive 

fully prospective payment based on 100 

percent of the Federal rate. (We refer 

readers to the 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 capitalrelated 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 § 412.308(c)(1), to 

account for capital input price increases 

and other factors. The regulations at 

§ 412.308(c)(2) provide that the capital 

Federal rate is adjusted annually by a 

factor equal to the estimated proportion 

of outlier payments under the capital 

Federal rate to total capital payments 

under the capital Federal rate. In 

addition, § 412.308(c)(3) requires that 

the capital Federal rate be reduced by an 

adjustment factor equal to the estimated 

proportion of payments for (regular and 

special) exceptions under § 412.348. 

Section 412.308(c)(4)(ii) requires that 

the capital standard Federal rate be 

adjusted so that the effects of the annual 

DRG reclassification and the 

recalibration of DRG weights, and 

changes in the geographic adjustment 

factor are budget neutral. 

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 


jlentini on PROD1PC65 with PROPOSALS2
23678 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 412.322 

of the regulations), disproportionate 

share hospitals (the DSH adjustment 

factor, under § 412.320), and large urban 

hospitals (the large urban location 

adjustment factor, under § 412.316(b)). 

The classes of hospitals eligible for 

these adjustments have been realizing 

much higher margins than other 

hospitals under the system. Specifically, 

teaching hospitals (11.6 percent for FYs 

1998 through 2004), 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

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Aggregate 

1996–2005 

Aggregate 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23679 

HOSPITAL INPATIENT MEDICARE CAPITAL MARGINS—Continued 

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Aggregate 

1996–2005 

Aggregate 

1998–2005 

$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 

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 


jlentini on PROD1PC65 with PROPOSALS2
23680 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

§ 413.40(a)) was set for each hospital or 

hospital unit based on the hospital’s 

own cost experience in its base year. 

The target amount was multiplied by 

the Medicare discharges and applied as 

an aggregate upper limit (the ceiling as 

defined in § 413.40(a)) on total inpatient 

operating costs for a hospital’s cost 

reporting period. Prior to October 1, 

1997, these payment provisions applied 

consistently to all categories of excluded 

providers, 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 § 403.752(a) of the regulations, 

RNHCIs are also subject to the rate-ofincrease limits established under 

§ 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-ofincrease 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 § 412.533(c) or a LTCH that is 

defined as new under § 412.23(e)(4), 

there was a transition period under 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23681 

adjustment, rural location, indirect 

teaching costs, the presence of a fullservice 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-toCharge 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 

§ 412.525(a)(4)(iv)(B) and 

§ 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 

§ 412.525(a)(4)(iv)(C) and 

§ 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 § 412.525(a)(4)(iv)(A) and 

§ 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 

§ 412.525(a)(4)(iv)(C)(2) for high-cost 

outliers and § 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 

§ 412.525(a)(4)(iv)(C) and the short-stay 

outlier policy at § 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 § 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 § 412.525(a)(4)(iv)(C)(2) for highcost outliers and 

§ 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 § 412.525(a)(4)(iv)(C) 

for high-cost outliers and 

§ 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 shortterm 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 


jlentini on PROD1PC65 with PROPOSALS2
23682 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 412.22) for a LTCH HwH that is colocated with another hospital. A colocated hospital is a hospital that 

occupies space in the same building or 

on the same campus as another hospital. 

The regulations at § 412.23(e) required 

that, to be excluded from the IPPS, longterm 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 § 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 colocated with another hospital are also 

required to meet the ‘‘separateness’’

criteria at § 412.22(e). 

In addition, a ‘‘grandfathering’’

provision was added to the regulations 

at § 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 

§ 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 § 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 § 412.22(f). Where 

a State law defines the structure and 

authority of the State’s agencies and 

institutions, and the State hospital is colocated 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 § 412.22(e)(1)(i) that 

requires the governing body of a colocated 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 § 412.22(f). These HwHs 

were IPPS-excluded even before the 

HwH criteria were implemented and 

only remain excluded HwHs under 

§ 412.22(f) as long as they continue to 

meet the requirements specified under 

§ 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 

(§ 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 

§ 412.22(e) because it cannot meet the 

HwH criteria at § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23683 

those hospitals that existed before the 

HwH regulations were established. 

Accordingly, we are proposing to add 

a new paragraph (e)(1)(vi) to § 412.22 to 

provide that if a hospital cannot meet 

the criteria in § 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 

§ 412.22(e) and—

• Both State hospitals share the same 

building or same campus and have been 

continuously owned and operated by 

the State since October 1, 1995; 

• 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 

• 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 § 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 

§ 412.22(e)(1)(i). 

VII. Disclosure Required of Certain 

Hospitals and Critical Access Hospitals 

Regarding Physician Ownership 

(§ 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 

§ 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 § 489.3. The disclosure 

requirement in current § 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 selfreferral 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 

§ 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 § 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 § 489.20(v) new 

language to provide for an exception to 

the disclosure requirements for a 

physician-owned hospital (as defined at 

§ 489.3) that does not have any 

physician owners who refer patients to 

the hospital (and that has no referring 

physicians (as defined at § 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 § 489.20 as 

paragraphs (w) and (x), respectively.) 

We are proposing to revise § 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 § 489.20(u) to specify that the 


jlentini on PROD1PC65 with PROPOSALS2
23684 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 

§ 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 § 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 § 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 § 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 

§ 489.53 to permit CMS to terminate the 

Medicare provider agreement if the 

hospital fails to comply with the 

provisions of proposed § 489.20(u)(1) or 

(u)(2). We believe that these revisions 

would be necessary to enforce the 

proposed disclosure requirements set 

forth in § 489.20. 

We are not inclined to make a 

corresponding change to the medical 

staff bylaws condition of participation 

(CoP) in § 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 § 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 § 489.20(v) and (w) as 

§ 489.20(w) and (x), respectively, to 

accommodate the addition of the 

proposed exception to the requirements 

in § 489.20(v) discussed above.) We 

stated that it is important to ensure that 

consumers are provided accurate 

information on the availability of 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 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 

§ 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 

(§§ 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 

§ 411.354 (72 FR 51026 through 51030). 

A ‘‘physician organization’’ is defined at 

§ 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 

§ 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 § 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 

§ 411.354(c)(1)(ii), § 411.354(c)(2)(iv), 

and § 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: 

• With respect to an AMC as 

described in § 411.355(e)(2), 


jlentini on PROD1PC65 with PROPOSALS2
23686 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

compensation arrangements between a 

faculty practice plan and another 

component of the same AMC; and 

• 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 § 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 

§ 411.357(c) (for bona fide employment 

relationships), the exception in 

§ 411.357(d) (for personal service 

arrangements), or the exception in 

§ 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 

§ 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 

§ 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 

§ 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 § 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 

§ 411.357(c), (d), or (l). We are soliciting 

public comments on this issue. 

As described above, a physicianemployee or contractor whose 

compensation arrangement with a 

physician organization does not satisfy 

the requirements of § 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 

§ 411.357(c)), and the physicianemployee’s DHS referrals to the group 

practice instead are protected under the 

exception for in-office ancillary services 

in § 411.355(b), there is risk that the 

physician-employee’s above-fair-marketvalue compensation may reflect the 

volume or value of referrals to the DHS 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 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 § 411.354(c)(3)(ii) to provide 

that the provisions of §§ 411.354(c)(1)(ii) 

and (c)(2)(iv) do not apply when the 

requirements of § 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 § 411.355(e) for services 

provided by an AMC. We note that, if 

all of the requirements of the exception 

in § 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 § 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 

§ 411.357(c), (d), and (l), respectively. 

We are proposing to include a specific 

revision to the regulation in 

§ 411.354(c)(2)(iv); however, we are 

seeking public comment as to whether 

this policy is better achieved by revising 

§ 411.354(c)(3) to delete the reference to 

applying the exceptions in § 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 

§ 411.355 are satisfied. 

In this first approach, we also propose 

to revise § 411.354(c)(3)(ii) to provide 

that the provisions of § 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 § 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 

§§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23688 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 antikickback 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 § 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 selfreferral 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 whollyowned 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: 

• 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). 

• 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. 

• 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—whollyowned 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 whollyowned by the hospital—employed 

physician of the group practice (whose 

compensation does not satisfy the 

requirements of the exception in 

§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23690 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

§ 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 

§ 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 

§ 411.352.’’ Our intent was that, when 

applying the physician ‘‘stand in the 

shoes’’ provisions in § 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 § 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 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 selfreferral 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 selfreferral law. 

At this time, we are proposing to 

amend § 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 § 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 § 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 

§ 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 § 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 

§ 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23692 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• Identify specific actions that would 

produce savings, such as limiting the 

inappropriate use of supplies; 

• Are transparent and disclosed to 

patients; 

• Include periodic reviews of quality 

of care by an independent organization; 

• 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; 

• Avoid rewarding physicians for 

increasing referrals to the hospitals, 

such as capping potential savings based 

on the number of prior year admissions; 

and 

• 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 allinclusive 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 


jlentini on PROD1PC65 with PROPOSALS2
23694 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 

§ 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 selfreferral exceptions (for example, the 

exception for indirect compensation 

arrangements in § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 

§ 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 § 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
23696 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 411.361 requires 

entities to report ‘‘any ownership or 

investment interest, as defined at 

§ 411.354(b), or any compensation 

arrangement, as defined at § 411.354(c), 

except for ownership or investment 

interests that satisfy the exceptions set 

forth in § 411.356(a) and § 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 § 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 § 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 

§ 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 § 411.361 to provide that 

entities need not report ownership or 

investment interests that satisfy the 

exceptions in § 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 Medicareparticipating 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 Medicareparticipating 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 


jlentini on PROD1PC65 with PROPOSALS2
23698 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• Whether the collection effort should 

be recurring, and, if so, whether it 

should be implemented on an annual or 

some other periodic basis. 

• Whether we are collecting too much 

or not enough information, and whether 

we are collecting the correct (or 

incorrect) type of information. 

• 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. 

• 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. 

• 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. 

Processing year Wage data 

year 

PPS fiscal 

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: 

• Notice of proposed rulemaking 

published in the Federal Register. 

• Final rule published in the Federal 

Register. 

Media: Diskette/most recent year on 

the Internet. 

File Cost: $165.00 per year. 

Periods Available: FY 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• Notice of proposed rulemaking 

published in the Federal Register. 

• 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 

on or after 

and before 

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 

on or after 

and before 

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 Medicarecertified 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 

on or after 

and before 

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 casemix 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: 

• Notice of proposed rulemaking 

published in the Federal Register. 

• Final rule published in the Federal 

Register. 

Media: Diskette/most recent year on 

Internet. 

Price: $165.00 per year/per file. 

Periods Available: FY 1985 through 

FY 2009. 


jlentini on PROD1PC65 with PROPOSALS2
23700 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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: 

• Notice of proposed rulemaking. 

• 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: 

• Notice of proposed rulemaking 

published in the Federal Register. 

• 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: 

• Notice of proposed rulemaking 

published in the Federal Register. 

• 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: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

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 (§ 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 

(§ 422.310) 

As discussed in section IV.H. of the 

preamble of this proposed rule, 

§ 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, 

§ 422.310(b) states that CMS may collect 

data necessary to characterize the 

functional limitations of enrollees of 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 (§ 489.20) 

As discussed in section IV.I. of the 

preamble of this proposed rule, 

proposed § 489.20(r)(2) states that a 

hospital, as defined in § 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 

§ 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 § 489.20(u)(1) states that, in 

the case of a physician-owned hospital 

as defined in § 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 § 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 

§ 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 § 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 § 489.20(v) states that the 

aforementioned requirements in 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23702 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 489.24(b), to 

furnish all patients notice, in 

accordance with § 482.13(b)(2), at the 

beginning of their hospital stay or 

outpatient visit if a doctor of medicine 

or a doctor of osteopathy is not present 

in the hospital 24 hours per day, 7 days 

per week. The notice must indicate how 

the hospital will meet the medical needs 

of any inpatient who develops an 

emergency medical condition, as 

defined in § 489.24(b), at a time when 

there is no physician present in the 

hospital. The burden associated with 

this requirement is the time and effort 

necessary for each hospital to develop a 

standard notice to furnish to its patients. 

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

Regulation 

section(s) 

OMB 

control 

No. 

Respondents Responses 

Burden per 

response 

(hours) 

Total 

annual 

burden 

(hours) 

§ 411.361 ........................................... 0938–New ........................................ 500 500 31 15,500 

§ 422.310(b) ...................................... 0938–0878 ....................................... 676 676 110 * 74,424 

§ 489.20(r) ......................................... 0938–New ........................................ 100 100 3 300 

§ 489.20(u)(1) and (w) ...................... 0938–1034 ....................................... 2,679 49,735,635 ** 839,599 

§ 489.20(u)(2) .................................... 0938–New ........................................ 175 175 4 700 

§ 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 addon 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-bycase 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• Pneumonia 30-day Mortality 

(Medicare patients); 

• SCIP Infection 4: Cardiac Surgery 

Patients with Controlled 6AM 

Postoperative Serum Glucose; and 

• 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: 

Carolyn_L._Raffaelli@omb.eop.gov. 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: 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
23704 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 411.352. 

* * * * * 

3. Section 411.353 is amended by 

revising paragraph (c) to read as follows: 

§ 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: 

§ 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 § 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 § 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 

§ 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 

§ 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: 

§ 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: 

§ 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: 

§ 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—


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23705 

a. Revising paragraph (b)(1). 

b. Adding a new paragraph (c). 

The revision and addition read as 

follows: 

§ 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: 

§ 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: 

§ 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: 

§ 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). 

§ 413.79 [Amended] 

14. In § 413.79(f)(6)(iv), remove the 

cross-reference ‘‘§ 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: 

§ 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, 


jlentini on PROD1PC65 with PROPOSALS2
23706 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

§§ 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 ‘‘physicianowned hospital’’ to read as follows: 

§ 489.3 Definitions. 

* * * * * 

Physician-owned hospital means any 

participating hospital (as defined in 

§ 489.24) in which a physician, or an 

immediate family member of a 

physician (as defined in § 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 

§ 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: 

§ 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 § 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 

§ 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 § 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 physicianowned hospital specified in § 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 § 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 § 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 § 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: 

§ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 § 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 oncall 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 § 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 § 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: 

§ 489.53 Termination by CMS. 

* * * * * 

(c) Termination of agreements with 

physician-owned hospitals. In the case 

of a physician-owned hospital, as 

defined at § 489.3, CMS may terminate 

the provider agreement if the hospital 

failed to comply with the requirements 

of § 489.20(u) 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 capitalrelated 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 hospitalspecific 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 hospitalspecific 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. 


jlentini on PROD1PC65 with PROPOSALS2
23708 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

For hospitals located in Puerto Rico, the 

payment per discharge is based on the sum 

of 25 percent of an updated Puerto Ricospecific 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-ofincrease 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 

§ 412.64. The basic methodology for 

determining the prospective payment rates 

for hospital inpatient operating costs for 

hospitals located in Puerto Rico for FY 2005 

and subsequent fiscal years is set forth at 

§§ 412.211 and 412.212. Below we discuss 

the factors used for determining the 

prospective payment rates. 

In summary, the proposed standardized 

amounts set forth in Tables 1A, 1B, and 1C, 

of section VI. of this Addendum reflect—

• Equalization of the standardized 

amounts for urban and other areas at the 

level computed for large urban hospitals 

during FY 2004 and onward, as provided for 

under section 1886(d)(3)(A)(iv) of the Act, 

updated by the applicable percentage 

increase required under sections 

1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of 

the Act. 

• The labor-related share that is applied to 

the standardized amounts and Puerto Ricospecific standardized amounts to give the 

hospital the highest payment, as provided for 

under sections 1886(d)(3)(E), and 

1886(d)(9)(C)(iv) of the Act. 

• Proposed updates of 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. 

• 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 

§ 412.211(c), which states that we update the 

Puerto Rico-specific standardized amount 

using the percentage increase specified in 

§ 412.64(d)(1), or the percentage increase in 

the market basket index for prospective 

payment hospitals for all areas. 

• An adjustment to the standardized 

amount to ensure budget neutrality for DRG 

recalibration and reclassification, as provided 

for under section 1886(d)(4)(C)(iii) of the Act. 

• An adjustment to ensure the wage index 

update and changes are budget neutral, as 

provided for under section 1886(d)(3)(E) of 

the Act. 

• An adjustment to ensure the effects of 

geographic reclassification are budget 

neutral, as provided for in section 

1886(d)(8)(D) of the Act, by removing the FY 

2008 budget neutrality factor and applying a 

revised factor. 

• An adjustment to remove the FY 2008 

outlier offset and apply an offset for FY 2009. 

• 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. 

• 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 timeto-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 nonlaborrelated 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 laborrelated share of 69.7 percent of the national 

standardized amount. For hospitals located 

in Puerto Rico, we are applying a laborrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 Ricospecific 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. 


jlentini on PROD1PC65 with PROPOSALS2
23710 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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-ofchange in hospital charges under the new 

outlier policy. 

Using the most recent data available, we 

calculated the 1-year average annualized rateof-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 ProviderSpecific 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

amounts 

Capital 

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 


jlentini on PROD1PC65 with PROPOSALS2
23712 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

27These figures represent 3.0 standard deviations 

from the mean of the log distribution of CCRs for 

all hospitals. 

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 § 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. 

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 dischargeweighted average of the national large urban 

standardized amount (this proposed amount 

is set forth in Table 1A). The proposed laborrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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

Full update (3.0 percent); wage index is 

greater than 1.0000 

Full update (3.0 percent); wage index is 

less than 1.0000 

Reduced update (1.0 

percent); wage index 

is greater than 1.0000 

Reduced update (1.0 

percent); wage index 

is less than 1.0000 

FY 2008 Base Rate, after removing geographic reclassification budget 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).

Labor: $3,723.07 ........

Nonlabor: $1,618.50 ..

Labor: $3,311.77 ........

Nonlabor: $2,029.80 ..

Labor: $3,723.07 ........

Nonlabor: $1,618.50 ..

Labor: $3,311.77 

Nonlabor: $2,029.80 

FY 2009 Update Factor ................................. 1.030 .......................... 1.030 .......................... 1.010 .......................... 1.010 

FY 2009 DRG Recalibrations and Wage 

Index Budget Neutrality Factor.

0.999525 .................... 0.999525 .................... 0.999525 .................... 0.999525 

FY 2009 Reclassification Budget Neutrality 

Factor.

0.992333 .................... 0.992333 .................... 0.992333 .................... 0.992333 

FY 2009 Outlier Factor .................................. 0.948928 .................... 0.948928 .................... 0.948928 .................... 0.948928 

Rural Demonstration Budget Neutrality Factor.0.999666 .................... 0.999666 .................... 0.999666 .................... 0.999666 

FY 2009 Documentation and Coding Adjustment and Actual FY 2008 Adjustment.0.985 .......................... 0.985 .......................... 0.985 .......................... 0.985 

Proposed Rate for FY 2009 ........................... Labor: $3,553.98 ........

Nonlabor: $1,544.98 ..

Labor: $3,161.36 ........

Nonlabor: $1,937.60 ..

Labor: $3,484.97 ........

Nonlabor: $1,514.98 ..

Labor: $3,099.97 

Nonlabor: $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 laborrelated 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 laborrelated 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

Area 

Cost of living 

adjustment 

factor 

Alaska: 

City of Anchorage and 80-kilometer (50-mile) radius by road ..................................................................................................... 1.24 


jlentini on PROD1PC65 with PROPOSALS2
23714 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE OF COST-OF-LIVING ADJUSTMENT FACTORS: ALASKA AND HAWAII HOSPITALS—Continued 

Area 

Cost of living 

adjustment 

factor 

City of Fairbanks and 80-kilometer (50-mile) radius by road ...................................................................................................... 1.24 

City of Juneau and 80-kilometer (50-mile) radius by road .......................................................................................................... 1.24 

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 hospitalspecific 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 hospitalspecific 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-ofincrease for hospitals that submit qualifying 

quality data and the market basket rate-ofincrease 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 hospitalspecific 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 CapitalRelated 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 § 412.304(c)(2)) are paid based on the 

capital Federal rate. For FY 1992, we 

computed the standard Federal payment rate 

for capital-related costs under the IPPS by 

updating the FY 1989 Medicare inpatient 

capital cost per case by an actuarial estimate 

of the increase in Medicare inpatient capital 

costs per case. Each year after FY 1992, we 

update the capital standard Federal rate, as 

provided at § 412.308(c)(1), to account for 

capital input price increases and other 

factors. The regulations at § 412.308(c)(2) 

provide that the capital Federal rate be 

adjusted annually by a factor equal to the 

estimated proportion of outlier payments 

under the capital Federal rate to total capital 

payments under the capital Federal rate. In 

addition, § 412.308(c)(3) requires that the 

capital Federal rate be reduced by an 

adjustment factor equal to the estimated 

proportion of payments for (regular and 

special) exceptions under § 412.348. Section 

412.308(c)(4)(ii) requires that the capital 

standard Federal rate be adjusted so that the 

effects of the annual DRG reclassification and 

the recalibration of DRG weights and changes 

in the geographic adjustment factor (GAF) are 

budget neutral. 

For FYs 1992 through 1995, § 412.352 

required that the capital Federal rate also be 

adjusted by a budget neutrality factor so that 

aggregate payments for inpatient hospital 

capital costs were projected to equal 90 

percent of the payments that would have 

been made for 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 

§ 412.308(b)(3) describes the 0.28 percent 

reduction to the capital Federal rate made in 

FY 1996 as a result of the revised policy for 

paying for transfers. In FY 1998, we 

implemented section 4402 of Pub. L. 105–33, 

which required that, for discharges occurring 

on or after October 1, 1997, the budget 

neutrality adjustment factor in effect as of 

September 30, 1995, be applied to the 

unadjusted capital standard Federal rate and 

the unadjusted hospital-specific rate. That 

factor was 0.8432, which was equivalent to 

a 15.68 percent reduction to the unadjusted 

capital payment rates. An additional 2.1 

percent reduction to the rates was effective 

from October 1, 1997 through September 30, 

2002, making the total reduction 17.78 

percent. As we discussed in the FY 2003 

IPPS final rule (67 FR 50102) and 

implemented in § 412.308(b)(6), the 2.1 

percent reduction was restored to the 

unadjusted capital payment rates effective 

October 1, 2002. 

To determine the appropriate budget 

neutrality adjustment factor and the regular 

exceptions payment adjustment during the 

10-year transition period, we developed a 

dynamic model of Medicare inpatient 

capital-related costs; that is, a model that 

projected changes in Medicare inpatient 

capital-related costs over time. With the 

expiration of the budget neutrality provision, 

the capital cost model was only used to 

estimate the regular exceptions payment 

adjustment and other factors during the 

transition period. As we explained in the FY 

2002 IPPS final rule (66 FR 39911), beginning 

in FY 2002, an adjustment for regular 

exception payments is no longer necessary 

because regular exception payments were 

only made for cost reporting periods 

beginning on or after October 1, 1991, and 

before October 1, 2001 (see § 412.348(b)). 

Because payments are no longer made under 

the regular exception policy effective with 

cost reporting periods beginning in FY 2002, 

we discontinued use of the capital cost 

model. The capital cost model and its 

application during the transition period are 

described in Appendix B of the FY 2002 IPPS 

final rule (66 FR 40099). 

Section 412.374 provides for the use of a 

blended payment system for payments to 

hospitals located in Puerto Rico under the 

IPPS for acute care hospital inpatient capitalrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
23716 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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: 

• The average resource use of Medicare 

patients changes (‘‘real’’ case-mix change); 

• Changes in hospital coding of patient 

records result in higher weight MS–DRG 

assignments (‘‘coding effects’’); and 

• 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 casemix 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 casemix change was not dependent on total 

change, but was usually a fairly steady 

increase of 1.0 to 1.5 percent per year. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 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 casemix 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 capitalrelated 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 


jlentini on PROD1PC65 with PROPOSALS2
23718 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23719 

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 


jlentini on PROD1PC65 with PROPOSALS2ep30ap08.021</GPH>
23720 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 § 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 hospitalspecific capital rates. 

An adjustment for regular exception 

payments is no longer necessary in 

determining the FY 2009 capital Federal rate 

because, in accordance with § 412.348(b), 

regular exception payments were only made 

for cost reporting periods beginning on or 

after October 1, 1991 and before October 1, 

2001. Accordingly, as we explained in the FY 

2002 IPPS final rule (66 FR 39949), in FY 

2002 and subsequent fiscal years, no 

payments are made under the regular 

exceptions provision. However, in 

accordance with § 412.308(c), we still need to 

compute a budget neutrality adjustment for 

special exception payments under 

§ 412.348(g). We describe our methodology 

for determining the exceptions adjustment 

used in calculating the FY 2008 capital 

Federal rate below. 

Under the special exceptions provision 

specified at § 412.348(g)(1), eligible hospitals 

include SCHs, urban hospitals with at least 

100 beds that have a disproportionate share 

percentage of at least 20.2 percent or qualify 

for DSH payments under § 412.106(c)(2), and 

hospitals with a combined Medicare and 

Medicaid inpatient utilization of at least 70 

percent. An eligible hospital may receive 

special exceptions payments if it meets the 

following criteria: (1) A project need 

requirement as described at § 412.348(g)(2), 

which, in the case of certain urban hospitals, 

includes an excess capacity test as described 

at § 412.348(g)(4); (2) an age of assets test as 

described at § 412.348(g)(3); and (3) a project 

size requirement as described at 

§ 412.348(g)(5). 

Based on information compiled from our 

fiscal intermediaries, six hospitals have 

qualified for special exceptions payments 

under § 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: 

• The proposed FY 2009 update factor is 

1.0070, that is, the update is 0.70 percent. 

• 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. 

• The proposed FY 2009 outlier 

adjustment factor is 0.9427. 

• The proposed FY 2009 (special) 

exceptions payment adjustment factor is 

0.9998. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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

FY 2008 Proposed FY 

2009 4 Change Percent 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 Adjustment Factor 3 .... 0.9940 0.9910 0.9910 ¥0.90 

Capital Federal Rate ........................................................................................ $426.14 $421.29 0.9886 ¥1.14 

1The 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. 2The 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. 3Proposed 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. 4Proposed factors for FY 2009, as discussed above in section III. of this Addendum. 

5Percent 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 capitalrelated 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 capitalblended 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 Ricospecific 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 § 412.324(b) 

and under § 412.304(c)(2)) are paid based on 

100 percent of the capital Federal rate in FY 

2007. The applicable capital Federal rate was 

determined by making the following 

adjustments: 

• For outliers, by dividing the capital 

standard Federal rate by the outlier reduction 

factor for that fiscal year; and 

• For the payment adjustments applicable 

to the hospital, by multiplying the hospital’s 

GAF, disproportionate share adjustment 

factor, and IME adjustment factor, when 

appropriate. 

For purposes of calculating payments for 

each discharge during FY 2009, the capital 

standard Federal rate would be adjusted as 

follows: (Standard Federal Rate) × (DRG 

weight) × (GAF) × (COLA for hospitals 

located in Alaska and Hawaii) × (1 + 

Disproportionate Share Adjustment Factor + 

IME Adjustment Factor, if applicable). The 

result is the adjusted capital Federal rate. (As 

discussed above and in section V. of the 

preamble of this proposed rule, we 

eliminated the large urban add-on adjustment 

in existing regulations at § 412.316, 

beginning in FY 2008.) 

Hospitals also may receive outlier 

payments for those cases that qualify under 

the thresholds established for each fiscal 

year. Section 412.312(c) provides for a single 


jlentini on PROD1PC65 with PROPOSALS2
23722 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

§ 412.348(g) up through the 10th year beyond 

the end of the capital transition period if it 

meets the following criteria: (1) A project 

need requirement described at 

§ 412.348(g)(2), which in the case of certain 

urban hospitals includes an excess capacity 

test as described at § 412.348(g)(4); and (2) a 

project size requirement as described at 

§ 412.348(g)(5). Eligible hospitals include 

SCHs, urban hospitals with at least 100 beds 

that have a DSH patient percentage of at least 

20.2 percent or qualify for DSH payments 

under § 412.106(c)(2), and hospitals that have 

a combined Medicare and Medicaid inpatient 

utilization of at least 70 percent. Under 

§ 412.348(g)(8), the amount of a special 

exceptions payment is determined by 

comparing the cumulative payments made to 

the hospital under the capital PPS to the 

cumulative minimum payment level. This 

amount is offset by: (1) Any amount by 

which a hospital’s cumulative capital 

payments exceed its cumulative minimum 

payment levels applicable under the regular 

exceptions process for cost reporting periods 

beginning during which the hospital has 

been subject to the capital PPS; and (2) any 

amount by which a hospital’s current year 

operating and capital payments (excluding 75 

percent of operating DSH payments) exceed 

its operating and capital costs. Under 

§ 412.348(g)(6), the minimum payment level 

is 70 percent for all eligible hospitals. 

During the transition period, new hospitals 

(as defined under § 412.300) were exempt 

from the capital IPPS for their first 2 years 

of operation and were paid 85 percent of 

their reasonable costs during that period. 

Effective with the third year of operation 

through the remainder of the transition 

period, under § 412.324(b), we paid the 

hospitals under the appropriate transition 

methodology (if the hold-harmless 

methodology were applicable, the holdharmless payment for assets in use during the 

base period would extend for 8 years, even 

if the hold-harmless payments extend beyond 

the normal transition period). 

Under § 412.304(c)(2), for cost reporting 

periods beginning on or after October 1, 

2002, we pay a new hospital 85 percent of 

its reasonable costs during the first 2 years 

of operation unless it elects to receive 

payment based on 100 percent of the capital 

Federal rate. Effective with the third year of 

operation, we pay the hospital based on 100 

percent of the capital Federal rate (that is, the 

same methodology used to pay all other 

hospitals subject to the capital PPS). 

C. Capital Input Price Index 

1. Background 

Like the operating input price index, the 

capital input price index (CIPI) is a fixedweight 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-ofincrease ceiling. An annual per discharge 

limit (the target amount as defined in 

§ 413.40(a)) was set for each hospital or 

hospital unit based on the hospital’s own 

cost experience in its base year. The target 

amount was multiplied by the Medicare 

discharges and applied as an aggregate upper 

limit (the ceiling as defined in § 413.40(a)) on 

total inpatient operating costs for a hospital’s 

cost reporting period. Prior to October 1, 

1997, these payment provisions applied 

consistently to all categories of excluded 

providers (rehabilitation hospitals and units 

(now referred to as IRFs), psychiatric 

hospitals and units (now referred to as IPFs), 

LTCHs, children’s hospitals, and cancer 

hospitals). 

Payment for 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 § 403.752(a), RNHCIs are also subject to 

the rate-of-increase limits established under 

§ 413.40 of the regulations.) 

We are proposing that the FY 2009 rate-ofincrease 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). 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

greater than 1 

Rates if wage index less 

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 

TABLE 1D.—CAPITAL STANDARD

FEDERAL PAYMENT RATE—Continued 

Rate 

Puerto Rico ................................. 197.19 


jlentini on PROD1PC65 with PROPOSALS2
23724 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23725 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23726 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23727 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23728 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23729 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23730 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23731 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23732 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23733 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 * * * * 


jlentini on PROD1PC65 with PROPOSALS2
23734 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23735 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23736 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23737 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23738 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23739 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 

1400103 .................................................... 1.4980 1.0334 31.8806 40.1360 39.3702 36.3250 

140B103 ................................................... *** * * 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 


jlentini on PROD1PC65 with PROPOSALS2
23740 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23741 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23742 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 * * * * 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23743 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23744 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23745 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23746 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23747 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23748 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 

2200744 .................................................... 1.3507 1.1338 30.5607 31.4730 33.2051 31.7041 

220B744 ................................................... *** * * 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23749 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23750 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 

2301045 .................................................... 1.5934 1.0113 32.4634 32.4125 34.0171 32.9570 

230B045 ................................................... *** * * * 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 * * * * 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23751 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23752 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23753 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23754 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23755 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23756 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 * * * * 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23757 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23758 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23759 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23760 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23761 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23762 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23763 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23764 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23765 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23766 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23767 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23768 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23769 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23770 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23771 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23772 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23773 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23774 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23775 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23776 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23777 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23778 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23779 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23780 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23781 

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—Continued 

Provider No. Case-mix 

index 2

FY 2009 wage 

index 

Average 

hourly wage 

FY 2007 

Average 

hourly wage 

FY 2008 

Average 

hourly wage 

FY 2009 1

Average 

hourly wage** 

(3 years) 

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 

1Based on salaries adjusted for occupational mix, according to the calculation in section III.D.2. of the preamble to this proposed rule. 2The case-mix index is based on the billed DRGs in the FY 2007 MedPAR file. It is not transfer adjusted. 

3Provider 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. 4Provider 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. 5Provider 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] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

10180 ....... Abilene, TX ........................................................................................................................................ 27.1004 25.7723 

10380 ....... Aguadilla-Isabela-San Sebastia ́n, PR ............................................................................................... 10.6709 10.7622 

10420 ....... Akron, OH .......................................................................................................................................... 28.3319 26.9292 

10500 ....... Albany, GA ......................................................................................................................................... 28.2617 27.2184 

10580 ....... Albany-Schenectady-Troy, NY .......................................................................................................... 28.4655 27.2227 

10740 ....... Albuquerque, NM ............................................................................................................................... 30.6500 29.7201 

10780 ....... Alexandria, LA ................................................................................................................................... 26.1655 24.7913 

10900 ....... Allentown-Bethlehem-Easton, PA-NJ ................................................................................................ 31.2097 30.7425 

11020 ....... Altoona, PA ........................................................................................................................................ 26.7060 25.9824 


jlentini on PROD1PC65 with PROPOSALS2
23782 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

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, GA ................................................................................................................ 30.9008 29.8591 

12060 ....... Atlanta-Sandy Springs-Marietta, GA ................................................................................................. 31.4502 30.3269 

12100 ....... Atlantic City-Hammonton, NJ ............................................................................................................ 38.0743 36.7794 

12220 ....... Auburn-Opelika, AL ........................................................................................................................... 24.3605 24.4407 

12260 ....... Augusta-Richmond County, GA-SC .................................................................................................. 30.9498 29.7603 

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, TX ................................................................................................................. 27.7045 26.7778 

13380 ....... Bellingham, WA ................................................................................................................................. 36.7964 34.7347 

13460 ....... Bend, OR ........................................................................................................................................... 35.6036 33.2554 

13644 ....... Bethesda-Frederick-Gaithersburg, MD .............................................................................................. 33.9508 32.8571 

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-Christiansburg-Radford, VA ............................................................................................ 26.1759 25.2599 

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-Venice, FL ........................................................................................................ 31.5095 30.2345 

14740 ....... Bremerton-Silverdale, WA ................................................................................................................. 34.5710 33.5071 

14860 ....... Bridgeport-Stamford-Norwalk, CT ..................................................................................................... 42.0944 39.8678 

15180 ....... Brownsville-Harlingen, TX ................................................................................................................. 29.7382 29.0319 

15260 ....... Brunswick, GA ................................................................................................................................... 32.6731 31.3350 

15380 ....... Buffalo-Niagara Falls, NY .................................................................................................................. 30.9123 29.5833 

15500 ....... Burlington, NC ................................................................................................................................... 27.7660 26.6186 

15540 ....... Burlington-South Burlington, VT ........................................................................................................ 29.6973 29.1460 

15764 ....... Cambridge-Newton-Framingham, MA ............................................................................................... 35.6990 34.3809 

15804 ....... Camden, NJ ....................................................................................................................................... 34.1250 32.6476 

15940 ....... Canton-Massillon, OH ........................................................................................................................ 28.5297 27.6782 

15980 ....... Cape Coral-Fort Myers, FL ................................................................................................................ 30.6869 29.4302 

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 Charleston-Summerville, SC ................................................................................. 29.7955 28.4097 

16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................................ 30.8456 29.4515 

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-Joliet, IL .............................................................................................................. 33.3033 32.5973 

17020 ....... Chico, CA ........................................................................................................................................... 35.0695 34.2761 

17140 ....... Cincinnati-Middletown, OH-KY-IN ..................................................................................................... 30.9027 29.7285 

17300 ....... Clarksville, TN-KY .............................................................................................................................. 26.7544 25.7478 

17420 ....... Cleveland, TN .................................................................................................................................... 26.2909 25.3790 

17460 ....... Cleveland-Elyria-Mentor, OH ............................................................................................................. 29.8896 28.9336 

17660 ....... Coeur d’Alene, ID .............................................................................................................................. 29.5998 28.7256 

17780 ....... College Station-Bryan, TX ................................................................................................................. 29.6321 28.1756 

17820 ....... Colorado Springs, CO ....................................................................................................................... 31.4793 29.6470 

17860 ....... Columbia, MO .................................................................................................................................... 27.2133 26.2863 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23783 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

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, TX ...................................................................................................................... 31.7539 30.5827 

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 Island, IA-IL ................................................................................................. 27.2010 26.8964 

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-Ormond Beach, FL ..................................................................................... 28.4632 27.8441 

19740 ....... Denver-Aurora, CO ............................................................................................................................ 34.1438 32.7970 

19780 ....... Des Moines-West Des Moines, IA .................................................................................................... 30.6173 28.7458 

19804 ....... Detroit-Livonia-Dearborn, MI ............................................................................................................. 32.3846 31.4605 

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, NJ ............................................................................................................... 36.1487 34.5118 

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-Springdale-Rogers, AR-MO ........................................................................................... 29.4256 27.9239 

22380 ....... Flagstaff, AZ ...................................................................................................................................... 37.5481 35.8798 

22420 ....... Flint, MI .............................................................................................................................................. 36.2781 34.1503 

22500 ....... Florence, SC ...................................................................................................................................... 27.3900 26.5639 

22520 ....... Florence-Muscle Shoals, AL .............................................................................................................. 25.2619 24.0763 

22540 ....... Fond du Lac, WI ................................................................................................................................ 30.7462 30.7188 

22660 ....... Fort Collins-Loveland, CO ................................................................................................................. 30.8219 29.2764 

22744 ....... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL .................................................................... 31.6349 30.8485 

22900 ....... Fort Smith, AR-OK ............................................................................................................................. 25.2751 24.4937 

23020 ....... Fort Walton Beach-Crestview-Destin, FL .......................................................................................... 28.1059 26.8450 

23060 ....... Fort Wayne, IN .................................................................................................................................. 28.8955 28.1729 

23104 ....... Fort Worth-Arlington, TX .................................................................................................................... 31.2137 29.8330 

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, MI .............................................................................................................. 29.9037 29.1399 

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, NC ............................................................................................................... 29.4639 28.1363 

24780 ....... Greenville, NC ................................................................................................................................... 30.1256 28.8796 

24860 ....... Greenville-Mauldin-Easley, SC .......................................................................................................... 31.0004 29.7649 

25020 ....... Guayama, PR .................................................................................................................................... 10.1106 09.6176 

25060 ....... Gulfport-Biloxi, MS ............................................................................................................................. 28.6731 27.0856 


jlentini on PROD1PC65 with PROPOSALS2
23784 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

25180 ....... Hagerstown-Martinsburg, MD-WV ..................................................................................................... 29.8828 28.7638 

25260 ....... Hanford-Corcoran, CA ....................................................................................................................... 35.7293 33.4052 

25420 ....... Harrisburg-Carlisle, PA ...................................................................................................................... 29.4620 28.6481 

25500 ....... Harrisonburg, VA ............................................................................................................................... 28.8643 27.8908 

25540 ....... Hartford-West Hartford-East Hartford, CT ......................................................................................... 36.0188 34.1981 

25620 ....... Hattiesburg, MS ................................................................................................................................. 24.2839 23.4139 

25860 ....... Hickory-Lenoir-Morganton, NC .......................................................................................................... 28.8353 27.7789 

25980 ....... 1 Hinesville-Fort Stewart, GA.

26100 ....... Holland-Grand Haven, MI .................................................................................................................. 29.3296 28.2605 

26180 ....... Honolulu, HI ....................................................................................................................................... 37.4061 34.9722 

26300 ....... Hot Springs, AR ................................................................................................................................. 29.4741 27.9457 

26380 ....... Houma-Bayou Cane-Thibodaux, LA .................................................................................................. 25.3740 24.7942 

26420 ....... Houston-Sugar Land-Baytown, TX .................................................................................................... 31.9906 30.9869 

26580 ....... Huntington-Ashland, WV-KY-OH ....................................................................................................... 29.4107 27.7644 

26620 ....... Huntsville, AL ..................................................................................................................................... 28.9607 27.8624 

26820 ....... Idaho Falls, ID ................................................................................................................................... 29.3359 28.2699 

26900 ....... Indianapolis-Carmel, IN ..................................................................................................................... 31.6890 30.3105 

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-Richland, WA ....................................................................................................... 31.3630 30.6561 

28660 ....... Killeen-Temple-Fort Hood, TX ........................................................................................................... 28.5417 26.9557 

28700 ....... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................ 25.3719 24.5154 

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 County, IL-WI ................................................................................................ 33.4390 32.6639 

29420 ....... Lake Havasu City-Kingman, AZ ........................................................................................................ 31.6370 29.6383 

29460 ....... Lakeland-Winter Haven, FL ............................................................................................................... 28.1459 27.5004 

29540 ....... Lancaster, PA .................................................................................................................................... 31.0576 30.0449 

29620 ....... Lansing-East Lansing, MI .................................................................................................................. 31.9010 30.9914 

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 Little Rock-Conway, AR ........................................................................................ 28.2114 28.2530 

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-Glendale, CA ............................................................................................ 38.9626 36.6108 

31140 ....... Louisville-Jefferson County, KY-IN .................................................................................................... 29.7925 28.3269 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23785 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

31540 ....... Madison, WI ....................................................................................................................................... 36.2618 34.3945 

31700 ....... Manchester-Nashua, NH ................................................................................................................... 33.0542 31.4821 

31900 ....... Mansfield, OH .................................................................................................................................... 29.9812 28.5726 

32420 ....... Mayagu ̈ez, PR ................................................................................................................................... 12.5555 11.7170 

32580 ....... McAllen-Edinburg-Mission, TX .......................................................................................................... 29.3886 27.9884 

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-Kendall, FL ........................................................................................................ 31.8599 30.6911 

33140 ....... Michigan City-La Porte, IN ................................................................................................................ 29.1570 27.7380 

33260 ....... Midland, TX ........................................................................................................................................ 30.8197 29.6993 

33340 ....... Milwaukee-Waukesha-West Allis, WI ................................................................................................ 32.8741 31.8085 

33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI ....................................................................................... 35.4391 33.7580 

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-Anacortes, WA ........................................................................................................... 32.2055 31.3429 

34620 ....... Muncie, IN .......................................................................................................................................... 26.7339 25.4260 

34740 ....... Muskegon-Norton Shores, MI ............................................................................................................ 32.9571 31.3172 

34820 ....... Myrtle Beach-North Myrtle Beach-Conway, SC ................................................................................ 28.0263 27.0772 

34900 ....... Napa, CA ........................................................................................................................................... 45.2771 42.3405 

34940 ....... Naples-Marco Island, FL ................................................................................................................... 31.7163 30.5323 

34980 ....... Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................................. 30.5185 29.8356 

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-Kenner, LA ..................................................................................................... 29.4715 27.1340 

35644 ....... New York-White Plains-Wayne, NY-NJ ............................................................................................. 42.0303 40.8866 

35660 ....... Niles-Benton Harbor, MI .................................................................................................................... 29.3085 28.0264 

35980 ....... Norwich-New London, CT ................................................................................................................. 36.8468 36.0398 

36084 ....... Oakland-Fremont-Hayward, CA ........................................................................................................ 49.9560 47.7941 

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, NE-IA ............................................................................................................ 30.2913 29.2081 

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-Ventura, CA ............................................................................................... 36.9286 35.1055 

37340 ....... Palm Bay-Melbourne-Titusville, FL .................................................................................................... 30.3622 29.2690 

37380 ....... 2Palm Coast, FL ................................................................................................................................ 28.3179 27.7197 

37460 ....... Panama City-Lynn Haven, FL ........................................................................................................... 27.4719 25.9842 

37620 ....... Parkersburg-Marietta-Vienna, WV-OH .............................................................................................. 25.9281 25.2122 

37700 ....... Pascagoula, MS ................................................................................................................................. 25.8776 25.5012 

37764 ....... Peabody, MA ..................................................................................................................................... 34.6216 32.8179 

37860 ....... Pensacola-Ferry Pass-Brent, FL ....................................................................................................... 26.1506 24.9081 

37900 ....... Peoria, IL ........................................................................................................................................... 29.1439 28.4392 

37964 ....... Philadelphia, PA ................................................................................................................................ 35.4610 33.9583 

38060 ....... Phoenix-Mesa-Scottsdale, AZ ........................................................................................................... 33.0972 31.5810 

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 Portland-Biddeford, ME ............................................................................................ 31.9890 30.7480 

38900 ....... Portland-Vancouver-Beaverton, OR-WA ........................................................................................... 36.1216 34.7569 

38940 ....... Port St. Lucie, FL ............................................................................................................................... 31.9898 30.8026 

39100 ....... Poughkeepsie-Newburgh-Middletown, NY ........................................................................................ 35.2679 33.9878 

39140 ....... Prescott, AZ ....................................................................................................................................... 32.8634 30.9614 

39300 ....... Providence-New Bedford-Fall River, RI-MA ...................................................................................... 34.3817 33.0490 

39340 ....... Provo-Orem, UT ................................................................................................................................ 29.1600 28.8274 


jlentini on PROD1PC65 with PROPOSALS2
23786 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

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 Bernardino-Ontario, CA ............................................................................................. 36.2653 34.0181 

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-Strafford County, NH ....................................................................................... 31.9359 31.0988 

40580 ....... Rocky Mount, NC .............................................................................................................................. 29.2288 27.8751 

40660 ....... Rome, GA .......................................................................................................................................... 31.2559 29.9017 

40900 ....... Sacramento-Arden-Arcade-Roseville, CA ......................................................................................... 41.9426 40.3835 

40980 ....... Saginaw-Saginaw Township North, MI ............................................................................................. 29.1128 28.2485 

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 Marcos, CA ............................................................................................... 36.2686 34.6834 

41780 ....... Sandusky, OH .................................................................................................................................... 28.4754 27.6992 

41884 ....... San Francisco-San Mateo-Redwood City, CA .................................................................................. 48.5597 46.7826 

41900 ....... San Germa ́n-Cabo Rojo, PR ............................................................................................................. 14.9779 14.5348 

41940 ....... San Jose-Sunnyvale-Santa Clara, CA .............................................................................................. 51.2569 48.2592 

41980 ....... San Juan-Caguas-Guaynabo, PR ..................................................................................................... 14.1930 13.8050 

42020 ....... San Luis Obispo-Paso Robles, CA ................................................................................................... 38.5623 36.3112 

42044 ....... Santa Ana-Anaheim-Irvine, CA ......................................................................................................... 38.1247 35.9846 

42060 ....... Santa Barbara-Santa Maria-Goleta, CA ............................................................................................ 37.7124 35.1162 

42100 ....... Santa Cruz-Watsonville, CA .............................................................................................................. 51.5525 48.3881 

42140 ....... Santa Fe, NM .................................................................................................................................... 34.1580 33.1619 

42220 ....... Santa Rosa-Petaluma, CA ................................................................................................................ 49.2189 45.6081 

42340 ....... Savannah, GA ................................................................................................................................... 28.8176 27.8424 

42540 ....... Scranton-Wilkes-Barre, PA ................................................................................................................ 26.5201 25.6648 

42644 ....... Seattle-Bellevue-Everett, WA ............................................................................................................ 37.3352 35.3387 

42680 ....... Sebastian-Vero Beach, FL ................................................................................................................ 30.7417 30.0442 

43100 ....... Sheboygan, WI .................................................................................................................................. 29.1159 28.0863 

43300 ....... Sherman-Denison, TX ....................................................................................................................... 29.9470 27.3065 

43340 ....... Shreveport-Bossier City, LA .............................................................................................................. 27.5578 26.7863 

43580 ....... Sioux City, IA-NE-SD ......................................................................................................................... 28.3024 27.7781 

43620 ....... Sioux Falls, SD .................................................................................................................................. 30.2235 29.2197 

43780 ....... South Bend-Mishawaka, IN-MI .......................................................................................................... 31.0993 30.1358 

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-Clearwater, FL .............................................................................................. 28.9032 28.1723 

45460 ....... Terre Haute, IN .................................................................................................................................. 29.4437 27.6736 

45500 ....... Texarkana, TX-Texarkana, AR .......................................................................................................... 26.4165 24.8363 

45780 ....... Toledo, OH ........................................................................................................................................ 29.8934 28.9126 

45820 ....... Topeka, KS ........................................................................................................................................ 28.5929 27.0599 

45940 ....... Trenton-Ewing, NJ ............................................................................................................................. 34.3697 33.3207 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23787 

TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued 

[*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Urban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

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-Bridgeton, NJ ......................................................................................................... 35.2379 33.0201 

47260 ....... Virginia Beach-Norfolk-Newport News, VA-NC ................................................................................. 28.5838 27.2923 

47300 ....... Visalia-Porterville, CA ........................................................................................................................ 33.2020 31.5996 

47380 ....... Waco, TX ........................................................................................................................................... 28.0515 26.9091 

47580 ....... Warner Robins, GA ........................................................................................................................... 30.5824 28.8902 

47644 ....... Warren-Troy-Farmington Hills, MI ..................................................................................................... 32.1363 31.0932 

47894 ....... Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................... 34.3840 33.3639 

47940 ....... Waterloo-Cedar Falls, IA ................................................................................................................... 28.0510 26.9028 

48140 ....... Wausau, WI ....................................................................................................................................... 31.6785 30.5738 

48260 ....... Weirton-Steubenville, WV-OH ........................................................................................................... 25.8721 24.7386 

48300 ....... Wenatchee, WA ................................................................................................................................. 30.3614 31.9688 

48424 ....... West Palm Beach-Boca Raton-Boynton Beach, FL .......................................................................... 31.1027 29.7030 

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-Boardman, OH-PA ........................................................................................... 28.8065 27.5854 

49700 ....... Yuba City, CA .................................................................................................................................... 34.7445 32.8688 

49740 ....... Yuma, AZ ........................................................................................................................................... 31.9135 30.1305 

1This area has no average hourly wage because there are no short-term, acute care hospitals in the area. 

2This 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] 

CBSA 

code Nonurban area 

FY 2009 average hourly 

wage 

3-Year average 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 


jlentini on PROD1PC65 with PROPOSALS2
23788 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 3B.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR RURAL AREAS BY CBSA—Continued 

[*Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009] 

CBSA 

code Nonurban area 

FY 2009 average hourly 

wage 

3-Year average hourly 

wage 

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 

1All 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.] 

CBSA Code Urban area State Wage 

index GAF 

10180 ........... Abilene, TX .................................................................................................................................... TX ..... 0.8408 0.8880 

10380 ........... Aguadilla-Isabela-San Sebastia ́n, PR ........................................................................................... PR ..... 0.3311 0.4691 

10420 ........... Akron, OH ...................................................................................................................................... OH .... 0.8784 0.9150 

10500 ........... Albany, GA ..................................................................................................................................... GA ..... 0.8770 0.9140 

10580 ........... Albany-Schenectady-Troy, NY ...................................................................................................... NY ..... 0.8833 0.9185 

10740 ........... Albuquerque, NM ........................................................................................................................... NM .... 0.9499 0.9654 

10780 ........... Alexandria, LA ............................................................................................................................... LA ..... 0.8127 0.8676 

10900 ........... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................ NJ ..... 1.1221 1.0821 

10900 ........... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................ PA ..... 0.9675 0.9776 

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 ...................................................................................................................... AL ..... 0.8007 0.8588 

11540 ........... Appleton, WI .................................................................................................................................. WI ..... 0.9511 0.9662 

11700 ........... Asheville, NC ................................................................................................................................. NC ..... 0.9192 0.9439 

12020 ........... Athens-Clarke County, GA ............................................................................................................ GA ..... 0.9589 0.9717 

12060 ........... Atlanta-Sandy Springs-Marietta, GA ............................................................................................. GA ..... 0.9760 0.9835 

12100 ........... Atlantic City-Hammonton, NJ ........................................................................................................ NJ ..... 1.1666 1.1113 

12220 ........... Auburn-Opelika, AL ....................................................................................................................... AL ..... 0.7647 0.8322 

12260 ........... Augusta-Richmond County, GA-SC .............................................................................................. GA ..... 0.9604 0.9727 

12260 ........... Augusta-Richmond County, GA-SC .............................................................................................. SC ..... 0.9589 0.9717 

12420 ........... Austin-Round Rock, TX ................................................................................................................. TX ..... 0.9521 0.9669 

12540 ........... Bakersfield, CA .............................................................................................................................. CA ..... 1.1822 1.1214 

12580 ........... Baltimore-Towson, MD .................................................................................................................. MD .... 0.9981 0.9987 

12620 ........... Bangor, ME .................................................................................................................................... ME .... 1.0115 1.0079 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23789 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

12700 ........... Barnstable Town, MA .................................................................................................................... MA .... 1.2672 1.1761 

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 Arthur, TX ............................................................................................................. TX ..... 0.8595 0.9015 

13380 ........... Bellingham, WA ............................................................................................................................. WA .... 1.1395 1.0935 

13460 ........... Bend, OR ....................................................................................................................................... OR .... 1.1043 1.0703 

13644 ........... Bethesda-Frederick-Gaithersburg, MD .......................................................................................... MD .... 1.1018 1.0686 

13740 ........... Billings, MT .................................................................................................................................... MT ..... 0.9045 0.9336 

13780 ........... Binghamton, NY ............................................................................................................................. NY ..... 0.8721 0.9105 

13820 ........... Birmingham-Hoover, AL ................................................................................................................ AL ..... 0.8786 0.9152 

13900 ........... Bismarck, ND ................................................................................................................................. ND ..... 0.7336 0.8088 

13980 ........... Blacksburg-Christiansburg-Radford, VA ........................................................................................ VA ..... 0.8122 0.8672 

14020 ........... Bloomington, IN ............................................................................................................................. IN ...... 0.9419 0.9598 

14060 ........... Bloomington-Normal, IL ................................................................................................................. IL ....... 0.9520 0.9669 

14260 ........... Boise City-Nampa, ID .................................................................................................................... ID ...... 0.9290 0.9508 

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-Sarasota-Venice, FL .................................................................................................... FL ...... 0.9757 0.9833 

14740 ........... Bremerton-Silverdale, WA ............................................................................................................. WA .... 1.0706 1.0478 

14860 ........... Bridgeport-Stamford-Norwalk, CT ................................................................................................. CT ..... 1.2591 1.1709 

15180 ........... Brownsville-Harlingen, TX ............................................................................................................. TX ..... 0.9226 0.9463 

15260 ........... Brunswick, GA ............................................................................................................................... GA ..... 1.0139 1.0095 

15380 ........... Buffalo-Niagara Falls, NY .............................................................................................................. NY ..... 0.9593 0.9719 

15500 ........... Burlington, NC ............................................................................................................................... NC ..... 0.8632 0.9042 

15540 ........... Burlington-South Burlington, VT .................................................................................................... VT ..... 0.9275 0.9498 

15764 ........... Cambridge-Newton-Framingham, MA ........................................................................................... MA .... 1.1078 1.0726 

15804 ........... Camden, NJ ................................................................................................................................... NJ ..... 1.1221 1.0821 

15940 ........... Canton-Massillon, OH .................................................................................................................... OH .... 0.8845 0.9194 

15980 ........... Cape Coral-Fort Myers, FL ............................................................................................................ FL ...... 0.9502 0.9656 

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 .................................................................................................................. IL ....... 0.9353 0.9552 

16620 ........... Charleston, WV .............................................................................................................................. WV .... 0.8398 0.8873 

16700 ........... Charleston-North Charleston-Summerville, SC ............................................................................. SC ..... 0.9231 0.9467 

16740 ........... Charlotte-Gastonia-Concord, NC-SC ............................................................................................ NC ..... 0.9570 0.9704 

16740 ........... Charlotte-Gastonia-Concord, NC-SC ............................................................................................ SC ..... 0.9557 0.9694 

16820 ........... Charlottesville, VA ......................................................................................................................... VA ..... 0.9728 0.9813 

16860 ........... Chattanooga, TN-GA ..................................................................................................................... GA ..... 0.8880 0.9219 

16860 ........... Chattanooga, TN-GA ..................................................................................................................... TN ..... 0.8857 0.9202 

16940 ........... Cheyenne, WY ............................................................................................................................... WY .... 0.9223 0.9461 

16974 ........... Chicago-Naperville-Joliet, IL .......................................................................................................... IL ....... 1.0334 1.0228 

17020 ........... Chico, CA ....................................................................................................................................... CA ..... 1.1822 1.1214 

17140 ........... Cincinnati-Middletown, OH-KY-IN ................................................................................................. IN ...... 0.9583 0.9713 

17140 ........... Cincinnati-Middletown, OH-KY-IN ................................................................................................. KY ..... 0.9590 0.9717 

17140 ........... Cincinnati-Middletown, OH-KY-IN ................................................................................................. OH .... 0.9581 0.9711 

17300 ........... Clarksville, TN-KY .......................................................................................................................... KY ..... 0.8302 0.8804 

17300 ........... Clarksville, TN-KY .......................................................................................................................... TN ..... 0.8280 0.8788 

17420 ........... Cleveland, TN ................................................................................................................................ TN ..... 0.8137 0.8683 

17460 ........... Cleveland-Elyria-Mentor, OH ......................................................................................................... OH .... 0.9266 0.9491 

17660 ........... Coeur d’Alene, ID .......................................................................................................................... ID ...... 0.9185 0.9434 

17780 ........... College Station-Bryan, TX ............................................................................................................. TX ..... 0.9193 0.9440 

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 ..... 0.9061 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 ......................................................................................................................... TX ..... 0.8494 0.8942 

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-Irving, TX .................................................................................................................. TX ..... 0.9852 0.9898 

19140 ........... Dalton, GA ..................................................................................................................................... GA ..... 0.8499 0.8946 

19180 ........... Danville, IL ..................................................................................................................................... IL ....... 0.9711 0.9801 

19260 ........... Danville, VA ................................................................................................................................... VA ..... 0.8483 0.8935 


jlentini on PROD1PC65 with PROPOSALS2
23790 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

19340 ........... Davenport-Moline-Rock Island, IA-IL ............................................................................................. IL ....... 0.8606 0.9023 

19340 ........... Davenport-Moline-Rock Island, IA-IL ............................................................................................. IA ...... 0.8709 0.9097 

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 Beach-Ormond Beach, FL ................................................................................. FL ...... 0.8814 0.9172 

19740 ........... Denver-Aurora, CO ........................................................................................................................ CO .... 1.0561 1.0381 

19780 ........... Des Moines-West Des Moines, IA ................................................................................................ IA ...... 0.9460 0.9627 

19804 ........... Detroit-Livonia-Dearborn, MI ......................................................................................................... MI ...... 1.0052 1.0036 

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 Brunswick, NJ ........................................................................................................... NJ ..... 1.1221 1.0821 

20940 ........... El Centro, CA ................................................................................................................................. CA ..... 1.1822 1.1214 

21060 ........... Elizabethtown, KY .......................................................................................................................... KY ..... 0.8466 0.8922 

21140 ........... Elkhart-Goshen, IN ........................................................................................................................ IN ...... 0.9547 0.9688 

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-Springfield, OR ................................................................................................................. OR .... 1.1157 1.0779 

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-Springdale-Rogers, AR-MO ....................................................................................... AR ..... 0.9131 0.9396 

22220 ........... Fayetteville-Springdale-Rogers, AR-MO ....................................................................................... MO .... 0.9123 0.9391 

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 Shoals, AL .......................................................................................................... AL ..... 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 ........... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ................................................................ FL ...... 1.0025 1.0017 

22900 ........... Fort Smith, AR-OK ......................................................................................................................... AR ..... 0.7843 0.8467 

22900 ........... Fort Smith, AR-OK ......................................................................................................................... OK ..... 0.8016 0.8595 

23020 ........... Fort Walton Beach-Crestview-Destin, FL ...................................................................................... FL ...... 0.8703 0.9093 

23060 ........... Fort Wayne, IN .............................................................................................................................. IN ...... 0.9004 0.9307 

23104 ........... Fort Worth-Arlington, TX ................................................................................................................ TX ..... 0.9684 0.9783 

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 ..................................................................................................................... MN .... 0.9120 0.9389 

24220 ........... Grand Forks, ND-MN ..................................................................................................................... ND ..... 0.7709 0.8368 

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 ................................................................................................................................... CO .... 1.0028 1.0019 

24580 ........... Green Bay, WI ............................................................................................................................... WI ..... 0.9511 0.9662 

24660 ........... Greensboro-High Point, NC ........................................................................................................... NC ..... 0.9141 0.9403 

24780 ........... Greenville, NC ............................................................................................................................... NC ..... 0.9346 0.9547 

24860 ........... Greenville-Mauldin-Easley, SC ...................................................................................................... SC ..... 0.9605 0.9728 

25020 ........... Guayama, PR ................................................................................................................................ PR ..... 0.3137 0.4521 

25060 ........... Gulfport-Biloxi, MS ......................................................................................................................... MS .... 0.8898 0.9232 

25180 ........... Hagerstown-Martinsburg, MD-WV ................................................................................................. MD .... 0.9273 0.9496 

25180 ........... Hagerstown-Martinsburg, MD-WV ................................................................................................. WV .... 0.9253 0.9482 

25260 ........... Hanford-Corcoran, CA ................................................................................................................... CA ..... 1.1822 1.1214 

25420 ........... Harrisburg-Carlisle, PA .................................................................................................................. PA ..... 0.9185 0.9434 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23791 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

25500 ........... Harrisonburg, VA ........................................................................................................................... VA ..... 0.8956 0.9273 

25540 ........... Hartford-West Hartford-East Hartford, CT ..................................................................................... CT ..... 1.1897 1.1263 

25620 ........... Hattiesburg, MS ............................................................................................................................. MS .... 0.7653 0.8326 

25860 ........... Hickory-Lenoir-Morganton, NC ...................................................................................................... NC ..... 0.8946 0.9266 

26100 ........... Holland-Grand Haven, MI .............................................................................................................. MI ...... 0.9101 0.9375 

26180 ........... Honolulu, HI ................................................................................................................................... HI ...... 1.1608 1.1075 

26300 ........... Hot Springs, AR ............................................................................................................................. AR ..... 0.9146 0.9407 

26380 ........... Houma-Bayou Cane-Thibodaux, LA .............................................................................................. LA ..... 0.7870 0.8487 

26420 ........... Houston-Sugar Land-Baytown, TX ................................................................................................ TX ..... 0.9925 0.9949 

26580 ........... Huntington-Ashland, WV-KY-OH ................................................................................................... KY ..... 0.9127 0.9394 

26580 ........... Huntington-Ashland, WV-KY-OH ................................................................................................... OH .... 0.9118 0.9387 

26580 ........... Huntington-Ashland, WV-KY-OH ................................................................................................... WV .... 0.9107 0.9380 

26620 ........... Huntsville, AL ................................................................................................................................. AL ..... 0.8987 0.9295 

26820 ........... Idaho Falls, ID ............................................................................................................................... ID ...... 0.9327 0.9534 

26900 ........... Indianapolis-Carmel, IN ................................................................................................................. IN ...... 0.9827 0.9881 

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 ......................................................................................................................... MO .... 0.9038 0.9331 

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-Portage, MI ................................................................................................................. MI ...... 1.0910 1.0615 

28100 ........... Kankakee-Bradley, IL .................................................................................................................... IL ....... 1.2018 1.1341 

28140 ........... Kansas City, MO-KS ...................................................................................................................... KS ..... 0.9453 0.9622 

28140 ........... Kansas City, MO-KS ...................................................................................................................... MO .... 0.9444 0.9616 

28420 ........... Kennewick-Pasco-Richland, WA ................................................................................................... WA .... 1.0164 1.0112 

28660 ........... Killeen-Temple-Fort Hood, TX ....................................................................................................... TX ..... 0.8855 0.9201 

28700 ........... Kingsport-Bristol-Bristol, TN-VA .................................................................................................... TN ..... 0.7957 0.8551 

28700 ........... Kingsport-Bristol-Bristol, TN-VA .................................................................................................... VA ..... 0.8061 0.8628 

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-Kenosha County, IL-WI ............................................................................................ IL ....... 1.0376 1.0256 

29404 ........... Lake County-Kenosha County, IL-WI ............................................................................................ WI ..... 1.0357 1.0243 

29420 ........... Lake Havasu City-Kingman, AZ .................................................................................................... AZ ..... 0.9817 0.9874 

29460 ........... Lakeland-Winter Haven, FL ........................................................................................................... FL ...... 0.8715 0.9101 

29540 ........... Lancaster, PA ................................................................................................................................ PA ..... 0.9799 0.9862 

29620 ........... Lansing-East Lansing, MI .............................................................................................................. MI ...... 0.9899 0.9931 

29700 ........... Laredo, TX ..................................................................................................................................... TX ..... 0.8816 0.9173 

29740 ........... Las Cruces, NM ............................................................................................................................. NM .... 0.8858 0.9203 

29820 ........... Las Vegas-Paradise, NV ............................................................................................................... NV ..... 1.1666 1.1113 

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 .................................................................................................................... ME .... 0.9326 0.9533 

30460 ........... Lexington-Fayette, KY ................................................................................................................... KY ..... 0.8950 0.9268 

30620 ........... Lima, OH ........................................................................................................................................ OH .... 0.9299 0.9514 

30700 ........... Lincoln, NE .................................................................................................................................... NE ..... 0.9620 0.9738 

30780 ........... Little Rock-North Little Rock-Conway, AR .................................................................................... AR ..... 0.8754 0.9129 

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 Beach-Glendale, CA ........................................................................................ CA ..... 1.1916 1.1275 

31140 ........... Louisville-Jefferson County, KY-IN ................................................................................................ IN ...... 0.9238 0.9472 


jlentini on PROD1PC65 with PROPOSALS2
23792 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

31140 ........... Louisville-Jefferson County, KY-IN ................................................................................................ KY ..... 0.9245 0.9477 

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-Nashua, NH ............................................................................................................... NH ..... 1.0807 1.0546 

31900 ........... Mansfield, OH ................................................................................................................................ OH .... 0.9295 0.9512 

32420 ........... Mayagu ̈ez, PR ............................................................................................................................... PR ..... 0.3896 0.5244 

32580 ........... McAllen-Edinburg-Mission, TX ...................................................................................................... TX ..... 0.9118 0.9387 

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-Kendall, FL .................................................................................................... FL ...... 0.9865 0.9907 

33140 ........... Michigan City-La Porte, IN ............................................................................................................ IN ...... 0.9041 0.9333 

33260 ........... Midland, TX .................................................................................................................................... TX ..... 0.9562 0.9698 

33340 ........... Milwaukee-Waukesha-West Allis, WI ............................................................................................ WI ..... 1.0182 1.0124 

33460 ........... Minneapolis-St. Paul-Bloomington, MN-WI ................................................................................... MN .... 1.0997 1.0672 

33460 ........... Minneapolis-St. Paul-Bloomington, MN-WI ................................................................................... WI ..... 1.0976 1.0659 

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-Anacortes, WA ....................................................................................................... WA .... 1.0164 1.0112 

34620 ........... Muncie, IN ...................................................................................................................................... IN ...... 0.8479 0.8932 

34740 ........... Muskegon-Norton Shores, MI ........................................................................................................ MI ...... 1.0227 1.0155 

34820 ........... Myrtle Beach-North Myrtle Beach-Conway, SC ............................................................................ SC ..... 0.8683 0.9078 

34900 ........... Napa, CA ....................................................................................................................................... CA ..... 1.3847 1.2497 

34940 ........... Naples-Marco Island, FL ............................................................................................................... FL ...... 0.9820 0.9876 

34980 ........... Nashville-Davidson-Murfreesboro-Franklin, TN ............................................................................. TN ..... 0.9445 0.9617 

35004 ........... Nassau-Suffolk, NY ....................................................................................................................... NY ..... 1.2729 1.1797 

35084 ........... Newark-Union, NJ-PA .................................................................................................................... NJ ..... 1.1440 1.0965 

35084 ........... Newark-Union, NJ-PA .................................................................................................................... PA ..... 1.1574 1.1053 

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-NJ ......................................................................................... NJ ..... 1.2878 1.1891 

35644 ........... New York-White Plains-Wayne, NY-NJ ......................................................................................... NY ..... 1.3043 1.1995 

35660 ........... Niles-Benton Harbor, MI ................................................................................................................ MI ...... 0.9095 0.9371 

35980 ........... Norwich-New London, CT ............................................................................................................. CT ..... 1.1897 1.1263 

36084 ........... Oakland-Fremont-Hayward, CA .................................................................................................... CA ..... 1.5278 1.3367 

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 ..................................................................................................................... UT ..... 0.9243 0.9475 

36420 ........... Oklahoma City, OK ........................................................................................................................ OK ..... 0.8686 0.9080 

36500 ........... Olympia, WA .................................................................................................................................. WA .... 1.1462 1.0979 

36540 ........... Omaha-Council Bluffs, NE-IA ........................................................................................................ IA ...... 0.9360 0.9557 

36540 ........... Omaha-Council Bluffs, NE-IA ........................................................................................................ NE ..... 0.9400 0.9585 

36740 ........... Orlando-Kissimmee, FL ................................................................................................................. FL ...... 0.9189 0.9437 

36780 ........... Oshkosh-Neenah, WI .................................................................................................................... WI ..... 0.9511 0.9662 

36980 ........... Owensboro, KY .............................................................................................................................. KY ..... 0.8764 0.9136 

37100 ........... Oxnard-Thousand Oaks-Ventura, CA ........................................................................................... CA ..... 1.1822 1.1214 

37340 ........... Palm Bay-Melbourne-Titusville, FL ................................................................................................ FL ...... 0.9401 0.9586 

37380 ........... Palm Coast, FL .............................................................................................................................. FL ...... 0.8769 0.9140 

37460 ........... Panama City-Lynn Haven, FL ....................................................................................................... FL ...... 0.8633 0.9042 

37620 ........... Parkersburg-Marietta-Vienna, WV-OH .......................................................................................... OH .... 0.8582 0.9006 

37620 ........... Parkersburg-Marietta-Vienna, WV-OH .......................................................................................... WV .... 0.8028 0.8603 

37700 ........... Pascagoula, MS ............................................................................................................................. MS .... 0.8030 0.8605 

37764 ........... Peabody, MA ................................................................................................................................. MA .... 1.0744 1.0504 

37860 ........... Pensacola-Ferry Pass-Brent, FL ................................................................................................... FL ...... 0.8633 0.9042 

37900 ........... Peoria, IL ....................................................................................................................................... IL ....... 0.9043 0.9334 

37964 ........... Philadelphia, PA ............................................................................................................................ PA ..... 1.0992 1.0669 

38060 ........... Phoenix-Mesa-Scottsdale, AZ ....................................................................................................... AZ ..... 1.0271 1.0185 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23793 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

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 Portland-Biddeford, ME ........................................................................................ ME .... 0.9927 0.9950 

38900 ........... Portland-Vancouver-Beaverton, OR-WA ....................................................................................... OR .... 1.1204 1.0810 

38900 ........... Portland-Vancouver-Beaverton, OR-WA ....................................................................................... WA .... 1.1186 1.0798 

38940 ........... Port St. Lucie, FL ........................................................................................................................... FL ...... 0.9905 0.9935 

39100 ........... Poughkeepsie-Newburgh-Middletown, NY .................................................................................... NY ..... 1.0944 1.0637 

39140 ........... Prescott, AZ ................................................................................................................................... AZ ..... 1.0198 1.0135 

39300 ........... Providence-New Bedford-Fall River, RI-MA .................................................................................. MA .... 1.0669 1.0453 

39300 ........... Providence-New Bedford-Fall River, RI-MA .................................................................................. RI ...... 1.0669 1.0453 

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 Bernardino-Ontario, CA ......................................................................................... CA ..... 1.1822 1.1214 

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-Strafford County, NH ................................................................................... NH ..... 1.0807 1.0546 

40580 ........... Rocky Mount, NC .......................................................................................................................... NC ..... 0.9068 0.9352 

40660 ........... Rome, GA ...................................................................................................................................... GA ..... 0.9699 0.9793 

40900 ........... Sacramento—Arden-Arcade—Roseville, CA ................................................................................ CA ..... 1.2827 1.1859 

40980 ........... Saginaw-Saginaw Township North, MI ......................................................................................... MI ...... 0.9034 0.9328 

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 ......................................................................................................................... UT ..... 0.9271 0.9495 

41660 ........... San Angelo, TX ............................................................................................................................. TX ..... 0.8600 0.9019 

41700 ........... San Antonio, TX ............................................................................................................................ TX ..... 0.8949 0.9268 

41740 ........... San Diego-Carlsbad-San Marcos, CA ........................................................................................... CA ..... 1.1822 1.1214 

41780 ........... Sandusky, OH ................................................................................................................................ OH .... 0.8828 0.9182 

41884 ........... San Francisco-San Mateo-Redwood City, CA .............................................................................. CA ..... 1.4879 1.3127 

41900 ........... San Germa ́n-Cabo Rojo, PR ......................................................................................................... PR ..... 0.4648 0.5918 

41940 ........... San Jose-Sunnyvale-Santa Clara, CA .......................................................................................... CA ..... 1.5758 1.3654 

41980 ........... San Juan-Caguas-Guaynabo, PR ................................................................................................. PR ..... 0.4404 0.5703 

42020 ........... San Luis Obispo-Paso Robles, CA ............................................................................................... CA ..... 1.1822 1.1214 

42044 ........... Santa Ana-Anaheim-Irvine, CA ..................................................................................................... CA ..... 1.1822 1.1214 

42060 ........... Santa Barbara-Santa Maria-Goleta, CA ........................................................................................ CA ..... 1.1822 1.1214 

42100 ........... Santa Cruz-Watsonville, CA .......................................................................................................... CA ..... 1.5766 1.3658 

42140 ........... Santa Fe, NM ................................................................................................................................ NM .... 1.0587 1.0398 

42220 ........... Santa Rosa-Petaluma, CA ............................................................................................................ CA ..... 1.5052 1.3232 

42340 ........... Savannah, GA ............................................................................................................................... GA ..... 0.8943 0.9264 

42540 ........... Scranton—Wilkes-Barre, PA ......................................................................................................... PA ..... 0.8342 0.8833 

42644 ........... Seattle-Bellevue-Everett, WA ........................................................................................................ WA .... 1.1562 1.1045 

42680 ........... Sebastian-Vero Beach, FL ............................................................................................................ FL ...... 0.9519 0.9668 

43100 ........... Sheboygan, WI .............................................................................................................................. WI ..... 0.9511 0.9662 

43300 ........... Sherman-Denison, TX ................................................................................................................... TX ..... 0.9291 0.9509 

43340 ........... Shreveport-Bossier City, LA .......................................................................................................... LA ..... 0.8547 0.8981 

43580 ........... Sioux City, IA-NE-SD ..................................................................................................................... IA ...... 0.8745 0.9123 

43580 ........... Sioux City, IA-NE-SD ..................................................................................................................... NE ..... 0.8783 0.9150 

43580 ........... Sioux City, IA-NE-SD ..................................................................................................................... SD ..... 0.8783 0.9150 

43620 ........... Sioux Falls, SD .............................................................................................................................. SD ..... 0.9379 0.9570 

43780 ........... South Bend-Mishawaka, IN-MI ...................................................................................................... IN ...... 0.9644 0.9755 


jlentini on PROD1PC65 with PROPOSALS2
23794 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY

STATE—FY 2009—Continued 

[Constituent counties are listed in Table 4E.] 

CBSA Code Urban area State Wage 

index GAF 

43780 ........... South Bend-Mishawaka, IN-MI ...................................................................................................... MI ...... 0.9651 0.9760 

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. Petersburg-Clearwater, FL .......................................................................................... FL ...... 0.8993 0.9299 

45460 ........... Terre Haute, IN .............................................................................................................................. IN ...... 0.9130 0.9396 

45500 ........... Texarkana, TX-Texarkana, AR ...................................................................................................... AR ..... 0.8197 0.8727 

45500 ........... Texarkana, TX-Texarkana, AR ...................................................................................................... TX ..... 0.8195 0.8726 

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-Fairfield, CA ....................................................................................................................... CA ..... 1.3974 1.2575 

47020 ........... Victoria, TX .................................................................................................................................... TX ..... 0.8153 0.8695 

47220 ........... Vineland-Millville-Bridgeton, NJ ..................................................................................................... NJ ..... 1.1221 1.0821 

47260 ........... Virginia Beach-Norfolk-Newport News, VA ................................................................................... NC ..... 0.8868 0.9210 

47260 ........... Virginia Beach-Norfolk-Newport News, VA ................................................................................... VA ..... 0.8869 0.9211 

47300 ........... Visalia-Porterville, CA .................................................................................................................... CA ..... 1.1822 1.1214 

47380 ........... Waco, TX ....................................................................................................................................... TX ..... 0.8703 0.9093 

47580 ........... Warner Robins, GA ....................................................................................................................... GA ..... 0.9490 0.9648 

47644 ........... Warren-Troy-Farmington-Hills, MI ................................................................................................. MI ...... 0.9972 0.9981 

47894 ........... Washington-Arlington-Alexandria, DC-VA-MD-WV ....................................................................... DC ..... 1.0670 1.0454 

47894 ........... Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ MD .... 1.0670 1.0454 

47894 ........... Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ VA ..... 1.0669 1.0453 

47894 ........... Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ WV .... 1.0647 1.0439 

47940 ........... Waterloo-Cedar Falls, IA ............................................................................................................... IA ...... 0.9248 0.9479 

48140 ........... Wausau, WI ................................................................................................................................... WI ..... 0.9823 0.9878 

48260 ........... Weirton-Steubenville, WV-OH ....................................................................................................... OH .... 0.8582 0.9006 

48260 ........... Weirton-Steubenville, WV-OH ....................................................................................................... WV .... 0.8011 0.8591 

48300 ........... Wenatchee, WA ............................................................................................................................. WA .... 1.0164 1.0112 

48424 ........... West Palm Beach-Boca Raton-Boynton Beach, FL ...................................................................... FL ...... 0.9631 0.9746 

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-NJ .................................................................................................................. DE ..... 1.0645 1.0437 

48864 ........... Wilmington, DE-MD-NJ .................................................................................................................. MD .... 1.0645 1.0437 

48864 ........... Wilmington, DE-MD-NJ .................................................................................................................. NJ ..... 1.1221 1.0821 

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-Boardman, OH-PA ....................................................................................... OH .... 0.8931 0.9255 

49660 ........... Youngstown-Warren-Boardman, OH-PA ....................................................................................... PA ..... 0.8930 0.9254 

49700 ........... Yuba City, CA ................................................................................................................................ CA ..... 1.1822 1.1214 

49740 ........... Yuma, AZ ....................................................................................................................................... AZ ..... 0.9903 0.9933 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 1 .................................................................................................................... RI ...... ........................ ........................

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 

1All counties in the State or Territory are classified as urban. The New Jersey floor is imputed as specified in § 412.64(h)(4) and discussed in 

the FY 2005 IPPS final rule (69 FR 49109) and in section III.B.2 of the preamble of 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-NJ ................................................................................. PA ..... 0.9675 0.9776 

11100 ....... Amarillo, TX ........................................................................................................................ KS ..... 0.8885 0.9222 

11100 ....... Amarillo, TX ........................................................................................................................ TX ..... 0.8883 0.9221 


jlentini on PROD1PC65 with PROPOSALS2
23796 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued 

CBSA 

code Area State Wage index GAF 

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, GA .................................................................................. AL ..... 0.9760 0.9835 

12060 ....... Atlanta-Sandy Springs-Marietta, GA .................................................................................. GA ..... 0.9760 0.9835 

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, MD ............................................................................... DC ..... 1.1018 1.0686 

13644 ....... Bethesda-Frederick-Gaithersburg, MD ............................................................................... PA ..... 1.1006 1.0678 

13644 ....... Bethesda-Frederick-Gaithersburg, MD ............................................................................... VA ..... 1.1017 1.0686 

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-Radford, VA ............................................................................. WV .... 0.7795 0.8432 

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-Summerville, SC .................................................................. SC ..... 0.9231 0.9467 

16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................. NC ..... 0.9570 0.9704 

16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................. SC ..... 0.9557 0.9694 

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 ................................................................................. IL ....... 0.8606 0.9023 

19340 ....... Davenport-Moline-Rock Island, IA-IL ................................................................................. IA ...... 0.8709 0.9097 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23797 

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued 

CBSA 

code Area State Wage index GAF 

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-MO ............................................................................ AR ..... 0.8952 0.9270 

22220 ....... Fayetteville-Springdale-Rogers, AR-MO ............................................................................ OK ..... 0.8950 0.9268 

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-Deerfield Beach, FL ........................................................ FL ...... 1.0025 1.0017 

23020 ....... Fort Walton Beach-Crestview-Destin, FL ........................................................................... FL ...... 0.8633 0.9042 

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 Hartford, CT .......................................................................... CT ..... 1.1897 1.1263 

25540 ....... Hartford-West Hartford-East Hartford, CT .......................................................................... MA .... 1.0972 1.0656 

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 


jlentini on PROD1PC65 with PROPOSALS2
23798 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued 

CBSA 

code Area State Wage index GAF 

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-Conway, AR ......................................................................... AR ..... 0.8650 0.9055 

30860 ....... Logan, UT-ID ...................................................................................................................... UT ..... 0.8827 0.9181 

30980 ....... Longview, TX ...................................................................................................................... TX ..... 0.8666 0.9066 

31084 ....... Los Angeles-Long Beach-Glendale, CA ............................................................................ CA ..... 1.1822 1.1214 

31140 ....... Louisville-Jefferson County, KY-IN ..................................................................................... KY ..... 0.9123 0.9391 

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 ................................................................................. WI ..... 1.0026 1.0018 

33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI ........................................................................ MN .... 1.0997 1.0672 

33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI ........................................................................ WI ..... 1.0976 1.0659 

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-Conway, SC ................................................................. NC ..... 0.8632 0.9042 

34820 ....... Myrtle Beach-North Myrtle Beach-Conway, SC ................................................................. SC ..... 0.8609 0.9025 

34980 ....... Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................. KY ..... 0.9276 0.9498 

34980 ....... Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................. TN ..... 0.9252 0.9482 

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-NJ ............................................................................. CT ..... 1.2391 1.1581 

35644 ....... New York-White Plains-Wayne, NY-NJ ............................................................................. NJ ..... 1.2693 1.1774 

35644 ....... New York-White Plains-Wayne, NY-NJ ............................................................................. NY ..... 1.2855 1.1877 

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-Biddeford, ME ............................................................................. ME .... 0.9644 0.9755 

38900 ....... Portland-Vancouver-Beaverton, OR-WA ............................................................................ OR .... 1.1204 1.0810 

38900 ....... Portland-Vancouver-Beaverton, OR-WA ............................................................................ WA .... 1.1186 1.0798 

38940 ....... Port St. Lucie, FL ............................................................................................................... FL ...... 0.9741 0.9822 

39100 ....... Poughkeepsie-Newburgh-Middletown, NY ......................................................................... NY ..... 1.0709 1.0480 

39140 ....... Prescott, AZ ........................................................................................................................ AZ ..... 1.0011 1.0008 

39340 ....... Provo-Orem, UT ................................................................................................................. UT ..... 0.9052 0.9341 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23799 

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued 

CBSA 

code Area State Wage index GAF 

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-Ontario, CA .............................................................................. AZ ..... 1.1254 1.0843 

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 County, NH ........................................................................ ME .... 1.0007 1.0005 

40660 ....... Rome, GA ........................................................................................................................... AL ..... 0.9524 0.9672 

40900 ....... Sacramento—Arden-Arcade—Roseville, CA ..................................................................... CA ..... 1.2710 1.1785 

40980 ....... Saginaw-Saginaw Township North, MI .............................................................................. MI ...... 0.8864 0.9207 

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 City, CA ................................................................... CA ..... 1.4879 1.3127 

41940 ....... San Jose-Sunnyvale-Santa Clara, CA ............................................................................... CA ..... 1.5758 1.3654 

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 ............................................................................... FL ...... 0.8993 0.9299 

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 News, VA ........................................................................ NC ..... 0.8868 0.9210 

47644 ....... Warren-Troy-Farmington-Hills, MI ...................................................................................... MI ...... 0.9972 0.9981 

47894 ....... Washington-Arlington-Alexandria, DC-VA .......................................................................... VA ..... 1.0669 1.0453 

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-PA ............................................................................ OH .... 0.8582 0.9006 

49660 ....... Youngstown-Warren-Boardman, OH-PA ............................................................................ PA ..... 0.8559 0.8989 

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 


jlentini on PROD1PC65 with PROPOSALS2
23800 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued 

CBSA 

code Area State Wage index GAF 

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 

State 

Rural floor 

budget 

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 ............................... ........................

TABLE 4D–1.—RURAL FLOOR BUDGET

NEUTRALITY FACTORS—FY 2009—

Continued 

State 

Rural floor 

budget 

neutrality 

ajustment 

factor 

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 

TABLE 4D–1.—RURAL FLOOR BUDGET

NEUTRALITY FACTORS—FY 2009—

Continued 

State 

Rural floor 

budget 

neutrality 

ajustment 

factor 

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.] 

CBSA code Urban area State * Rural or imputed floor 

wage index 

10900 ......................... Allentown-Bethlehem-Easton, PA–NJ ................................................ NJ ............................... 1.1221 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23801 

TABLE 4D–2.—URBAN AREAS WITH HOSPITALS RECEIVING THE STATEWIDE RURAL FLOOR OR IMPUTED FLOOR WAGE

INDEX—FY 2009—Continued 

[*Only hospitals that are geographically located in the specified State receive the State’s rural or imputed floor wage index.] 

CBSA code Urban area State * Rural or imputed floor 

wage index 

15540 ......................... Burlington-South Burlington, VT ......................................................... VT .............................. 0.9275 

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 Island, IA–IL ................................................. IA ................................ 0.8709 

19500 ......................... Decatur, IL .......................................................................................... IL ................................ 0.8428 

20220 ......................... Dubuque, IA ........................................................................................ IA ................................ 0.8709 

20764 ......................... Edison-New Brunswick, NJ ................................................................ NJ ............................... 1.1221 

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-East Hartford, CT .......................................... CT .............................. 1.1897 

25620 ......................... Hattiesburg, MS .................................................................................. MS .............................. 0.7653 

27340 ......................... Jacksonville, NC ................................................................................. NC .............................. 0.8632 

27780 ......................... Johnstown, PA .................................................................................... PA .............................. 0.8342 

28420 ......................... Kennewick-Pasco-Richland, WA ........................................................ WA ............................. 1.0164 

28700 ......................... Kingsport-Bristol-Bristol, TN–VA ........................................................ TN .............................. 0.7957 

28700 ......................... Kingsport-Bristol-Bristol, TN–VA ........................................................ VA .............................. 0.8061 

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 ............................................................ WA ............................. 1.0164 

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-Ventura, CA ................................................ CA .............................. 1.1822 

37460 ......................... Panama City-Lynn Haven, FL ............................................................ FL ............................... 0.8633 

37620 ......................... Parkersburg-Marietta-Vienna, WV–OH .............................................. OH .............................. 0.8582 

37860 ......................... Pensacola-Ferry Pass-Brent, FL ........................................................ FL ............................... 0.8633 

39380 ......................... Pueblo, CO ......................................................................................... CO .............................. 0.9303 

39540 ......................... Racine, WI .......................................................................................... WI ............................... 0.9511 

40140 ......................... Riverside-San Bernardino-Ontario, CA .............................................. CA .............................. 1.1822 

40484 ......................... Rockingham County-Strafford County, NH ........................................ NH .............................. 1.0807 

41740 ......................... San Diego-Carlsbad-San Marcos, CA ............................................... CA .............................. 1.1822 

42020 ......................... San Luis Obispo-Paso Robles, CA .................................................... CA .............................. 1.1822 

42044 ......................... Santa Ana-Anaheim-Irvine, CA .......................................................... CA .............................. 1.1822 

42060 ......................... Santa Barbara-Santa Maria-Goleta, CA ............................................. CA .............................. 1.1822 

42540 ......................... Scranton-Wilkes-Barre, PA ................................................................. PA .............................. 0.8342 

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-Bridgeton, NJ .......................................................... NJ ............................... 1.1221 

47300 ......................... Visalia-Porterville, CA ......................................................................... CA .............................. 1.1822 

48260 ......................... Weirton-Steubenville, WV–OH ........................................................... OH .............................. 0.8582 

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 


jlentini on PROD1PC65 with PROPOSALS2
23802 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4D–2.—URBAN AREAS WITH HOSPITALS RECEIVING THE STATEWIDE RURAL FLOOR OR IMPUTED FLOOR WAGE

INDEX—FY 2009—Continued 

[*Only hospitals that are geographically located in the specified State receive the State’s rural or imputed floor wage index.] 

CBSA code Urban area State * Rural or imputed floor 

wage index 

49420 ......................... Yakima, WA ........................................................................................ WA ............................. 1.0164 

49700 ......................... Yuba City, CA ..................................................................................... CA .............................. 1.1822 

TABLE 4E.—URBAN CBSAS AND

CONSTITUENT COUNTIES—FY 2009 

CBSA 

code 

Urban area 

(constituent counties) 

10180 ...... Abilene, TX 

Callahan County, TX 

Jones County, TX 

Taylor County, TX 

10380 ...... Aguadilla-Isabela-San Sebastia ́n, 

PR 

Aguada Municipio, PR 

Aguadilla Municipio, PR 

An ̃asco Municipio, PR 

Isabela Municipio, PR 

Lares Municipio, PR 

Moca Municipio, PR 

Rinco ́n Municipio, PR 

San Sebastia ́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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Atlanta-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, GASC 

Burke County, GA 

Columbia County, GA 

McDuffie County, GA 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

Richmond County, GA 

Aiken County, SC 

Edgefield County, SC 

12420 ...... 1Austin-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 ...... 1Baltimore-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 ...... 1Bethesda-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 ...... 1Birmingham-Hoover, AL 

Bibb County, AL 

Blount County, AL 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23803 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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-ChristiansburgRadford, 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 ...... 1Boston-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 ...... 1Buffalo-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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 CharlestonSummerville, 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-KYIN 

Dearborn County, IN 

Franklin County, IN 

Ohio County, IN 

Boone County, KY 

Bracken County, KY 

Campbell County, KY 

Gallatin County, KY 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23804 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

Orange County, NC 

Person County, NC 

20740 ...... Eau Claire, WI 

Chippewa County, WI 

Eau Claire County, WI 

20764 ...... 1Edison-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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

22744 ...... 1Fort 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-CrestviewDestin, FL 

Okaloosa County, FL 

23060 ...... Fort Wayne, IN 

Allen County, IN 

Wells County, IN 

Whitley County, IN 

23104 ...... 1Fort 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23805 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

25020 ...... Guayama, PR 

Arroyo Municipio, PR 

Guayama Municipio, PR 

Patillas Municipio, PR 

25060 ...... Gulfport-Biloxi, MS 

Hancock County, MS 

Harrison County, MS 

Stone County, MS 

25180 ...... Hagerstown-Martinsburg, MDWV 

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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Kansas City, MO-KS 

Franklin County, KS 

Johnson County, KS 

Leavenworth County, KS 

Linn County, KS 

Miami County, KS 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23806 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 RockConway, 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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... Mayagu ̈ez, PR 

Hormigueros Municipio, PR 

Mayagu ̈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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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-DavidsonMurfreesboro-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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23807 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Oakland-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 ...... 1Oklahoma 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 ...... 1Orlando-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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Philadelphia, PA 

Bucks County, PA 

Chester County, PA 

Delaware County, PA 

Montgomery County, PA 

Philadelphia County, PA 

38060 ...... 1Phoenix-Mesa-Scottsdale, AZ 

Maricopa County, AZ 

Pinal County, AZ 

38220 ...... Pine Bluff, AR 

Cleveland County, AR 

Jefferson County, AR 

Lincoln County, AR 

38300 ...... 1Pittsburgh, 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 Dı ́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 ...... 1Portland-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 ...... 1Providence-New Bedford-Fall 

River, RI-MA 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— 

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 


jlentini on PROD1PC65 with PROPOSALS2
23808 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Sacramento—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 ...... 1St. 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 ...... 1San Antonio, TX 

Atascosa County, TX 

Bandera County, TX 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

Bexar County, TX 

Comal County, TX 

Guadalupe County, TX 

Kendall County, TX 

Medina County, TX 

Wilson County, TX 

41740 ...... 1San Diego-Carlsbad-San 

Marcos, CA 

San Diego County, CA 

41780 ...... Sandusky, OH 

Erie County, OH 

41884 ...... 1San Francisco-San Mateo-Redwood City, CA 

Marin County, CA 

San Francisco County, CA 

San Mateo County, CA 

41900 ...... San Germa ́n-Cabo Rojo, PR 

Cabo Rojo Municipio, PR 

Lajas Municipio, PR 

Sabana Grande Municipio, PR 

San Germa ́n Municipio, PR 

41940 ...... 1San Jose-Sunnyvale-Santa 

Clara, CA 

San Benito County, CA 

Santa Clara County, CA 

41980 ...... 1San Juan-Caguas-Guaynabo, 

PR 

Aguas Buenas Municipio, PR 

Aibonito Municipio, PR 

Arecibo Municipio, PR 

Barceloneta Municipio, PR 

Barranquitas Municipio, PR 

Bayamo ́n Municipio, PR 

Caguas Municipio, PR 

Camuy Municipio, PR 

Cano ́vanas Municipio, PR 

Carolina Municipio, PR 

Catan ̃o Municipio, PR 

Cayey Municipio, PR 

Ciales Municipio, PR 

Cidra Municipio, PR 

Comer ́ıo 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 ́ıza Municipio, PR 

Manat ́ı Municipio, PR 

Maunabo Municipio, PR 

Morovis Municipio, PR 

Naguabo Municipio, PR 

Naranjito Municipio, PR 

Orocovis Municipio, PR 

Quebradillas Municipio, PR 

R ́ıo 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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

42020 ...... San Luis Obispo-Paso Robles, 

CA 

San Luis Obispo County, CA 

42044 ...... 1Santa Ana-Anaheim-Irvine, CA 

Orange County, CA 

42060 ...... Santa Barbara-Santa MariaGoleta, 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 ...... 1Seattle-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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23809 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Tampa-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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1Virginia 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 ...... 1Warren-Troy-Farmington Hills, 

MI 

Lapeer County, MI 

Livingston County, MI 

Macomb County, MI 

Oakland County, MI 

St. Clair County, MI 

47894 ...... 1Washington-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 

TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009—

Continued 

CBSA 

code 

Urban area 

(constituent counties) 

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 ...... 1West Palm Beach-Boca RatonBoynton 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 

Gua ́nica Municipio, PR 

Guayanilla Municipio, PR 

Pen ̃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. 


jlentini on PROD1PC65 with PROPOSALS2
23810 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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.] 

CBSA code Area Wage index GAF 

Wage 

index—reclassified 

hospitals 

GAF—reclassified 

hospitals 

10380 ....... Aguadilla-Isabela-San Sebastia ́n, PR ....................................................... 0.7845 0.8469 .................... ....................

21940 ....... Fajardo, PR ............................................................................................... 0.9572 0.9705 .................... ....................

25020 ....... Guayama, PR ............................................................................................ 0.7472 0.8191 .................... ....................

32420 ....... Mayagu ̈ez, PR ........................................................................................... 0.9236 0.9470 .................... ....................

38660 ....... Ponce, PR ................................................................................................. 0.9757 0.9833 .................... ....................

41900 ....... San Germa ́n-Cabo Rojo, PR .................................................................... 1.0864 1.0584 .................... ....................

41980 ....... San Juan-Caguas-Guaynabo, PR ............................................................. 1.0348 1.0237 .................... ....................

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 outmigration adjustment instead within 45 days 

from the publication of this proposed rule. 

These notifications should be sent to the 

following address: Centers for Medicare and 

Medicaid Services, Center for Medicare 

Management, 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 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23811 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
23812 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23813 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
23814 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23815 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
23816 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23817 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
23818 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23819 

TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued 

Provider No. Reclassified 

for FY 2009 

Out-migration 

adjustment Qualifying county name County code 

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

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

001 ........... No ............ No ............ PRE SURG ...... Heart transplant or implant of heart 

assist system w MCC.

23.4061 29.1 40.2 

002 ........... No ............ No ............ PRE SURG ...... Heart transplant or implant of heart 

assist system w/o MCC.

12.8956 18.4 24.7 


jlentini on PROD1PC65 with PROPOSALS2
23820 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

003 ........... Yes .......... No ............ PRE SURG ...... ECMO or trach w MV 96+ hrs or PDX 

exc face, mouth & neck w maj O.R.

18.3635 32.5 39.6 

004 ........... Yes .......... No ............ PRE SURG ...... Trach w MV 96+ hrs or PDX exc face, 

mouth & neck w/o maj O.R..

11.1684 23.5 28.8 

005 ........... No ............ No ............ PRE SURG ...... Liver transplant w MCC or intestinal 

transplant.

10.7436 15.9 21.2 

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/kidney transplant.4.8917 10.1 11.9 

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 face,mouth & neck 

diagnoses w MCC.

4.8900 13.1 16.7 

012 ........... No ............ No ............ PRE SURG ...... Tracheostomy for face,mouth & neck 

diagnoses w CC.

3.0563 8.9 10.7 

013 ........... No ............ No ............ PRE SURG ...... Tracheostomy for face,mouth & neck 

diagnoses w/o CC/MCC.

1.9057 5.9 6.9 

020 ........... No ............ No ............ 01 SURG ...... Intracranial vascular procedures w 

PDX hemorrhage w MCC.

8.3276 14.8 18.4 

021 ........... No ............ No ............ 01 SURG ...... Intracranial vascular procedures w 

PDX hemorrhage w CC.

6.3534 13.7 15.4 

022 ........... No ............ No ............ 01 SURG ...... Intracranial vascular procedures w 

PDX hemorrhage w/o CC/MCC.

4.2072 7.6 9.4 

023 ........... No ............ No ............ 01 SURG ...... Cranio w major dev impl/acute complex CNS PDX w MCC or chemo 

implant.

5.0763 8.9 12.7 

024 ........... No ............ No ............ 01 SURG ...... Cranio w major dev impl/acute complex CNS PDX w/o MCC.3.4757 6.3 9.0 

025 ........... Yes .......... No ............ 01 SURG ...... Craniotomy & endovascular 

intracranial procedures w MCC.

5.0324 9.9 13.0 

026 ........... Yes .......... No ............ 01 SURG ...... Craniotomy & endovascular 

intracranial procedures w CC.

3.0107 6.5 8.2 

027 ........... Yes .......... No ............ 01 SURG ...... Craniotomy & endovascular 

intracranial procedures w/o CC/ 

MCC.

2.1083 3.5 4.5 

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 spinal 

neurostimulators.

2.7949 5.1 7.1 

030 ........... Yes .......... Yes .......... 01 SURG ...... Spinal procedures w/o CC/MCC ......... 1.5395 2.8 3.7 

031 ........... Yes .......... No ............ 01 SURG ...... Ventricular shunt procedures w MCC 4.3899 9.4 13.1 

032 ........... Yes .......... No ............ 01 SURG ...... Ventricular shunt procedures w CC .... 1.9471 4.0 6.0 

033 ........... Yes .......... No ............ 01 SURG ...... Ventricular shunt procedures w/o CC/ 

MCC.

1.3334 2.3 3.0 

034 ........... No ............ No ............ 01 SURG ...... Carotid artery stent procedure w MCC 3.2182 4.6 7.2 

035 ........... No ............ No ............ 01 SURG ...... Carotid artery stent procedure w CC .. 2.0258 2.1 3.3 

036 ........... No ............ No ............ 01 SURG ...... Carotid artery stent procedure w/o 

CC/MCC.

1.5706 1.3 1.6 

037 ........... No ............ No ............ 01 SURG ...... Extracranial procedures w MCC ......... 3.0208 5.9 8.5 

038 ........... No ............ No ............ 01 SURG ...... Extracranial procedures w CC ............ 1.5585 2.5 3.8 

039 ........... No ............ No ............ 01 SURG ...... Extracranial procedures w/o CC/MCC 1.0057 1.5 1.8 

040 ........... Yes .......... Yes .......... 01 SURG ...... Periph/cranial nerve & other nerv syst 

proc w MCC.

3.9691 9.7 13.3 

041 ........... Yes .......... Yes .......... 01 SURG ...... Periph/cranial nerve & other nerv syst 

proc w CC or periph neurostim.

2.1517 5.3 7.2 

042 ........... Yes .......... Yes .......... 01 SURG ...... Periph/cranial nerve & other nerv syst 

proc w/o CC/MCC.

1.6771 2.5 3.6 

052 ........... No ............ No ............ 01 MED ......... Spinal disorders & injuries w CC/MCC 1.6271 4.9 6.7 

053 ........... No ............ No ............ 01 MED ......... Spinal disorders & injuries w/o CC/ 

MCC.

0.8617 3.2 4.0 

054 ........... Yes .......... No ............ 01 MED ......... Nervous system neoplasms w MCC ... 1.5844 5.2 7.0 

055 ........... Yes .......... No ............ 01 MED ......... Nervous system neoplasms w/o MCC 1.0781 3.8 5.1 

056 ........... Yes .......... No ............ 01 MED ......... Degenerative nervous system disorders w MCC.1.6311 5.7 7.8 

057 ........... Yes .......... No ............ 01 MED ......... Degenerative nervous system disorders w/o MCC.0.8755 3.9 5.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23821 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

058 ........... No ............ No ............ 01 MED ......... Multiple sclerosis & cerebellar ataxia 

w MCC.

1.5373 5.7 7.6 

059 ........... No ............ No ............ 01 MED ......... Multiple sclerosis & cerebellar ataxia 

w CC.

0.9404 4.2 5.1 

060 ........... No ............ No ............ 01 MED ......... Multiple sclerosis & cerebellar ataxia 

w/o CC/MCC.

0.6978 3.4 4.0 

061 ........... No ............ No ............ 01 MED ......... Acute ischemic stroke w use of 

thrombolytic agent w MCC.

2.8759 6.8 8.9 

062 ........... No ............ No ............ 01 MED ......... Acute ischemic stroke w use of 

thrombolytic agent w CC.

1.9505 5.3 6.3 

063 ........... No ............ No ............ 01 MED ......... Acute ischemic stroke w use of 

thrombolytic agent w/o CC/MCC.

1.5168 3.9 4.5 

064 ........... Yes .......... No ............ 01 MED ......... Intracranial hemorrhage or cerebral infarction w MCC.1.8446 5.5 7.5 

065 ........... Yes .......... No ............ 01 MED ......... Intracranial hemorrhage or cerebral infarction w CC.1.1748 4.3 5.2 

066 ........... Yes .......... No ............ 01 MED ......... Intracranial hemorrhage or cerebral infarction w/o CC/MCC.0.8426 3.1 3.7 

067 ........... No ............ No ............ 01 MED ......... Nonspecific cva & precerebral occlusion w/o infarct w MCC.1.3899 4.4 5.8 

068 ........... No ............ No ............ 01 MED ......... Nonspecific cva & precerebral occlusion w/o infarct w/o MCC.0.8449 2.7 3.4 

069 ........... No ............ No ............ 01 MED ......... Transient ischemia .............................. 0.7143 2.4 3.0 

070 ........... Yes .......... No ............ 01 MED ......... Nonspecific cerebrovascular disorders 

w MCC.

1.8241 6.0 7.9 

071 ........... Yes .......... No ............ 01 MED ......... Nonspecific cerebrovascular disorders 

w CC.

1.1307 4.4 5.6 

072 ........... Yes .......... No ............ 01 MED ......... Nonspecific cerebrovascular disorders 

w/o CC/MCC.

0.7629 2.8 3.5 

073 ........... No ............ No ............ 01 MED ......... Cranial & peripheral nerve disorders w 

MCC.

1.3037 4.7 6.2 

074 ........... No ............ No ............ 01 MED ......... Cranial & peripheral nerve disorders 

w/o MCC.

0.8406 3.4 4.3 

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/MCC .............. 0.8544 3.4 4.1 

077 ........... No ............ No ............ 01 MED ......... Hypertensive encephalopathy w MCC 1.6225 5.2 6.7 

078 ........... No ............ No ............ 01 MED ......... Hypertensive encephalopathy w CC ... 1.0050 3.6 4.4 

079 ........... No ............ No ............ 01 MED ......... Hypertensive encephalopathy w/o CC/ 

MCC.

0.7377 2.8 3.4 

080 ........... No ............ No ............ 01 MED ......... Nontraumatic stupor & coma w MCC 1.1007 3.8 5.1 

081 ........... No ............ No ............ 01 MED ......... Nontraumatic stupor & coma w/o 

MCC.

0.7094 2.7 3.5 

082 ........... No ............ No ............ 01 MED ......... Traumatic stupor & coma, coma >1 hr 

w MCC.

2.0177 3.7 6.4 

083 ........... No ............ No ............ 01 MED ......... Traumatic stupor & coma, coma >1 hr 

w CC.

1.3027 3.7 5.0 

084 ........... No ............ No ............ 01 MED ......... Traumatic stupor & coma, coma >1 hr 

w/o CC/MCC.

0.8720 2.4 3.1 

085 ........... Yes .......... No ............ 01 MED ......... Traumatic stupor & coma, coma <1 hr 

w MCC.

2.0942 5.5 7.6 

086 ........... Yes .......... No ............ 01 MED ......... Traumatic stupor & coma, coma <1 hr 

w CC.

1.2049 3.9 5.0 

087 ........... Yes .......... No ............ 01 MED ......... Traumatic stupor & coma, coma <1 hr 

w/o CC/MCC.

0.8008 2.6 3.3 

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 nervous system w 

MCC.

1.5641 4.6 6.4 

092 ........... Yes .......... No ............ 01 MED ......... Other disorders of nervous system w 

CC.

0.9195 3.5 4.5 

093 ........... Yes .......... No ............ 01 MED ......... Other disorders of nervous system w/ 

o CC/MCC.

0.6753 2.6 3.2 

094 ........... No ............ No ............ 01 MED ......... Bacterial & tuberculous infections of 

nervous system w MCC.

3.3477 9.2 11.9 

095 ........... No ............ No ............ 01 MED ......... Bacterial & tuberculous infections of 

nervous system w CC.

2.1934 6.9 8.6 


jlentini on PROD1PC65 with PROPOSALS2
23822 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

096 ........... No ............ No ............ 01 MED ......... Bacterial & tuberculous infections of 

nervous system w/o CC/MCC.

1.8297 5.0 6.2 

097 ........... No ............ No ............ 01 MED ......... Non-bacterial infect of nervous sys 

exc viral meningitis w MCC.

3.2101 9.9 12.6 

098 ........... No ............ No ............ 01 MED ......... Non-bacterial infect of nervous sys 

exc viral meningitis w CC.

1.8564 6.8 8.4 

099 ........... No ............ No ............ 01 MED ......... Non-bacterial infect of nervous sys 

exc viral meningitis w/o CC/MCC.

1.2533 4.6 5.9 

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/MCC ........... 1.5656 3.8 5.6 

114 ........... No ............ No ............ 02 SURG ...... Orbital procedures w/o CC/MCC ........ 0.8313 1.9 2.6 

115 ........... No ............ No ............ 02 SURG ...... Extraocular procedures except orbit ... 1.0625 3.3 4.3 

116 ........... No ............ No ............ 02 SURG ...... Intraocular procedures w CC/MCC ..... 1.1338 2.6 4.1 

117 ........... No ............ No ............ 02 SURG ...... Intraocular procedures w/o CC/MCC .. 0.6699 1.6 2.2 

121 ........... No ............ No ............ 02 MED ......... Acute major eye infections w CC/MCC 0.9556 4.4 5.5 

122 ........... No ............ No ............ 02 MED ......... Acute major eye infections w/o CC/ 

MCC.

0.6127 3.4 4.0 

123 ........... No ............ No ............ 02 MED ......... Neurological eye disorders .................. 0.6840 2.3 2.9 

124 ........... No ............ No ............ 02 MED ......... Other disorders of the eye w MCC ..... 1.0620 3.9 5.3 

125 ........... No ............ No ............ 02 MED ......... Other disorders of the eye w/o MCC .. 0.6660 2.8 3.5 

129 ........... No ............ No ............ 03 SURG ...... Major head & neck procedures w CC/ 

MCC or major device.

2.0147 3.7 5.2 

130 ........... No ............ No ............ 03 SURG ...... Major head & neck procedures w/o 

CC/MCC.

1.1588 2.4 2.9 

131 ........... No ............ No ............ 03 SURG ...... Cranial/facial procedures w CC/MCC 1.9768 4.0 5.7 

132 ........... No ............ No ............ 03 SURG ...... Cranial/facial procedures w/o CC/ 

MCC.

1.1041 2.1 2.7 

133 ........... No ............ No ............ 03 SURG ...... Other ear, nose, mouth & throat O.R. 

procedures w CC/MCC.

1.5491 3.6 5.3 

134 ........... No ............ No ............ 03 SURG ...... Other ear, nose, mouth & throat O.R. 

procedures w/o CC/MCC.

0.8243 1.7 2.2 

135 ........... No ............ No ............ 03 SURG ...... Sinus & mastoid procedures w CC/ 

MCC.

1.6842 3.8 5.8 

136 ........... No ............ No ............ 03 SURG ...... Sinus & mastoid procedures w/o CC/ 

MCC.

0.9023 1.7 2.3 

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/MCC ......... 0.7368 1.9 2.5 

139 ........... No ............ No ............ 03 SURG ...... Salivary gland procedures ................... 0.8176 1.4 1.8 

146 ........... No ............ No ............ 03 MED ......... Ear, nose, mouth & throat malignancy 

w MCC.

2.0489 6.7 9.4 

147 ........... No ............ No ............ 03 MED ......... Ear, nose, mouth & throat malignancy 

w CC.

1.2486 4.3 6.1 

148 ........... No ............ No ............ 03 MED ......... Ear, nose, mouth & throat malignancy 

w/o CC/MCC.

0.8181 2.7 3.8 

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 MCC .............. 0.5948 2.6 3.2 

154 ........... No ............ No ............ 03 MED ......... Other ear, nose, mouth & throat diagnoses w MCC.1.3768 4.6 6.3 

155 ........... No ............ No ............ 03 MED ......... Other ear, nose, mouth & throat diagnoses w CC.0.8779 3.5 4.4 

156 ........... No ............ No ............ 03 MED ......... Other ear, nose, mouth & throat diagnoses w/o CC/MCC.0.6306 2.5 3.2 

157 ........... No ............ No ............ 03 MED ......... Dental & oral diseases w MCC ........... 1.4793 4.7 6.7 

158 ........... No ............ No ............ 03 MED ......... Dental & oral diseases w CC .............. 0.8615 3.4 4.5 

159 ........... No ............ No ............ 03 MED ......... Dental & oral diseases w/o CC/MCC .. 0.5952 2.4 3.1 

163 ........... Yes .......... No ............ 04 SURG ...... Major chest procedures w MCC ......... 4.9951 12.2 14.9 

164 ........... Yes .......... No ............ 04 SURG ...... Major chest procedures w CC ............ 2.5982 6.7 8.1 

165 ........... Yes .......... No ............ 04 SURG ...... Major chest procedures w/o CC/MCC 1.8086 4.3 5.1 

166 ........... Yes .......... No ............ 04 SURG ...... Other resp system O.R. procedures w 

MCC.

3.6865 10.0 12.9 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23823 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

167 ........... Yes .......... No ............ 04 SURG ...... Other resp system O.R. procedures w 

CC.

2.0256 6.3 8.0 

168 ........... Yes .......... No ............ 04 SURG ...... Other resp system O.R. procedures 

w/o CC/MCC.

1.3443 3.9 5.3 

175 ........... Yes .......... No ............ 04 MED ......... Pulmonary embolism w MCC .............. 1.5777 6.0 7.3 

176 ........... Yes .......... No ............ 04 MED ......... Pulmonary embolism w/o MCC ........... 1.0696 4.6 5.3 

177 ........... Yes .......... No ............ 04 MED ......... Respiratory infections & inflammations 

w MCC.

2.0391 7.2 9.1 

178 ........... Yes .......... No ............ 04 MED ......... Respiratory infections & inflammations 

w CC.

1.4979 6.0 7.4 

179 ........... Yes .......... No ............ 04 MED ......... Respiratory infections & inflammations 

w/o CC/MCC.

1.0409 4.6 5.6 

180 ........... No ............ No ............ 04 MED ......... Respiratory neoplasms w MCC .......... 1.6938 6.0 7.9 

181 ........... No ............ No ............ 04 MED ......... Respiratory neoplasms w CC ............. 1.2293 4.5 5.9 

182 ........... No ............ No ............ 04 MED ......... Respiratory neoplasms w/o CC/MCC 0.8712 3.2 4.2 

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/MCC ....... 0.6755 2.9 3.4 

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/MCC ............. 0.8121 3.1 4.0 

189 ........... No ............ No ............ 04 MED ......... Pulmonary edema & respiratory failure 1.3473 4.8 6.1 

190 ........... Yes .......... No ............ 04 MED ......... Chronic obstructive pulmonary disease w MCC.1.3004 5.0 6.3 

191 ........... Yes .......... No ............ 04 MED ......... Chronic obstructive pulmonary disease w CC.0.9734 4.1 5.0 

192 ........... Yes .......... No ............ 04 MED ......... Chronic obstructive pulmonary disease w/o CC/MCC.0.7239 3.3 4.0 

193 ........... Yes .......... No ............ 04 MED ......... Simple pneumonia & pleurisy w MCC 1.4303 5.4 6.8 

194 ........... Yes .......... No ............ 04 MED ......... Simple pneumonia & pleurisy w CC ... 1.0041 4.4 5.3 

195 ........... Yes .......... No ............ 04 MED ......... Simple pneumonia & pleurisy w/o CC/ 

MCC.

0.7301 3.5 4.1 

196 ........... Yes .......... No ............ 04 MED ......... Interstitial lung disease w MCC .......... 1.6006 5.9 7.4 

197 ........... Yes .......... No ............ 04 MED ......... Interstitial lung disease w CC ............. 1.0973 4.4 5.4 

198 ........... Yes .......... No ............ 04 MED ......... Interstitial lung disease w/o CC/MCC 0.8158 3.3 4.1 

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/MCC ......... 0.8135 3.5 4.4 

203 ........... No ............ No ............ 04 MED ......... Bronchitis & asthma w/o CC/MCC ...... 0.5938 2.8 3.4 

204 ........... No ............ No ............ 04 MED ......... Respiratory signs & symptoms ........... 0.6533 2.2 2.9 

205 ........... Yes .......... No ............ 04 MED ......... Other respiratory system diagnoses w 

MCC.

1.2427 4.0 5.5 

206 ........... Yes .......... No ............ 04 MED ......... Other respiratory system diagnoses w/ 

o MCC.

0.7266 2.7 3.4 

207 ........... Yes .......... No ............ 04 MED ......... Respiratory system diagnosis w ventilator support 96+ hours.5.1153 12.8 15.1 

208 ........... No ............ No ............ 04 MED ......... Respiratory system diagnosis w ventilator support <96 hours.2.1827 5.2 7.2 

215 ........... No ............ No ............ 05 SURG ...... Other heart assist system implant ...... 12.3351 7.8 14.2 

216 ........... Yes .......... No ............ 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w card cath w 

MCC.

1..1072 15.7 18.4 

217 ........... Yes .......... No ............ 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w card cath w 

CC.

7.0028 10.9 12.3 

218 ........... Yes .......... No ............ 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w card cath w/o 

CC/MCC.

5.4355 8.4 9.1 

219 ........... Yes .......... Yes .......... 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w/o card cath w 

MCC.

8.0764 11.5 14.0 

220 ........... Yes .......... Yes .......... 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w/o card cath w 

CC.

5.3066 7.7 8.6 


jlentini on PROD1PC65 with PROPOSALS2
23824 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

221 ........... Yes .......... Yes .......... 05 SURG ...... Cardiac valve & oth maj 

cardiothoracic proc w/o card cath w/ 

o CC/MCC.

4.4089 6.0 6.4 

222 ........... No ............ No ............ 05 SURG ...... Cardiac defib implant w cardiac cath 

w AMI/HF/shock w MCC.

8.6586 10.7 13.1 

223 ........... No ............ No ............ 05 SURG ...... Cardiac defib implant w cardiac cath 

w AMI/HF/shock w/o MCC.

6.3035 4.6 6.3 

224 ........... No ............ No ............ 05 SURG ...... Cardiac defib implant w cardiac cath 

w/o AMI/HF/shock w MCC.

7.9767 9.2 11.4 

225 ........... No ............ No ............ 05 SURG ...... Cardiac defib implant w cardiac cath 

w/o AMI/HF/shock w/o MCC.

5.9123 4.5 5.6 

226 ........... No ............ No ............ 05 SURG ...... Cardiac defibrillator implant w/o cardiac cath w MCC.6.7278 6.2 9.3 

227 ........... No ............ No ............ 05 SURG ...... Cardiac defibrillator implant w/o cardiac cath w/o MCC.5.0145 1.8 2.8 

228 ........... Yes .......... No ............ 05 SURG ...... Other cardiothoracic procedures w 

MCC.

7.8191 12.1 14.7 

229 ........... Yes .......... No ............ 05 SURG ...... Other cardiothoracic procedures w CC 5.0358 7.9 9.1 

230 ........... Yes .......... No ............ 05 SURG ...... Other cardiothoracic procedures w/o 

CC/MCC.

4.0677 5.6 6.5 

231 ........... No ............ No ............ 05 SURG ...... Coronary bypass w PTCA w MCC ..... 7.6801 11.2 13.3 

232 ........... No ............ No ............ 05 SURG ...... Coronary bypass w PTCA w/o MCC .. 5.5460 8.3 9.2 

233 ........... Yes .......... No ............ 05 SURG ...... Coronary bypass w cardiac cath w 

MCC.

7.0378 12.4 14.2 

234 ........... Yes .......... No ............ 05 SURG ...... Coronary bypass w cardiac cath w/o 

MCC.

4.6193 8.3 8.9 

235 ........... Yes .......... No ............ 05 SURG ...... Coronary bypass w/o cardiac cath w 

MCC.

5.6992 9.5 11.2 

236 ........... Yes .......... No ............ 05 SURG ...... Coronary bypass w/o cardiac cath w/o 

MCC.

3.6122 6.1 6.6 

237 ........... No ............ No ............ 05 SURG ...... Major cardiovasc procedures w MCC 

or thoracic aortic aneurysm repair.

5.0881 7.5 10.8 

238 ........... No ............ No ............ 05 SURG ...... Major cardiovasc procedures w/o 

MCC.

2.8962 3.2 4.6 

239 ........... Yes .......... No ............ 05 SURG ...... Amputation for circ sys disorders exc 

upper limb & toe w MCC.

4.4798 12.0 15.3 

240 ........... Yes .......... No ............ 05 SURG ...... Amputation for circ sys disorders exc 

upper limb & toe w CC.

2.6706 8.3 10.4 

241 ........... Yes .......... No ............ 05 SURG ...... Amputation for circ sys disorders exc 

upper limb & toe w/o CC/MCC.

1.5740 5.6 6.8 

242 ........... Yes .......... No ............ 05 SURG ...... Permanent cardiac pacemaker implant 

w MCC.

3.7041 6.7 8.8 

243 ........... Yes .......... No ............ 05 SURG ...... Permanent cardiac pacemaker implant 

w CC.

2.5934 3.8 5.1 

244 ........... Yes .......... No ............ 05 SURG ...... Permanent cardiac pacemaker implant 

w/o CC/MCC.

2.0098 2.2 2.9 

245 ........... No ............ No ............ 05 SURG ...... AICD generator procedures ................ 4.0022 2.1 3.2 

246 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w drug-eluting 

stent w MCC or 4+ vessels/stents.

3.1498 3.6 5.3 

247 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w drug-eluting 

stent w/o MCC.

1.9134 1.7 2.2 

248 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w non-drugeluting stent w MCC or 4+ ves/ 

stents.

2.8065 4.2 6.0 

249 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w non-drugeluting stent w/o MCC.1.6397 1.9 2.5 

250 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w/o coronary artery stent w MCC.2.9923 5.4 7.8 

251 ........... No ............ No ............ 05 SURG ...... Perc cardiovasc proc w/o coronary artery stent w/o MCC.1.6023 2.1 2.8 

252 ........... No ............ No ............ 05 SURG ...... Other vascular procedures w MCC ..... 2.9526 5.5 8.5 

253 ........... No ............ No ............ 05 SURG ...... Other vascular procedures w CC ........ 2.2593 4.2 6.0 

254 ........... No ............ No ............ 05 SURG ...... Other vascular procedures w/o CC/ 

MCC.

1.5485 2.0 2.7 

255 ........... Yes .......... No ............ 05 SURG ...... Upper limb & toe amputation for circ 

system disorders w MCC.

2.4040 7.1 9.7 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23825 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

256 ........... Yes .......... No ............ 05 SURG ...... Upper limb & toe amputation for circ 

system disorders w CC.

1.5895 5.8 7.5 

257 ........... Yes .......... No ............ 05 SURG ...... Upper limb & toe amputation for circ 

system disorders w/o CC/MCC.

1.0216 3.6 4.8 

258 ........... No ............ No ............ 05 SURG ...... Cardiac pacemaker device replacement w MCC.2.8434 5.4 7.4 

259 ........... No ............ No ............ 05 SURG ...... Cardiac pacemaker device replacement w/o MCC.1.6944 2.0 2.8 

260 ........... No ............ No ............ 05 SURG ...... Cardiac pacemaker revision except 

device replacement w MCC.

3.4221 8.1 11.2 

261 ........... No ............ No ............ 05 SURG ...... Cardiac pacemaker revision except 

device replacement w CC.

1.4398 3.0 4.2 

262 ........... No ............ No ............ 05 SURG ...... Cardiac pacemaker revision except 

device replacement w/o CC/MCC.

1.0173 2.0 2.6 

263 ........... No ............ No ............ 05 SURG ...... Vein ligation & stripping ...................... 1.5392 3.4 5.4 

264 ........... Yes .......... No ............ 05 SURG ...... Other circulatory system O.R. procedures.2.5265 5.8 8.9 

265 ........... No ............ No ............ 05 SURG ...... AICD lead procedures ......................... 2.2140 2.2 3.5 

280 ........... Yes .......... No ............ 05 MED ......... Acute myocardial infarction, discharged alive w MCC.1.9395 5.8 7.3 

281 ........... Yes .......... No ............ 05 MED ......... Acute myocardial infarction, discharged alive w CC.1.2210 3.9 4.8 

282 ........... Yes .......... No ............ 05 MED ......... Acute myocardial infarction, discharged alive w/o CC/MCC.0.8698 2.6 3.2 

283 ........... No ............ No ............ 05 MED ......... Acute myocardial infarction, expired w 

MCC.

1.6979 3.4 5.5 

284 ........... No ............ No ............ 05 MED ......... Acute myocardial infarction, expired w 

CC.

0.9130 2.2 3.2 

285 ........... No ............ No ............ 05 MED ......... Acute myocardial infarction, expired 

w/o CC/MCC.

0.6059 1.7 2.2 

286 ........... No ............ No ............ 05 MED ......... Circulatory disorders except AMI, w 

card cath w MCC.

1.9745 5.2 6.9 

287 ........... No ............ No ............ 05 MED ......... Circulatory disorders except AMI, w 

card cath w/o MCC.

1.0225 2.4 3.1 

288 ........... Yes .......... No ............ 05 MED ......... Acute & subacute endocarditis w 

MCC.

3.0720 9.2 11.8 

289 ........... Yes .......... No ............ 05 MED ......... Acute & subacute endocarditis w CC 1.9524 7.0 8.7 

290 ........... Yes .......... No ............ 05 MED ......... Acute & subacute endocarditis w/o 

CC/MCC.

1.4507 5.2 6.5 

291 ........... Yes .......... No ............ 05 MED ......... Heart failure & shock w MCC ............. 1.4576 5.0 6.5 

292 ........... Yes .......... No ............ 05 MED ......... Heart failure & shock w CC ................ 1.0053 4.1 5.0 

293 ........... Yes .......... No ............ 05 MED ......... Heart failure & shock w/o CC/MCC .... 0.7205 3.1 3.7 

294 ........... No ............ No ............ 05 MED ......... Deep vein thrombophlebitis w CC/ 

MCC.

0.9564 4.6 5.5 

295 ........... No ............ No ............ 05 MED ......... Deep vein thrombophlebitis w/o CC/ 

MCC.

0.6347 3.7 4.3 

296 ........... No ............ No ............ 05 MED ......... Cardiac arrest, unexplained w MCC ... 1.1910 1.9 3.0 

297 ........... No ............ No ............ 05 MED ......... Cardiac arrest, unexplained w CC ...... 0.6502 1.4 1.8 

298 ........... No ............ No ............ 05 MED ......... Cardiac arrest, unexplained w/o CC/ 

MCC.

0.4438 1.1 1.3 

299 ........... Yes .......... No ............ 05 MED ......... Peripheral vascular disorders w MCC 1.4326 5.0 6.7 

300 ........... Yes .......... No ............ 05 MED ......... Peripheral vascular disorders w CC ... 0.9245 4.1 5.0 

301 ........... Yes .......... No ............ 05 MED ......... Peripheral vascular disorders w/o CC/ 

MCC.

0.6580 3.0 3.7 

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 & valvular disorders w MCC.1.5655 4.4 6.3 

307 ........... No ............ No ............ 05 MED ......... Cardiac congenital & valvular disorders w/o MCC.0.7476 2.7 3.4 

308 ........... No ............ No ............ 05 MED ......... Cardiac arrhythmia & conduction disorders w MCC.1.2981 4.1 5.5 

309 ........... No ............ No ............ 05 MED ......... Cardiac arrhythmia & conduction disorders w CC.0.8320 3.1 3.9 


jlentini on PROD1PC65 with PROPOSALS2
23826 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

310 ........... No ............ No ............ 05 MED ......... Cardiac arrhythmia & conduction disorders w/o CC/MCC.0.5829 2.3 2.8 

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 diagnoses w 

MCC.

1.7517 5.0 7.0 

315 ........... Yes .......... No ............ 05 MED ......... Other circulatory system diagnoses w 

CC.

0.9922 3.5 4.6 

316 ........... Yes .......... No ............ 05 MED ......... Other circulatory system diagnoses w/ 

o CC/MCC.

0.6513 2.4 3.0 

326 ........... Yes .......... No ............ 06 SURG ...... Stomach, esophageal & duodenal 

proc w MCC.

5.8025 13.2 17.1 

327 ........... Yes .......... No ............ 06 SURG ...... Stomach, esophageal & duodenal 

proc w CC.

2.8389 7.8 10.1 

328 ........... Yes .......... No ............ 06 SURG ...... Stomach, esophageal & duodenal 

proc w/o CC/MCC.

1.4576 3.2 4.4 

329 ........... Yes .......... No ............ 06 SURG ...... Major small & large bowel procedures 

w MCC.

5.1793 12.8 16.0 

330 ........... Yes .......... No ............ 06 SURG ...... Major small & large bowel procedures 

w CC.

2.5644 8.3 9.7 

331 ........... Yes .......... No ............ 06 SURG ...... Major small & large bowel procedures 

w/o CC/MCC.

1.6250 5.2 5.9 

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/MCC ............ 1.6247 4.7 5.5 

335 ........... Yes .......... No ............ 06 SURG ...... Peritoneal adhesiolysis w MCC .......... 4.0903 11.6 14.1 

336 ........... Yes .......... No ............ 06 SURG ...... Peritoneal adhesiolysis w CC ............. 2.2387 7.5 9.1 

337 ........... Yes .......... No ............ 06 SURG ...... Peritoneal adhesiolysis w/o CC/MCC 1.4519 4.4 5.6 

338 ........... No ............ No ............ 06 SURG ...... Appendectomy w complicated principal diag w MCC.3.1787 8.8 10.7 

339 ........... No ............ No ............ 06 SURG ...... Appendectomy w complicated principal diag w CC.1.8625 6.0 7.0 

340 ........... No ............ No ............ 06 SURG ...... Appendectomy w complicated principal diag w/o CC/MCC.1.2267 3.5 4.2 

341 ........... No ............ No ............ 06 SURG ...... Appendectomy w/o complicated principal diag w MCC.2.1659 5.3 7.1 

342 ........... No ............ No ............ 06 SURG ...... Appendectomy w/o complicated principal diag w CC.1.3154 3.2 4.1 

343 ........... No ............ No ............ 06 SURG ...... Appendectomy w/o complicated principal diag w/o CC/MCC.0.9067 1.8 2.2 

344 ........... No ............ No ............ 06 SURG ...... Minor small & large bowel procedures 

w MCC.

3.0822 9.2 11.8 

345 ........... No ............ No ............ 06 SURG ...... Minor small & large bowel procedures 

w CC.

1.6391 6.2 7.2 

346 ........... No ............ No ............ 06 SURG ...... Minor small & large bowel procedures 

w/o CC/MCC.

1.1869 4.4 4.9 

347 ........... No ............ No ............ 06 SURG ...... Anal & stomal procedures w MCC ...... 2.1823 6.4 8.8 

348 ........... No ............ No ............ 06 SURG ...... Anal & stomal procedures w CC ......... 1.2860 4.4 5.7 

349 ........... No ............ No ............ 06 SURG ...... Anal & stomal procedures w/o CC/ 

MCC.

0.7681 2.4 3.1 

350 ........... No ............ No ............ 06 SURG ...... Inguinal & femoral hernia procedures 

w MCC.

2.2486 5.8 8.0 

351 ........... No ............ No ............ 06 SURG ...... Inguinal & femoral hernia procedures 

w CC.

1.2638 3.4 4.6 

352 ........... No ............ No ............ 06 SURG ...... Inguinal & femoral hernia procedures 

w/o CC/MCC.

0.8131 2.0 2.5 

353 ........... No ............ No ............ 06 SURG ...... Hernia procedures except inguinal & 

femoral w MCC.

2.4935 6.4 8.4 

354 ........... No ............ No ............ 06 SURG ...... Hernia procedures except inguinal & 

femoral w CC.

1.4046 4.0 5.1 

355 ........... No ............ No ............ 06 SURG ...... Hernia procedures except inguinal & 

femoral w/o CC/MCC.

0.9675 2.4 2.9 

356 ........... Yes .......... No ............ 06 SURG ...... Other digestive system O.R. procedures w MCC.3.8574 9.5 12.9 

357 ........... Yes .......... No ............ 06 SURG ...... Other digestive system O.R. procedures w CC.2.1703 6.2 8.1 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23827 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

358 ........... Yes .......... No ............ 06 SURG ...... Other digestive system O.R. procedures w/o CC/MCC.1.3493 3.3 4.5 

368 ........... No ............ No ............ 06 MED ......... Major esophageal disorders w MCC ... 1.6184 5.1 6.6 

369 ........... No ............ No ............ 06 MED ......... Major esophageal disorders w CC ...... 1.0703 3.8 4.7 

370 ........... No ............ No ............ 06 MED ......... Major esophageal disorders w/o CC/ 

MCC.

0.7835 2.8 3.4 

371 ........... Yes .......... No ............ 06 MED ......... Major gastrointestinal disorders & 

peritoneal infections w MCC.

1.9062 6.7 8.7 

372 ........... Yes .......... No ............ 06 MED ......... Major gastrointestinal disorders & 

peritoneal infections w CC.

1.3025 5.6 6.9 

373 ........... Yes .......... No ............ 06 MED ......... Major gastrointestinal disorders & 

peritoneal infections w/o CC/MCC.

0.8646 4.2 4.9 

374 ........... Yes .......... No ............ 06 MED ......... Digestive malignancy w MCC ............. 1.9057 6.3 8.6 

375 ........... Yes .......... No ............ 06 MED ......... Digestive malignancy w CC ................ 1.2523 4.6 6.0 

376 ........... Yes .......... No ............ 06 MED ......... Digestive malignancy w/o CC/MCC .... 0.8820 3.2 4.2 

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/MCC ............ 0.7567 2.9 3.4 

380 ........... Yes .......... No ............ 06 MED ......... Complicated peptic ulcer w MCC ........ 1.7995 5.6 7.3 

381 ........... Yes .......... No ............ 06 MED ......... Complicated peptic ulcer w CC ........... 1.1138 4.2 5.2 

382 ........... Yes .......... No ............ 06 MED ......... Complicated peptic ulcer w/o CC/MCC 0.8208 3.1 3.7 

383 ........... No ............ No ............ 06 MED ......... Uncomplicated peptic ulcer w MCC .... 1.1789 4.4 5.5 

384 ........... No ............ No ............ 06 MED ......... Uncomplicated peptic ulcer w/o MCC 0.7818 3.1 3.7 

385 ........... No ............ No ............ 06 MED ......... Inflammatory bowel disease w MCC .. 1.8541 6.5 8.8 

386 ........... No ............ No ............ 06 MED ......... Inflammatory bowel disease w CC ..... 1.0601 4.5 5.7 

387 ........... No ............ No ............ 06 MED ......... Inflammatory bowel disease w/o CC/ 

MCC.

0.7746 3.5 4.3 

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/MCC .............. 0.6333 3.0 3.6 

391 ........... No ............ No ............ 06 MED ......... Esophagitis, gastroent & misc digest 

disorders w MCC.

1.0810 3.9 5.2 

392 ........... No ............ No ............ 06 MED ......... Esophagitis, gastroent & misc digest 

disorders w/o MCC.

0.6685 2.8 3.5 

393 ........... No ............ No ............ 06 MED ......... Other digestive system diagnoses w 

MCC.

1.5367 4.9 6.9 

394 ........... No ............ No ............ 06 MED ......... Other digestive system diagnoses w 

CC.

0.9489 3.8 4.8 

395 ........... No ............ No ............ 06 MED ......... Other digestive system diagnoses w/o 

CC/MCC.

0.6745 2.6 3.3 

405 ........... Yes .......... No ............ 07 SURG ...... Pancreas, liver & shunt procedures w 

MCC.

5.6481 12.4 17.0 

406 ........... Yes .......... No ............ 07 SURG ...... Pancreas, liver & shunt procedures w 

CC.

2.7895 7.0 9.2 

407 ........... Yes .......... No ............ 07 SURG ...... Pancreas, liver & shunt procedures w/ 

o CC/MCC.

1.8411 4.2 5.5 

408 ........... No ............ No ............ 07 SURG ...... Biliary tract proc except only cholecyst 

w or w/o c.d.e. w MCC.

4.2539 12.1 15.0 

409 ........... No ............ No ............ 07 SURG ...... Biliary tract proc except only cholecyst 

w or w/o c.d.e. w CC.

2.5819 8.3 9.8 

410 ........... No ............ No ............ 07 SURG ...... Biliary tract proc except only cholecyst 

w or w/o c.d.e. w/o CC/MCC.

1.6374 5.4 6.5 

411 ........... No ............ No ............ 07 SURG ...... Cholecystectomy w c.d.e. w MCC ...... 3.7602 10.4 12.4 

412 ........... No ............ No ............ 07 SURG ...... Cholecystectomy w c.d.e. w CC ......... 2.3633 7.5 8.6 

413 ........... No ............ No ............ 07 SURG ...... Cholecystectomy w c.d.e. w/o CC/ 

MCC.

1.6896 5.0 5.9 

414 ........... Yes .......... No ............ 07 SURG ...... Cholecystectomy except by 

laparoscope w/o c.d.e. w MCC.

3.5777 9.7 11.7 

415 ........... Yes .......... No ............ 07 SURG ...... Cholecystectomy except by 

laparoscope w/o c.d.e. w CC.

2.0372 6.5 7.6 

416 ........... Yes .......... No ............ 07 SURG ...... Cholecystectomy except by 

laparoscope w/o c.d.e. w/o CC/ 

MCC.

1.3290 4.1 4.8 

417 ........... No ............ No ............ 07 SURG ...... Laparoscopic cholecystectomy w/o 

c.d.e. w MCC.

2.4851 6.5 8.4 

418 ........... No ............ No ............ 07 SURG ...... Laparoscopic cholecystectomy w/o 

c.d.e. w CC.

1.6541 4.5 5.6 


jlentini on PROD1PC65 with PROPOSALS2
23828 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

419 ........... No ............ No ............ 07 SURG ...... Laparoscopic cholecystectomy w/o 

c.d.e. w/o CC/MCC.

1.1296 2.5 3.2 

420 ........... No ............ No ............ 07 SURG ...... Hepatobiliary diagnostic procedures w 

MCC.

4.0976 9.9 13.7 

421 ........... No ............ No ............ 07 SURG ...... Hepatobiliary diagnostic procedures w 

CC.

1.8978 5.6 7.7 

422 ........... No ............ No ............ 07 SURG ...... Hepatobiliary diagnostic procedures 

w/o CC/MCC.

1.2275 3.2 4.4 

423 ........... No ............ No ............ 07 SURG ...... Other hepatobiliary or pancreas O.R. 

procedures w MCC.

4.5535 11.8 15.9 

424 ........... No ............ No ............ 07 SURG ...... Other hepatobiliary or pancreas O.R. 

procedures w CC.

2.5159 7.9 10.4 

425 ........... No ............ No ............ 07 SURG ...... Other hepatobiliary or pancreas O.R. 

procedures w/o CC/MCC.

1.3760 4.0 5.4 

432 ........... No ............ No ............ 07 MED ......... Cirrhosis & alcoholic hepatitis w MCC 1.6776 5.2 7.0 

433 ........... No ............ No ............ 07 MED ......... Cirrhosis & alcoholic hepatitis w CC ... 0.9378 3.8 4.9 

434 ........... No ............ No ............ 07 MED ......... Cirrhosis & alcoholic hepatitis w/o CC/ 

MCC.

0.6551 2.9 3.7 

435 ........... No ............ No ............ 07 MED ......... Malignancy of hepatobiliary system or 

pancreas w MCC.

1.7117 5.7 7.6 

436 ........... No ............ No ............ 07 MED ......... Malignancy of hepatobiliary system or 

pancreas w CC.

1.1892 4.5 5.8 

437 ........... No ............ No ............ 07 MED ......... Malignancy of hepatobiliary system or 

pancreas w/o CC/MCC.

0.9506 3.2 4.3 

438 ........... No ............ No ............ 07 MED ......... Disorders of pancreas except malignancy w MCC.1.6992 5.5 7.5 

439 ........... No ............ No ............ 07 MED ......... Disorders of pancreas except malignancy w CC.1.0223 4.2 5.3 

440 ........... No ............ No ............ 07 MED ......... Disorders of pancreas except malignancy w/o CC/MCC.0.6963 3.2 3.8 

441 ........... Yes .......... No ............ 07 MED ......... Disorders of liver except malig, cirr, 

alc hepa w MCC.

1.6580 5.1 7.0 

442 ........... Yes .......... No ............ 07 MED ......... Disorders of liver except malig, cirr, 

alc hepa w CC.

0.9825 3.9 5.1 

443 ........... Yes .......... No ............ 07 MED ......... Disorders of liver except malig, cirr, 

alc hepa w/o CC/MCC.

0.6945 3.0 3.8 

444 ........... No ............ No ............ 07 MED ......... Disorders of the biliary tract w MCC ... 1.5579 5.0 6.6 

445 ........... No ............ No ............ 07 MED ......... Disorders of the biliary tract w CC ...... 1.0375 3.8 4.7 

446 ........... No ............ No ............ 07 MED ......... Disorders of the biliary tract w/o CC/ 

MCC.

0.7225 2.6 3.3 

453 ........... No ............ No ............ 08 SURG ...... Combined anterior/posterior spinal fusion w MCC.9.8724 12.0 15.7 

454 ........... No ............ No ............ 08 SURG ...... Combined anterior/posterior spinal fusion w CC.7.0370 6.5 8.0 

455 ........... No ............ No ............ 08 SURG ...... Combined anterior/posterior spinal fusion w/o CC/MCC.5.1744 3.7 4.4 

456 ........... No ............ No ............ 08 SURG ...... Spinal fus exc cerv w spinal curv/ 

malig/infec or 9+ fus w MCC.

8.5225 11.6 14.7 

457 ........... No ............ No ............ 08 SURG ...... Spinal fus exc cerv w spinal curv/ 

malig/infec or 9+ fus w CC.

5.6672 6.2 7.5 

458 ........... No ............ No ............ 08 SURG ...... Spinal fus exc cerv w spinal curv/ 

malig/infec or 9+ fus w/o CC/MCC.

4.7056 4.0 4.5 

459 ........... Yes .......... No ............ 08 SURG ...... Spinal fusion except cervical w MCC 5.9847 7.6 9.4 

460 ........... Yes .......... No ............ 08 SURG ...... Spinal fusion except cervical w/o MCC 3.5746 3.6 4.2 

461 ........... No ............ No ............ 08 SURG ...... Bilateral or multiple major joint procs 

of lower extremity w MCC.

4.5636 6.8 8.4 

462 ........... No ............ No ............ 08 SURG ...... Bilateral or multiple major joint procs 

of lower extremity w/o MCC.

3.1564 3.9 4.2 

463 ........... Yes .......... No ............ 08 SURG ...... Wnd debrid & skn grft exc hand, for 

musculo-conn tiss dis w MCC.

4.6669 12.0 16.6 

464 ........... Yes .......... No ............ 08 SURG ...... Wnd debrid & skn grft exc hand, for 

musculo-conn tiss dis w CC.

2.6117 7.7 10.2 

465 ........... Yes .......... No ............ 08 SURG ...... Wnd debrid & skn grft exc hand, for 

musculo-conn tiss dis w/o CC/MCC.

1.4955 4.4 5.9 

466 ........... Yes .......... No ............ 08 SURG ...... Revision of hip or knee replacement w 

MCC.

4.5564 7.4 9.2 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23829 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

467 ........... Yes .......... No ............ 08 SURG ...... Revision of hip or knee replacement w 

CC.

3.0720 4.8 5.5 

468 ........... Yes .......... No ............ 08 SURG ...... Revision of hip or knee replacement 

w/o CC/MCC.

2.4597 3.6 3.9 

469 ........... Yes .......... No ............ 08 SURG ...... Major joint replacement or reattachment of lower extremity w MCC.3.2979 6.9 8.2 

470 ........... Yes .......... No ............ 08 SURG ...... Major joint replacement or reattachment of lower extremity w/o MCC.2.0144 3.6 3.9 

471 ........... No ............ No ............ 08 SURG ...... Cervical spinal fusion w MCC ............. 4.4277 7.0 9.8 

472 ........... No ............ No ............ 08 SURG ...... Cervical spinal fusion w CC ................ 2.6200 2.8 4.1 

473 ........... No ............ No ............ 08 SURG ...... Cervical spinal fusion w/o CC/MCC .... 1.9213 1.6 2.0 

474 ........... Yes .......... No ............ 08 SURG ...... Amputation for musculoskeletal sys & 

conn tissue dis w MCC.

3.4435 9.5 12.6 

475 ........... Yes .......... No ............ 08 SURG ...... Amputation for musculoskeletal sys & 

conn tissue dis w CC.

1.9768 6.5 8.4 

476 ........... Yes .......... No ............ 08 SURG ...... Amputation for musculoskeletal sys & 

conn tissue dis w/o CC/MCC.

1.1001 3.7 4.8 

477 ........... Yes .......... Yes .......... 08 SURG ...... Biopsies of musculoskeletal system & 

connective tissue w MCC.

3.2545 8.9 11.9 

478 ........... Yes .......... Yes .......... 08 SURG ...... Biopsies of musculoskeletal system & 

connective tissue w CC.

2.1266 4.6 6.6 

479 ........... Yes .......... Yes .......... 08 SURG ...... Biopsies of musculoskeletal system & 

connective tissue w/o CC/MCC.

1.4779 1.9 2.8 

480 ........... Yes .......... Yes .......... 08 SURG ...... Hip & femur procedures except major 

joint w MCC.

2.9050 7.8 9.3 

481 ........... Yes .......... Yes .......... 08 SURG ...... Hip & femur procedures except major 

joint w CC.

1.8204 5.4 5.9 

482 ........... Yes .......... Yes .......... 08 SURG ...... Hip & femur procedures except major 

joint w/o CC/MCC.

1.4976 4.5 4.8 

483 ........... Yes .......... No ............ 08 SURG ...... Major joint & limb reattachment proc 

of upper extremity w CC/MCC.

2.2601 3.4 4.2 

484 ........... Yes .......... No ............ 08 SURG ...... Major joint & limb reattachment proc 

of upper extremity w/o CC/MCC.

1.7535 2.1 2.4 

485 ........... No ............ No ............ 08 SURG ...... Knee procedures w pdx of infection w 

MCC.

3.3033 9.8 12.1 

486 ........... No ............ No ............ 08 SURG ...... Knee procedures w pdx of infection w 

CC.

2.1664 6.8 8.0 

487 ........... No ............ No ............ 08 SURG ...... Knee procedures w pdx of infection w/ 

o CC/MCC.

1.5507 4.9 5.7 

488 ........... Yes .......... No ............ 08 SURG ...... Knee procedures w/o pdx of infection 

w CC/MCC.

1.6836 4.1 5.2 

489 ........... Yes .......... No ............ 08 SURG ...... Knee procedures w/o pdx of infection 

w/o CC/MCC.

1.1604 2.6 3.0 

490 ........... No ............ No ............ 08 SURG ...... Back & neck proc exc spinal fusion w 

CC/MCC or disc device/neurostim.

1.7221 3.0 4.3 

491 ........... No ............ No ............ 08 SURG ...... Back & neck proc exc spinal fusion w/ 

o CC/MCC.

0.9413 1.8 2.2 

492 ........... Yes .......... Yes .......... 08 SURG ...... Lower extrem & humer proc except 

hip,foot,femur w MCC.

2.7705 6.8 8.5 

493 ........... Yes .......... Yes .......... 08 SURG ...... Lower extrem & humer proc except 

hip,foot,femur w CC.

1.7631 4.3 5.3 

494 ........... Yes .......... Yes .......... 08 SURG ...... Lower extrem & humer proc except 

hip,foot,femur w/o CC/MCC.

1.2385 2.8 3.4 

495 ........... Yes .......... No ............ 08 SURG ...... Local excision & removal int fix devices exc hip & femur w MCC.3.1782 8.1 11.0 

496 ........... Yes .......... No ............ 08 SURG ...... Local excision & removal int fix devices exc hip & femur w CC.1.7775 4.6 6.0 

497 ........... Yes .......... No ............ 08 SURG ...... Local excision & removal int fix devices exc hip & femur w/o CC/MCC.1.1277 2.3 3.0 

498 ........... No ............ No ............ 08 SURG ...... Local excision & removal int fix devices of hip & femur w CC/MCC.2.0274 5.5 7.9 

499 ........... No ............ No ............ 08 SURG ...... Local excision & removal int fix devices of hip & femur w/o CC/MCC.0.9097 2.3 3.0 

500 ........... Yes .......... Yes .......... 08 SURG ...... Soft tissue procedures w MCC ........... 2.8423 7.8 10.8 

501 ........... Yes .......... Yes .......... 08 SURG ...... Soft tissue procedures w CC .............. 1.4718 4.5 6.0 

502 ........... Yes .......... Yes .......... 08 SURG ...... Soft tissue procedures w/o CC/MCC .. 0.9585 2.3 2.9 

503 ........... No ............ No ............ 08 SURG ...... Foot procedures w MCC ..................... 2.3059 7.2 9.5 


jlentini on PROD1PC65 with PROPOSALS2
23830 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

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/MCC ............ 0.9882 2.6 3.4 

506 ........... No ............ No ............ 08 SURG ...... Major thumb or joint procedures ......... 1.0286 2.5 3.4 

507 ........... No ............ No ............ 08 SURG ...... Major shoulder or elbow joint procedures w CC/MCC.1.7188 3.7 5.1 

508 ........... No ............ No ............ 08 SURG ...... Major shoulder or elbow joint procedures w/o CC/MCC.1.1156 1.7 2.1 

509 ........... No ............ No ............ 08 SURG ...... Arthroscopy ......................................... 1.1762 2.0 3.1 

510 ........... Yes .......... No ............ 08 SURG ...... Shoulder,elbow or forearm proc, exc 

major joint proc w MCC.

1.9973 4.9 6.4 

511 ........... Yes .......... No ............ 08 SURG ...... Shoulder,elbow or forearm proc, exc 

major joint proc w CC.

1.3434 3.2 4.0 

512 ........... Yes .......... No ............ 08 SURG ...... Shoulder,elbow or forearm proc, exc 

major joint proc w/o CC/MCC.

0.9533 1.8 2.2 

513 ........... No ............ No ............ 08 SURG ...... Hand or wrist proc, except major 

thumb or joint proc w CC/MCC.

1.2813 3.6 5.0 

514 ........... No ............ No ............ 08 SURG ...... Hand or wrist proc, except major 

thumb or joint proc w/o CC/MCC.

0.8067 2.1 2.8 

515 ........... Yes .......... Yes .......... 08 SURG ...... Other musculoskelet sys & conn tiss 

O.R. proc w MCC.

3.0601 7.9 10.4 

516 ........... Yes .......... Yes .......... 08 SURG ...... Other musculoskelet sys & conn tiss 

O.R. proc w CC.

1.8073 4.5 6.0 

517 ........... Yes .......... Yes .......... 08 SURG ...... Other musculoskelet sys & conn tiss 

O.R. proc w/o CC/MCC.

1.3326 2.1 3.0 

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 MCC ............... 0.7318 3.3 4.0 

535 ........... Yes .......... No ............ 08 MED ......... Fractures of hip & pelvis w MCC ........ 1.3327 4.8 6.2 

536 ........... Yes .......... No ............ 08 MED ......... Fractures of hip & pelvis w/o MCC ..... 0.6934 3.4 3.9 

537 ........... No ............ No ............ 08 MED ......... Sprains, strains, & dislocations of hip, 

pelvis & thigh w CC/MCC.

0.8871 3.6 4.5 

538 ........... No ............ No ............ 08 MED ......... Sprains, strains, & dislocations of hip, 

pelvis & thigh w/o CC/MCC.

0.5787 2.7 3.2 

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 & 

musculoskelet & conn tiss malig w 

MCC.

1.8953 6.7 8.8 

543 ........... Yes .......... No ............ 08 MED ......... Pathological fractures & 

musculoskelet & conn tiss malig w 

CC.

1.1263 4.8 5.9 

544 ........... Yes .......... No ............ 08 MED ......... Pathological fractures & 

musculoskelet & conn tiss malig w/o 

CC/MCC.

0.7672 3.7 4.4 

545 ........... Yes .......... No ............ 08 MED ......... Connective tissue disorders w MCC ... 2.3477 6.5 9.1 

546 ........... Yes .......... No ............ 08 MED ......... Connective tissue disorders w CC ...... 1.0951 4.4 5.5 

547 ........... Yes .......... No ............ 08 MED ......... Connective tissue disorders w/o CC/ 

MCC.

0.7224 3.1 3.8 

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/MCC ............... 0.8006 3.7 4.5 

551 ........... Yes .......... No ............ 08 MED ......... Medical back problems w MCC .......... 1.5261 5.4 7.1 

552 ........... Yes .......... No ............ 08 MED ......... Medical back problems w/o MCC ....... 0.7623 3.4 4.1 

553 ........... No ............ No ............ 08 MED ......... Bone diseases & arthropathies w 

MCC.

1.0978 4.7 6.0 

554 ........... No ............ No ............ 08 MED ......... Bone diseases & arthropathies w/o 

MCC.

0.6305 3.0 3.7 

555 ........... No ............ No ............ 08 MED ......... Signs & symptoms of musculoskeletal 

system & conn tissue w MCC.

1.0014 3.6 4.8 

556 ........... No ............ No ............ 08 MED ......... Signs & symptoms of musculoskeletal 

system & conn tissue w/o MCC.

0.5738 2.5 3.1 

557 ........... Yes .......... No ............ 08 MED ......... Tendonitis, myositis & bursitis w MCC 1.4264 5.2 6.6 

558 ........... Yes .......... No ............ 08 MED ......... Tendonitis, myositis & bursitis w/o 

MCC.

0.8009 3.5 4.3 

559 ........... Yes .......... No ............ 08 MED ......... Aftercare, musculoskeletal system & 

connective tissue w MCC.

1.7085 5.3 7.6 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23831 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

560 ........... Yes .......... No ............ 08 MED ......... Aftercare, musculoskeletal system & 

connective tissue w CC.

0.9491 3.6 4.7 

561 ........... Yes .......... No ............ 08 MED ......... Aftercare, musculoskeletal system & 

connective tissue w/o CC/MCC.

0.5794 2.1 2.8 

562 ........... Yes .......... No ............ 08 MED ......... Fx, sprn, strn & disl except femur, hip, 

pelvis & thigh w MCC.

1.3933 4.9 6.4 

563 ........... Yes .......... No ............ 08 MED ......... Fx, sprn, strn & disl except femur, hip, 

pelvis & thigh w/o MCC.

0.6749 3.1 3.7 

564 ........... No ............ No ............ 08 MED ......... Other musculoskeletal sys & connective tissue diagnoses w MCC.1.4053 5.2 7.0 

565 ........... No ............ No ............ 08 MED ......... Other musculoskeletal sys & connective tissue diagnoses w CC.0.8848 3.9 5.0 

566 ........... No ............ No ............ 08 MED ......... Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC.0.6673 3.0 3.7 

573 ........... Yes .......... No ............ 09 SURG ...... Skin graft &/or debrid for skn ulcer or 

cellulitis w MCC.

3.1703 9.6 13.1 

574 ........... Yes .......... No ............ 09 SURG ...... Skin graft &/or debrid for skn ulcer or 

cellulitis w CC.

1.9362 7.1 9.3 

575 ........... Yes .......... No ............ 09 SURG ...... Skin graft &/or debrid for skn ulcer or 

cellulitis w/o CC/MCC.

1.1176 4.7 5.9 

576 ........... No ............ No ............ 09 SURG ...... Skin graft &/or debrid exc for skin 

ulcer or cellulitis w MCC.

3.4522 8.4 13.0 

577 ........... No ............ No ............ 09 SURG ...... Skin graft &/or debrid exc for skin 

ulcer or cellulitis w CC.

1.5788 4.2 6.1 

578 ........... No ............ No ............ 09 SURG ...... Skin graft &/or debrid exc for skin 

ulcer or cellulitis w/o CC/MCC.

0.9803 2.4 3.3 

579 ........... Yes .......... No ............ 09 SURG ...... Other skin, subcut tiss & breast proc 

w MCC.

2.7821 7.8 10.7 

580 ........... Yes .......... No ............ 09 SURG ...... Other skin, subcut tiss & breast proc 

w CC.

1.4093 3.7 5.5 

581 ........... Yes .......... No ............ 09 SURG ...... Other skin, subcut tiss & breast proc 

w/o CC/MCC.

0.8606 1.9 2.6 

582 ........... No ............ No ............ 09 SURG ...... Mastectomy for malignancy w CC/ 

MCC.

0.9682 2.1 2.8 

583 ........... No ............ No ............ 09 SURG ...... Mastectomy for malignancy w/o CC/ 

MCC.

0.7498 1.6 1.8 

584 ........... No ............ No ............ 09 SURG ...... Breast biopsy, local excision & other 

breast procedures w CC/MCC.

1.4344 4.0 6.0 

585 ........... No ............ No ............ 09 SURG ...... Breast biopsy, local excision & other 

breast procedures w/o CC/MCC.

0.7995 1.7 2.2 

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 MCC ............... 1.8159 6.2 8.3 

596 ........... No ............ No ............ 09 MED ......... Major skin disorders w/o MCC ............ 0.8200 3.8 4.8 

597 ........... No ............ No ............ 09 MED ......... Malignant breast disorders w MCC ..... 1.6001 5.9 8.2 

598 ........... No ............ No ............ 09 MED ......... Malignant breast disorders w CC ........ 1.0812 4.3 5.7 

599 ........... No ............ No ............ 09 MED ......... Malignant breast disorders w/o CC/ 

MCC.

0.7309 2.7 3.7 

600 ........... No ............ No ............ 09 MED ......... Non-malignant breast disorders w CC/ 

MCC.

0.9433 4.1 5.1 

601 ........... No ............ No ............ 09 MED ......... Non-malignant breast disorders w/o 

CC/MCC.

0.6539 3.1 3.9 

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, subcut tiss & 

breast w MCC.

1.1875 4.3 5.7 

605 ........... No ............ No ............ 09 MED ......... Trauma to the skin, subcut tiss & 

breast w/o MCC.

0.6739 2.8 3.5 

606 ........... No ............ No ............ 09 MED ......... Minor skin disorders w MCC ............... 1.2415 4.4 6.3 

607 ........... No ............ No ............ 09 MED ......... Minor skin disorders w/o MCC ............ 0.6434 2.9 3.8 

614 ........... No ............ No ............ 10 SURG ...... Adrenal & pituitary procedures w CC/ 

MCC.

2.5046 5.1 7.0 

615 ........... No ............ No ............ 10 SURG ...... Adrenal & pituitary procedures w/o 

CC/MCC.

1.3782 2.7 3.2 

616 ........... Yes .......... No ............ 10 SURG ...... Amputat of lower limb for endocrine, 

nutrit, & metabol dis w MCC.

4.6284 13.3 16.9 


jlentini on PROD1PC65 with PROPOSALS2
23832 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

617 ........... Yes .......... No ............ 10 SURG ...... Amputat of lower limb for endocrine, 

nutrit, & metabol dis w CC.

2.0940 7.0 8.8 

618 ........... Yes .......... No ............ 10 SURG ...... Amputat of lower limb for endocrine, 

nutrit, & metabol dis w/o CC/MCC.

1.3234 5.1 6.4 

619 ........... No ............ No ............ 10 SURG ...... O.R. procedures for obesity w MCC ... 3.3383 5.2 8.2 

620 ........... No ............ No ............ 10 SURG ...... O.R. procedures for obesity w CC ...... 1.8739 2.9 3.7 

621 ........... No ............ No ............ 10 SURG ...... O.R. procedures for obesity w/o CC/ 

MCC.

1.4269 1.9 2.2 

622 ........... Yes .......... No ............ 10 SURG ...... Skin grafts & wound debrid for endoc, 

nutrit & metab dis w MCC.

3.1268 9.4 13.2 

623 ........... Yes .......... No ............ 10 SURG ...... Skin grafts & wound debrid for endoc, 

nutrit & metab dis w CC.

1.8728 6.7 8.6 

624 ........... Yes .......... No ............ 10 SURG ...... Skin grafts & wound debrid for endoc, 

nutrit & metab dis w/o CC/MCC.

1.0877 4.8 6.0 

625 ........... No ............ No ............ 10 SURG ...... Thyroid, parathyroid & thyroglossal 

procedures w MCC.

2.1260 4.7 7.1 

626 ........... No ............ No ............ 10 SURG ...... Thyroid, parathyroid & thyroglossal 

procedures w CC.

1.1284 2.1 3.1 

627 ........... No ............ No ............ 10 SURG ...... Thyroid, parathyroid & thyroglossal 

procedures w/o CC/MCC.

0.7378 1.3 1.5 

628 ........... Yes .......... No ............ 10 SURG ...... Other endocrine, nutrit & metab O.R. 

proc w MCC.

3.2732 7.5 11.2 

629 ........... Yes .......... No ............ 10 SURG ...... Other endocrine, nutrit & metab O.R. 

proc w CC.

2.2931 6.9 8.7 

630 ........... Yes .......... No ............ 10 SURG ...... Other endocrine, nutrit & metab O.R. 

proc w/o CC/MCC.

1.5069 4.0 5.5 

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 metabolic disorders 

w MCC.

1.1105 3.9 5.4 

641 ........... Yes .......... No ............ 10 MED ......... Nutritional & misc metabolic disorders 

w/o MCC.

0.6798 3.1 3.8 

642 ........... No ............ No ............ 10 MED ......... Inborn errors of metabolism ................ 1.0169 3.7 5.2 

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 CC/MCC ...... 0.7164 3.1 3.9 

652 ........... No ............ No ............ 11 SURG ...... Kidney transplant ................................. 2.9787 6.6 7.8 

653 ........... Yes .......... No ............ 11 SURG ...... Major bladder procedures w MCC ...... 5.8091 13.6 16.9 

654 ........... Yes .......... No ............ 11 SURG ...... Major bladder procedures w CC ......... 2.9531 8.7 9.9 

655 ........... Yes .......... No ............ 11 SURG ...... Major bladder procedures w/o CC/ 

MCC.

2.0241 5.7 6.5 

656 ........... No ............ No ............ 11 SURG ...... Kidney & ureter procedures for neoplasm w MCC.3.2762 8.0 10.1 

657 ........... No ............ No ............ 11 SURG ...... Kidney & ureter procedures for neoplasm w CC.1.8655 5.0 6.0 

658 ........... No ............ No ............ 11 SURG ...... Kidney & ureter procedures for neoplasm w/o CC/MCC.1.3790 3.3 3.7 

659 ........... Yes .......... No ............ 11 SURG ...... Kidney & ureter procedures for nonneoplasm w MCC.3.3225 8.0 11.2 

660 ........... Yes .......... No ............ 11 SURG ...... Kidney & ureter procedures for nonneoplasm w CC.1.8913 4.8 6.5 

661 ........... Yes .......... No ............ 11 SURG ...... Kidney & ureter procedures for nonneoplasm w/o CC/MCC.1.2600 2.6 3.3 

662 ........... No ............ No ............ 11 SURG ...... Minor bladder procedures w MCC ...... 2.7078 7.4 10.3 

663 ........... No ............ No ............ 11 SURG ...... Minor bladder procedures w CC ......... 1.4443 3.7 5.3 

664 ........... No ............ No ............ 11 SURG ...... Minor bladder procedures w/o CC/ 

MCC.

0.9940 1.6 2.1 

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 w MCC ....... 2.2348 6.2 8.5 

669 ........... No ............ No ............ 11 SURG ...... Transurethral procedures w CC .......... 1.2049 3.1 4.4 

670 ........... No ............ No ............ 11 SURG ...... Transurethral procedures w/o CC/ 

MCC.

0.7672 1.9 2.5 

671 ........... No ............ No ............ 11 SURG ...... Urethral procedures w CC/MCC ......... 1.4136 4.1 5.9 

672 ........... No ............ No ............ 11 SURG ...... Urethral procedures w/o CC/MCC ...... 0.7962 1.9 2.5 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23833 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

673 ........... No ............ No ............ 11 SURG ...... Other kidney & urinary tract procedures w MCC.2.7645 5.8 9.7 

674 ........... No ............ No ............ 11 SURG ...... Other kidney & urinary tract procedures w CC.2.1527 4.6 7.2 

675 ........... No ............ No ............ 11 SURG ...... Other kidney & urinary tract procedures w/o CC/MCC.1.3137 1.5 2.1 

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 neoplasms w 

MCC.

1.6240 5.6 7.6 

687 ........... No ............ No ............ 11 MED ......... Kidney & urinary tract neoplasms w 

CC.

1.0719 4.1 5.4 

688 ........... No ............ No ............ 11 MED ......... Kidney & urinary tract neoplasms w/o 

CC/MCC.

0.6816 2.5 3.3 

689 ........... Yes .......... No ............ 11 MED ......... Kidney & urinary tract infections w 

MCC.

1.2271 4.9 6.2 

690 ........... Yes .......... No ............ 11 MED ......... Kidney & urinary tract infections w/o 

MCC.

0.7559 3.5 4.2 

691 ........... No ............ No ............ 11 MED ......... Urinary stones w esw lithotripsy w 

CC/MCC.

1.4503 2.9 4.0 

692 ........... No ............ No ............ 11 MED ......... Urinary stones w esw lithotripsy w/o 

CC/MCC.

1.1528 1.9 2.4 

693 ........... No ............ No ............ 11 MED ......... Urinary stones w/o esw lithotripsy w 

MCC.

1.1915 3.6 4.8 

694 ........... No ............ No ............ 11 MED ......... Urinary stones w/o esw lithotripsy w/o 

MCC.

0.6573 2.0 2.6 

695 ........... No ............ No ............ 11 MED ......... Kidney & urinary tract signs & symptoms w MCC.1.1723 4.2 5.5 

696 ........... No ............ No ............ 11 MED ......... Kidney & urinary tract signs & symptoms w/o MCC.0.6308 2.6 3.3 

697 ........... No ............ No ............ 11 MED ......... Urethral stricture .................................. 0.6938 2.4 3.1 

698 ........... Yes .......... No ............ 11 MED ......... Other kidney & urinary tract diagnoses 

w MCC.

1.4719 5.0 6.7 

699 ........... Yes .......... No ............ 11 MED ......... Other kidney & urinary tract diagnoses 

w CC.

0.9700 3.7 4.8 

700 ........... Yes .......... No ............ 11 MED ......... Other kidney & urinary tract diagnoses 

w/o CC/MCC.

0.6813 2.8 3.6 

707 ........... No ............ No ............ 12 SURG ...... Major male pelvic procedures w CC/ 

MCC.

1.6265 3.4 4.4 

708 ........... No ............ No ............ 12 SURG ...... Major male pelvic procedures w/o CC/ 

MCC.

1.1839 1.8 2.1 

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/MCC .......... 1.2586 1.4 1.8 

711 ........... No ............ No ............ 12 SURG ...... Testes procedures w CC/MCC ........... 2.0318 5.5 8.2 

712 ........... No ............ No ............ 12 SURG ...... Testes procedures w/o CC/MCC ........ 0.8077 2.2 3.0 

713 ........... No ............ No ............ 12 SURG ...... Transurethral prostatectomy w CC/ 

MCC.

1.1188 2.9 4.2 

714 ........... No ............ No ............ 12 SURG ...... Transurethral prostatectomy w/o CC/ 

MCC.

0.6333 1.7 1.9 

715 ........... No ............ No ............ 12 SURG ...... Other male reproductive system O.R. 

proc for malignancy w CC/MCC.

1.7120 3.9 6.3 

716 ........... No ............ No ............ 12 SURG ...... Other male reproductive system O.R. 

proc for malignancy w/o CC/MCC.

0.9713 1.2 1.4 

717 ........... No ............ No ............ 12 SURG ...... Other male reproductive system O.R. 

proc exc malignancy w CC/MCC.

1.8091 5.1 7.2 

718 ........... No ............ No ............ 12 SURG ...... Other male reproductive system O.R. 

proc exc malignancy w/o CC/MCC.

0.7849 2.2 2.8 

722 ........... No ............ No ............ 12 MED ......... Malignancy, male reproductive system 

w MCC.

1.5588 5.7 7.6 

723 ........... No ............ No ............ 12 MED ......... Malignancy, male reproductive system 

w CC.

0.9901 4.1 5.3 

724 ........... No ............ No ............ 12 MED ......... Malignancy, male reproductive system 

w/o CC/MCC.

0.6006 2.4 3.2 

725 ........... No ............ No ............ 12 MED ......... Benign prostatic hypertrophy w MCC 1.0462 4.2 5.5 


jlentini on PROD1PC65 with PROPOSALS2
23834 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

726 ........... No ............ No ............ 12 MED ......... Benign prostatic hypertrophy w/o 

MCC.

0.6675 2.7 3.5 

727 ........... No ............ No ............ 12 MED ......... Inflammation of the male reproductive 

system w MCC.

1.3016 5.0 6.4 

728 ........... No ............ No ............ 12 MED ......... Inflammation of the male reproductive 

system w/o MCC.

0.6911 3.3 4.0 

729 ........... No ............ No ............ 12 MED ......... Other male reproductive system diagnoses w CC/MCC.1.0993 4.0 5.6 

730 ........... No ............ No ............ 12 MED ......... Other male reproductive system diagnoses w/o CC/MCC.0.5963 2.4 3.1 

734 ........... No ............ No ............ 13 SURG ...... Pelvic evisceration, rad hysterectomy 

& rad vulvectomy w CC/MCC.

2.3505 6.0 8.0 

735 ........... No ............ No ............ 13 SURG ...... Pelvic evisceration, rad hysterectomy 

& rad vulvectomy w/o CC/MCC.

1.1311 2.9 3.4 

736 ........... No ............ No ............ 13 SURG ...... Uterine & adnexa proc for ovarian or 

adnexal malignancy w MCC.

4.1736 11.2 13.8 

737 ........... No ............ No ............ 13 SURG ...... Uterine & adnexa proc for ovarian or 

adnexal malignancy w CC.

1.9577 6.0 7.2 

738 ........... No ............ No ............ 13 SURG ...... Uterine & adnexa proc for ovarian or 

adnexal malignancy w/o CC/MCC.

1.1577 3.5 3.9 

739 ........... No ............ No ............ 13 SURG ...... Uterine, adnexa proc for non-ovarian/ 

adnexal malig w MCC.

3.0131 7.8 10.2 

740 ........... No ............ No ............ 13 SURG ...... Uterine, adnexa proc for non-ovarian/ 

adnexal malig w CC.

1.4661 4.3 5.2 

741 ........... No ............ No ............ 13 SURG ...... Uterine, adnexa proc for non-ovarian/ 

adnexal malig w/o CC/MCC.

1.0021 2.7 3.0 

742 ........... No ............ No ............ 13 SURG ...... Uterine & adnexa proc for non-malignancy w CC/MCC.1.3433 3.5 4.5 

743 ........... No ............ No ............ 13 SURG ...... Uterine & adnexa proc for non-malignancy w/o CC/MCC.0.8469 2.0 2.3 

744 ........... No ............ No ............ 13 SURG ...... D&C, conization, laparoscopy & tubal 

interruption w CC/MCC.

1.3918 4.1 5.8 

745 ........... No ............ No ............ 13 SURG ...... D&C, conization, laparoscopy & tubal 

interruption w/o CC/MCC.

0.7460 2.1 2.6 

746 ........... No ............ No ............ 13 SURG ...... Vagina, cervix & vulva procedures w 

CC/MCC.

1.2662 3.0 4.2 

747 ........... No ............ No ............ 13 SURG ...... Vagina, cervix & vulva procedures w/o 

CC/MCC.

0.8403 1.6 1.9 

748 ........... No ............ No ............ 13 SURG ...... Female reproductive system reconstructive procedures.0.8193 1.5 1.7 

749 ........... No ............ No ............ 13 SURG ...... Other female reproductive system 

O.R. procedures w CC/MCC.

2.4919 6.7 9.3 

750 ........... No ............ No ............ 13 SURG ...... Other female reproductive system 

O.R. procedures w/o CC/MCC.

0.9660 2.5 3.1 

754 ........... No ............ No ............ 13 MED ......... Malignancy, female reproductive system w MCC.1.7520 6.2 8.3 

755 ........... No ............ No ............ 13 MED ......... Malignancy, female reproductive system w CC.1.0769 4.3 5.7 

756 ........... No ............ No ............ 13 MED ......... Malignancy, female reproductive system w/o CC/MCC.0.6327 2.5 3.1 

757 ........... No ............ No ............ 13 MED ......... Infections, female reproductive system 

w MCC.

1.5775 6.5 8.1 

758 ........... No ............ No ............ 13 MED ......... Infections, female reproductive system 

w CC.

1.0621 4.9 6.1 

759 ........... No ............ No ............ 13 MED ......... Infections, female reproductive system 

w/o CC/MCC.

0.7646 3.6 4.5 

760 ........... No ............ No ............ 13 MED ......... Menstrual & other female reproductive 

system disorders w CC/MCC.

0.7917 3.0 4.0 

761 ........... No ............ No ............ 13 MED ......... Menstrual & other female reproductive 

system disorders w/o CC/MCC.

0.5008 1.9 2.4 

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/MCC .......... 0.7486 3.0 3.2 

767 ........... No ............ No ............ 14 SURG ...... Vaginal delivery w sterilization &/or 

D&C.

0.9741 2.6 3.4 

768 ........... No ............ No ............ 14 SURG ...... Vaginal delivery w O.R. proc except 

steril &/or D&C.

1.7321 0.0 0.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23835 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

769 ........... No ............ No ............ 14 SURG ...... Postpartum & post abortion diagnoses 

w O.R. procedure.

1.2935 3.2 4.6 

770 ........... No ............ No ............ 14 SURG ...... Abortion w D&C, aspiration curettage 

or hysterotomy.

0.6677 1.6 2.2 

774 ........... No ............ No ............ 14 MED ......... Vaginal delivery w complicating diagnoses.0.6571 2.6 3.2 

775 ........... No ............ No ............ 14 MED ......... Vaginal delivery w/o complicating diagnoses.0.4830 2.0 2.2 

776 ........... No ............ No ............ 14 MED ......... Postpartum & post abortion diagnoses 

w/o O.R. procedure.

0.6192 2.5 3.3 

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 diagnoses w medical complications.0.6154 2.6 3.8 

782 ........... No ............ No ............ 14 MED ......... Other antepartum diagnoses w/o medical complications.0.3926 1.7 2.5 

789 ........... No ............ No ............ 15 MED ......... Neonates, died or transferred to another acute care facility.1.4227 0.0 0.0 

790 ........... No ............ No ............ 15 MED ......... Extreme immaturity or respiratory distress syndrome, neonate.4.6916 0.0 0.0 

791 ........... No ............ No ............ 15 MED ......... Prematurity w major problems ............ 3.2042 0.0 0.0 

792 ........... No ............ No ............ 15 MED ......... Prematurity w/o major problems ......... 1.9334 0.0 0.0 

793 ........... No ............ No ............ 15 MED ......... Full term neonate w major problems .. 3.2914 0.0 0.0 

794 ........... No ............ No ............ 15 MED ......... Neonate w other significant problems 1.1650 0.0 0.0 

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 blood & blood 

forming organs w MCC.

3.3539 8.9 12.2 

803 ........... No ............ No ............ 16 SURG ...... Other O.R. proc of the blood & blood 

forming organs w CC.

1.7689 4.7 6.7 

804 ........... No ............ No ............ 16 SURG ...... Other O.R. proc of the blood & blood 

forming organs w/o CC/MCC.

1.0613 2.5 3.4 

808 ........... No ............ No ............ 16 MED ......... Major hematol/immun diag exc sickle 

cell crisis & coagul w MCC.

1.9850 6.3 8.2 

809 ........... No ............ No ............ 16 MED ......... Major hematol/immun diag exc sickle 

cell crisis & coagul w CC.

1.1737 4.2 5.3 

810 ........... No ............ No ............ 16 MED ......... Major hematol/immun diag exc sickle 

cell crisis & coagul w/o CC/MCC.

0.8957 3.2 4.0 

811 ........... No ............ No ............ 16 MED ......... Red blood cell disorders w MCC ........ 1.2742 4.0 5.7 

812 ........... No ............ No ............ 16 MED ......... Red blood cell disorders w/o MCC ..... 0.7629 2.8 3.7 

813 ........... No ............ No ............ 16 MED ......... Coagulation disorders ......................... 1.3556 3.7 5.1 

814 ........... No ............ No ............ 16 MED ......... Reticuloendothelial & immunity disorders w MCC.1.4932 5.0 6.7 

815 ........... No ............ No ............ 16 MED ......... Reticuloendothelial & immunity disorders w CC.0.9973 3.8 5.0 

816 ........... No ............ No ............ 16 MED ......... Reticuloendothelial & immunity disorders w/o CC/MCC.0.6989 2.8 3.5 

820 ........... No ............ No ............ 17 SURG ...... Lymphoma & leukemia w major O.R. 

procedure w MCC.

5.6401 13.3 17.7 

821 ........... No ............ No ............ 17 SURG ...... Lymphoma & leukemia w major O.R. 

procedure w CC.

2.2489 5.5 7.9 

822 ........... No ............ No ............ 17 SURG ...... Lymphoma & leukemia w major O.R. 

procedure w/o CC/MCC.

1.2399 2.6 3.5 

823 ........... No ............ No ............ 17 SURG ...... Lymphoma & non-acute leukemia w 

other O.R. proc w MCC.

4.0990 12.1 15.4 

824 ........... No ............ No ............ 17 SURG ...... Lymphoma & non-acute leukemia w 

other O.R. proc w CC.

2.1791 6.6 8.7 

825 ........... No ............ No ............ 17 SURG ...... Lymphoma & non-acute leukemia w 

other O.R. proc w/o CC/MCC.

1.2059 3.0 4.3 

826 ........... No ............ No ............ 17 SURG ...... Myeloprolif disord or poorly diff neopl 

w maj O.R. proc w MCC.

4.6385 11.1 15.0 

827 ........... No ............ No ............ 17 SURG ...... Myeloprolif disord or poorly diff neopl 

w maj O.R. proc w CC.

2.2759 5.9 8.0 


jlentini on PROD1PC65 with PROPOSALS2
23836 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

828 ........... No ............ No ............ 17 SURG ...... Myeloprolif disord or poorly diff neopl 

w maj O.R. proc w/o CC/MCC.

1.3050 3.0 3.8 

829 ........... No ............ No ............ 17 SURG ...... Myeloprolif disord or poorly diff neopl 

w other O.R. proc w CC/MCC.

2.8972 7.0 10.7 

830 ........... No ............ No ............ 17 SURG ...... Myeloprolif disord or poorly diff neopl 

w other O.R. proc w/o CC/MCC.

1.0802 2.5 3.7 

834 ........... No ............ No ............ 17 MED ......... Acute leukemia w/o major O.R. procedure w MCC.4.5854 9.5 15.5 

835 ........... No ............ No ............ 17 MED ......... Acute leukemia w/o major O.R. procedure w CC.2.5840 6.2 10.4 

836 ........... No ............ No ............ 17 MED ......... Acute leukemia w/o major O.R. procedure w/o CC/MCC.1.2085 3.4 5.2 

837 ........... No ............ No ............ 17 MED ......... Chemo w acute leukemia as sdx or w 

high dose chemo agent w MCC.

6.4047 17.6 23.1 

838 ........... No ............ No ............ 17 MED ......... Chemo w acute leukemia as sdx w 

CC or high dose chemo agent.

2.9669 7.9 12.3 

839 ........... No ............ No ............ 17 MED ......... Chemo w acute leukemia as sdx w/o 

CC/MCC.

1.4181 5.0 6.4 

840 ........... Yes .......... No ............ 17 MED ......... Lymphoma & non-acute leukemia w 

MCC.

2.6031 7.7 10.4 

841 ........... Yes .......... No ............ 17 MED ......... Lymphoma & non-acute leukemia w 

CC.

1.5529 5.2 6.9 

842 ........... Yes .......... No ............ 17 MED ......... Lymphoma & non-acute leukemia w/o 

CC/MCC.

1.0261 3.4 4.6 

843 ........... No ............ No ............ 17 MED ......... Other myeloprolif dis or poorly diff 

neopl diag w MCC.

1.8203 6.1 8.5 

844 ........... No ............ No ............ 17 MED ......... Other myeloprolif dis or poorly diff 

neopl diag w CC.

1.2030 4.6 6.1 

845 ........... No ............ No ............ 17 MED ......... Other myeloprolif dis or poorly diff 

neopl diag w/o CC/MCC.

0.8143 3.3 4.3 

846 ........... No ............ No ............ 17 MED ......... Chemotherapy w/o acute leukemia as 

secondary diagnosis w MCC.

2.1299 5.8 8.4 

847 ........... No ............ No ............ 17 MED ......... Chemotherapy w/o acute leukemia as 

secondary diagnosis w CC.

0.9436 2.7 3.4 

848 ........... No ............ No ............ 17 MED ......... Chemotherapy w/o acute leukemia as 

secondary diagnosis w/o CC/MCC.

0.7995 2.5 3.1 

849 ........... No ............ No ............ 17 MED ......... Radiotherapy ....................................... 1.2021 4.4 6.0 

853 ........... Yes .......... No ............ 18 SURG ...... Infectious & parasitic diseases w O.R. 

procedure w MCC.

5.4286 12.7 16.7 

854 ........... Yes .......... No ............ 18 SURG ...... Infectious & parasitic diseases w O.R. 

procedure w CC.

2.9171 9.1 11.1 

855 ........... Yes .......... No ............ 18 SURG ...... Infectious & parasitic diseases w O.R. 

procedure w/o CC/MCC.

1.8093 5.6 7.0 

856 ........... Yes .......... No ............ 18 SURG ...... Postoperative or post-traumatic infections w O.R. proc w MCC.4.7315 11.5 15.4 

857 ........... Yes .......... No ............ 18 SURG ...... Postoperative or post-traumatic infections w O.R. proc w CC.2.0472 6.6 8.5 

858 ........... Yes .......... No ............ 18 SURG ...... Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC.1.3563 4.5 5.7 

862 ........... Yes .......... No ............ 18 MED ......... Postoperative & post-traumatic infections w MCC.1.9123 6.1 8.2 

863 ........... Yes .......... No ............ 18 MED ......... Postoperative & post-traumatic infections w/o MCC.0.9575 4.2 5.2 

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 & parasitic diseases 

diagnoses w MCC.

2.3423 7.0 9.6 

868 ........... Yes .......... No ............ 18 MED ......... Other infectious & parasitic diseases 

diagnoses w CC.

1.0761 4.5 5.8 

869 ........... Yes .......... No ............ 18 MED ......... Other infectious & parasitic diseases 

diagnoses w/o CC/MCC.

0.7628 3.5 4.3 

870 ........... Yes .......... No ............ 18 MED ......... Septicemia or severe sepsis w MV 

96+ hours.

5.7422 12.9 15.5 

871 ........... Yes .......... No ............ 18 MED ......... Septicemia or severe sepsis w/o MV 

96+ hours w MCC.

1.8211 5.5 7.5 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23837 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

872 ........... Yes .......... No ............ 18 MED ......... Septicemia or severe sepsis w/o MV 

96+ hours w/o MCC.

1.1188 4.7 5.7 

876 ........... No ............ No ............ 19 SURG ...... O.R. procedure w principal diagnoses 

of mental illness.

2.4279 7.8 11.9 

880 ........... No ............ No ............ 19 MED ......... Acute adjustment reaction & psychosocial dysfunction.0.5867 2.4 3.2 

881 ........... No ............ No ............ 19 MED ......... Depressive neuroses ........................... 0.5784 3.1 4.2 

882 ........... No ............ No ............ 19 MED ......... Neuroses except depressive ............... 0.6086 3.1 4.4 

883 ........... No ............ No ............ 19 MED ......... Disorders of personality & impulse 

control.

1.0102 4.4 7.4 

884 ........... Yes .......... No ............ 19 MED ......... Organic disturbances & mental retardation.0.8923 4.1 5.5 

885 ........... No ............ No ............ 19 MED ......... Psychoses ........................................... 0.8380 5.5 7.6 

886 ........... No ............ No ............ 19 MED ......... Behavioral & developmental disorders 0.7479 4.0 6.1 

887 ........... No ............ No ............ 19 MED ......... Other mental disorder diagnoses ........ 0.7275 3.0 4.6 

894 ........... No ............ No ............ 20 MED ......... Alcohol/drug abuse or dependence, 

left ama.

0.3842 2.1 3.0 

895 ........... No ............ No ............ 20 MED ......... Alcohol/drug abuse or dependence w 

rehabilitation therapy.

0.8727 8.1 10.5 

896 ........... Yes .......... No ............ 20 MED ......... Alcohol/drug abuse or dependence w/ 

o rehabilitation therapy w MCC.

1.3787 4.8 6.6 

897 ........... Yes .......... No ............ 20 MED ......... Alcohol/drug abuse or dependence w/ 

o rehabilitation therapy w/o MCC.

0.6152 3.3 4.1 

901 ........... No ............ No ............ 21 SURG ...... Wound debridements for injuries w 

MCC.

3.8708 9.9 15.1 

902 ........... No ............ No ............ 21 SURG ...... Wound debridements for injuries w 

CC.

1.6889 5.5 7.7 

903 ........... No ............ No ............ 21 SURG ...... Wound debridements for injuries w/o 

CC/MCC.

0.9976 3.4 4.6 

904 ........... No ............ No ............ 21 SURG ...... Skin grafts for injuries w CC/MCC ...... 2.9204 7.0 11.2 

905 ........... No ............ No ............ 21 SURG ...... Skin grafts for injuries w/o CC/MCC ... 1.1156 3.4 4.7 

906 ........... No ............ No ............ 21 SURG ...... Hand procedures for injuries ............... 0.9941 2.1 3.1 

907 ........... Yes .......... No ............ 21 SURG ...... Other O.R. procedures for injuries w 

MCC.

3.6871 8.0 11.6 

908 ........... Yes .......... No ............ 21 SURG ...... Other O.R. procedures for injuries w 

CC.

1.9162 4.9 6.8 

909 ........... Yes .......... No ............ 21 SURG ...... Other O.R. procedures for injuries w/o 

CC/MCC.

1.1372 2.7 3.6 

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 MCC ................. 0.4409 1.7 2.1 

917 ........... Yes .......... No ............ 21 MED ......... Poisoning & toxic effects of drugs w 

MCC.

1.4143 3.7 5.2 

918 ........... Yes .......... No ............ 21 MED ......... Poisoning & toxic effects of drugs w/o 

MCC.

0.5809 2.1 2.7 

919 ........... No ............ No ............ 21 MED ......... Complications of treatment w MCC .... 1.5200 4.5 6.4 

920 ........... No ............ No ............ 21 MED ......... Complications of treatment w CC ....... 0.9220 3.3 4.4 

921 ........... No ............ No ............ 21 MED ......... Complications of treatment w/o CC/ 

MCC.

0.6097 2.3 3.0 

922 ........... No ............ No ............ 21 MED ......... Other injury, poisoning & toxic effect 

diag w MCC.

1.3580 4.1 6.0 

923 ........... No ............ No ............ 21 MED ......... Other injury, poisoning & toxic effect 

diag w/o MCC.

0.6142 2.4 3.2 

927 ........... No ............ No ............ 22 SURG ...... Extensive burns or full thickness 

burns w MV 96+ hrs w skin graft.

14.0060 23.4 31.1 

928 ........... No ............ No ............ 22 SURG ...... Full thickness burn w skin graft or 

inhal inj w CC/MCC.

5.0621 11.7 16.0 

929 ........... No ............ No ............ 22 SURG ...... Full thickness burn w skin graft or 

inhal inj w/o CC/MCC.

2.1574 5.3 7.7 

933 ........... No ............ No ............ 22 MED ......... Extensive burns or full thickness 

burns w MV 96+ hrs w/o skin graft.

2.1246 2.3 4.3 

934 ........... No ............ No ............ 22 MED ......... Full thickness burn w/o skin grft or 

inhal inj.

1.2949 4.4 6.2 

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 other contact w health services w MCC.2.6570 6.6 10.1 


jlentini on PROD1PC65 with PROPOSALS2
23838 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, 

AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued 

MS–DRG 

FY 2009 

proposed 

rule postacute DRG 

FY 2009 

proposed 

rule 

special pay 

DRG 

MDC Type MS–DRG title Weights Geometric 

mean LOS 

Arithmetic 

mean LOS 

940 ........... No ............ No ............ 23 SURG ...... O.R. proc w diagnoses of other contact w health services w CC.1.6379 3.6 5.4 

941 ........... No ............ No ............ 23 SURG ...... O.R. proc w diagnoses of other contact w health services w/o CC/MCC.1.0782 2.1 2.7 

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 health status 0.7442 2.2 4.7 

955 ........... No ............ No ............ 24 SURG ...... Craniotomy for multiple significant 

trauma.

5.0969 8.6 12.3 

956 ........... Yes .......... No ............ 24 SURG ...... Limb reattachment, hip & femur proc 

for multiple significant trauma.

3.5263 7.6 9.3 

957 ........... No ............ No ............ 24 SURG ...... Other O.R. procedures for multiple 

significant trauma w MCC.

6.0787 10.2 14.9 

958 ........... No ............ No ............ 24 SURG ...... Other O.R. procedures for multiple 

significant trauma w CC.

3.6129 8.0 10.4 

959 ........... No ............ No ............ 24 SURG ...... Other O.R. procedures for multiple 

significant trauma w/o CC/MCC.

2.3808 4.9 6.3 

963 ........... No ............ No ............ 24 MED ......... Other multiple significant trauma w 

MCC.

2.8713 6.7 9.5 

964 ........... No ............ No ............ 24 MED ......... Other multiple significant trauma w 

CC.

1.6024 4.9 6.2 

965 ........... No ............ No ............ 24 MED ......... Other multiple significant trauma w/o 

CC/MCC.

0.9832 3.4 4.1 

969 ........... No ............ No ............ 25 SURG ...... HIV w extensive O.R. procedure w 

MCC.

5.3749 12.9 18.8 

970 ........... No ............ No ............ 25 SURG ...... HIV w extensive O.R. procedure w/o 

MCC.

2.4892 6.5 9.8 

974 ........... No ............ No ............ 25 MED ......... HIV w major related condition w MCC 2.5595 7.3 10.4 

975 ........... No ............ No ............ 25 MED ......... HIV w major related condition w CC ... 1.3571 5.3 7.0 

976 ........... No ............ No ............ 25 MED ......... HIV w major related condition w/o CC/ 

MCC.

0.8910 3.8 4.9 

977 ........... No ............ No ............ 25 MED ......... HIV w or w/o other related condition .. 1.0965 3.9 5.3 

981 ........... Yes .......... No ............ ........ SURG ...... Extensive O.R. procedure unrelated to 

principal diagnosis w MCC.

5.0175 11.7 15.1 

982 ........... Yes .......... No ............ ........ SURG ...... Extensive O.R. procedure unrelated to 

principal diagnosis w CC.

3.0780 7.5 9.7 

983 ........... Yes .......... No ............ ........ SURG ...... Extensive O.R. procedure unrelated to 

principal diagnosis w/o CC/MCC.

1.9959 3.9 5.4 

984 ........... No ............ No ............ ........ SURG ...... Prostatic O.R. procedure unrelated to 

principal diagnosis w MCC.

3.3256 11.8 14.6 

985 ........... No ............ No ............ ........ SURG ...... Prostatic O.R. procedure unrelated to 

principal diagnosis w CC.

2.2113 7.3 9.7 

986 ........... No ............ No ............ ........ SURG ...... Prostatic O.R. procedure unrelated to 

principal diagnosis w/o CC/MCC.

1.2767 3.5 5.3 

987 ........... Yes .......... No ............ ........ SURG ...... Non-extensive O.R. proc unrelated to 

principal diagnosis w MCC.

3.4336 9.8 13.0 

988 ........... Yes .......... No ............ ........ SURG ...... Non-extensive O.R. proc unrelated to 

principal diagnosis w CC.

1.8752 5.8 7.8 

989 ........... Yes .......... No ............ ........ SURG ...... Non-extensive O.R. proc unrelated to 

principal diagnosis w/o CC/MCC.

1.1032 2.9 4.1 

998 ........... No ............ No ............ ........ ** .............. Principal diagnosis invalid as discharge diagnosis.0.0000 0.0 0.0 

999 ........... No ............ No ............ ........ ** .............. Ungroupable ........................................ 0.0000 0.0 0.0 

MS–DRGs 998 and 999 contain cases that could not be assigned to valid DRGs. 

NOTE: If there is no value in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to obtain a meaningful computation of these statistics. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23839 

TABLE 6A.—NEW DIAGNOSIS CODES

Diagnosis 

code Description CC MDC MS–DRG 

046.11 ...... Variant Creutzfeldt-Jakob disease .............................................................................................. CC .... 01 056, 057 

046.19 ...... Other and unspecified Creutzfeldt-Jakob disease ...................................................................... CC .... 01 056, 057 

046.71 ...... Gerstmann-Stra ̈ussler-Scheinker syndrome ............................................................................... CC .... 01 056, 057 

25 974, 975, 976 

046.72 ...... Fatal familial insomnia ................................................................................................................. CC .... 01 056, 057 

25 974, 975, 976 

046.79 ...... Other and unspecified prion disease of central nervous system ................................................ CC .... 01 056, 057 

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, unspecified ........................................................................................... N ....... 18 865, 866 

059.01 ...... Monkeypox .................................................................................................................................. CC .... 18 865, 866 

059.09 ...... Other orthopoxvirus infections ..................................................................................................... N ....... 18 865, 866 

059.10 ...... Parapoxvirus infection, unspecified ............................................................................................. N ....... 18 865, 866 

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, unspecified ............................................................................................. N ....... 18 865, 866 

059.8 ........ Other poxvirus infections ............................................................................................................. N ....... 18 865, 866 

059.9 ........ Poxvirus infections, unspecified .................................................................................................. N ....... 18 865, 866 

078.12 ...... Plantar wart ................................................................................................................................. N ....... 09 606, 607 

136.21 ...... Specific infection due to acanthamoeba ..................................................................................... N ....... 18 867, 868, 869 

136.29 ...... Other specific infections by free-living amebae .......................................................................... CC .... 18 867, 868, 869 

199.2 ........ Malignant neoplasm associated with transplant organ ............................................................... CC .... 17 843, 844, 845 

203.02 ...... Multiple myeloma, in relapse ....................................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

203.12 ...... Plasma cell leukemia, in relapse ................................................................................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

203.82 ...... Other immunoproliferative neoplasms, in relapse ....................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.02 ...... Acute lymphoid leukemia, in relapse .......................................................................................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

204.12 ...... Chronic lymphoid leukemia, in relapse ....................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.22 ...... Subacute lymphoid leukemia, in relapse .................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.82 ...... Other lymphoid leukemia, in relapse ........................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.92 ...... Unspecified lymphoid leukemia, in relapse ................................................................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.02 ...... Acute myeloid leukemia, in relapse ............................................................................................ CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

205.12 ...... Chronic myeloid leukemia, in relapse ......................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.22 ...... Subacute myeloid leukemia, in relapse ...................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

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 relapse ............................................................................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.92 ...... Unspecified myeloid leukemia, in relapse ................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 


jlentini on PROD1PC65 with PROPOSALS2
23840 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

206.02 ...... Acute monocytic leukemia, in relapse ......................................................................................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

206.12 ...... Chronic monocytic leukemia, in relapse ..................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.22 ...... Subacute monocytic leukemia, in relapse ................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.82 ...... Other monocytic leukemia, in relapse ......................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.92 ...... Unspecified monocytic leukemia, in relapse ............................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.02 ...... Acute erythremia and erythroleukemia, in relapse ..................................................................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

207.12 ...... Chronic erythremia, in relapse .................................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.22 ...... Megakaryocytic leukemia, in relapse .......................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.82 ...... Other specified leukemia, in relapse ........................................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.02 ...... Acute leukemia of unspecified cell type, in relapse .................................................................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

208.12 ...... Chronic leukemia of unspecified cell type, in relapse ................................................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.22 ...... Subacute leukemia of unspecified cell type, in relapse .............................................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.82 ...... Other leukemia of unspecified cell type, in relapse .................................................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.92 ...... Unspecified leukemia, in relapse ................................................................................................ CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

209.00 ...... Malignant carcinoid tumor of the small intestine, unspecified portion ........................................ CC .... 06 374, 375, 376 

209.01 ...... Malignant carcinoid tumor of the duodenum ............................................................................... CC .... 06 374, 375, 376 

209.02 ...... Malignant carcinoid tumor of the jejunum ................................................................................... CC .... 06 374, 375, 376 

209.03 ...... Malignant carcinoid tumor of the ileum ....................................................................................... CC .... 06 374, 375, 376 

209.10 ...... Malignant carcinoid tumor of the large intestine, unspecified portion ........................................ CC .... 06 374, 375, 376 

209.11 ...... Malignant carcinoid tumor of the appendix ................................................................................. CC .... 06 338, 339, 340, 

374, 375, 376 

209.12 ...... Malignant carcinoid tumor of the cecum ..................................................................................... CC .... 06 374, 375, 376 

209.13 ...... Malignant carcinoid tumor of the ascending colon ..................................................................... CC .... 06 374, 375, 376 

209.14 ...... Malignant carcinoid tumor of the transverse colon ..................................................................... CC .... 06 374, 375, 376 

209.15 ...... Malignant carcinoid tumor of the descending colon ................................................................... CC .... 06 374, 375, 376 

209.16 ...... Malignant carcinoid tumor of the sigmoid colon ......................................................................... CC .... 06 374, 375, 376 

209.17 ...... Malignant carcinoid tumor of the rectum ..................................................................................... CC .... 06 374, 375, 376 

209.20 ...... Malignant carcinoid tumor of unknown primary site ................................................................... CC .... 17 843, 844, 845 

209.21 ...... Malignant carcinoid tumor of the bronchus and lung .................................................................. CC .... 04 180, 181, 182 

209.22 ...... Malignant carcinoid tumor of the thymus .................................................................................... CC .... 17 843, 844, 845 

209.23 ...... Malignant carcinoid tumor of the stomach .................................................................................. CC .... 06 374, 375, 376 

209.24 ...... Malignant carcinoid tumor of the kidney ..................................................................................... CC .... 11 656, 657, 658, 

686, 687, 688 

209.25 ...... Malignant carcinoid tumor of foregut, not otherwise specified ................................................... CC .... 06 374, 375, 376 

209.26 ...... Malignant carcinoid tumor of midgut, not otherwise specified .................................................... CC .... 06 374, 375, 376 

209.27 ...... Malignant carcinoid tumor of hindgut, not otherwise specified ................................................... CC .... 06 374, 375, 376 

209.29 ...... Malignant carcinoid tumor of other sites ..................................................................................... CC .... 17 843, 844, 845 

209.30 ...... Malignant poorly differentiated neuroendocrine carcinoma, any site ......................................... CC .... 17 843, 844, 845 

209.40 ...... Benign carcinoid tumor of the small intestine, unspecified portion ............................................ N ....... 06 393, 394, 395 

209.41 ...... Benign carcinoid tumor of the duodenum ................................................................................... N ....... 06 393, 394, 395 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23841 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

209.42 ...... Benign carcinoid tumor of the jejunum ....................................................................................... N ....... 06 393, 394, 395 

209.43 ...... Benign carcinoid tumor of the ileum ........................................................................................... N ....... 06 393, 394, 395 

209.50 ...... Benign carcinoid tumor of the large intestine, unspecified portion ............................................. N ....... 06 393, 394, 395 

209.51 ...... Benign carcinoid tumor of the appendix ..................................................................................... N ....... 06 393, 394, 395 

209.52 ...... Benign carcinoid tumor of the cecum ......................................................................................... N ....... 06 393, 394, 395 

209.53 ...... Benign carcinoid tumor of the ascending colon .......................................................................... N ....... 06 393, 394, 395 

209.54 ...... Benign carcinoid tumor of the transverse colon ......................................................................... N ....... 06 393, 394, 395 

209.55 ...... Benign carcinoid tumor of the descending colon ........................................................................ N ....... 06 393, 394, 395 

209.56 ...... Benign carcinoid tumor of the sigmoid colon .............................................................................. N ....... 06 393, 394, 395 

209.57 ...... Benign carcinoid tumor of the rectum ......................................................................................... N ....... 06 393, 394, 395 

209.60 ...... Benign carcinoid tumor of unknown primary site ........................................................................ N ....... 17 843, 844, 845 

209.61 ...... Benign carcinoid tumor of the bronchus and lung ...................................................................... N ....... 04 180, 181, 182 

209.62 ...... Benign carcinoid tumor of the thymus ........................................................................................ N ....... 16 814, 815, 816 

209.63 ...... Benign carcinoid tumor of the stomach ...................................................................................... N ....... 06 393, 394, 395 

209.64 ...... Benign carcinoid tumor of the kidney .......................................................................................... N ....... 11 656, 657, 658, 

686, 687, 688 

209.65 ...... Benign carcinoid tumor of foregut, not otherwise specified ........................................................ N ....... 06 393, 394, 395 

209.66 ...... Benign carcinoid tumor of midgut, not otherwise specified ........................................................ N ....... 06 393, 394, 395 

209.67 ...... Benign carcinoid tumor of hindgut, not otherwise specified ....................................................... N ....... 06 393, 394, 395 

209.69 ...... Benign carcinoid tumor of other sites ......................................................................................... N ....... 17 843, 844, 845 

238.77 ...... Post-transplant lymphoproliferative disorder (PTLD) .................................................................. CC .... 21 919, 920, 921 

249.00 ...... Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or 

unspecified.

N ....... PRE 

10 

008, 010 

637, 638, 639 

249.01 ...... Secondary diabetes mellitus without mention of complication, uncontrolled .............................. N ....... PRE 

10 

008, 010 

637, 638, 639 

249.10 ...... Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified ...... MCC PRE 

10 

008, 010 

637, 638, 639 

249.11 ...... Secondary diabetes mellitus with ketoacidosis, uncontrolled ..................................................... MCC PRE 

10 

008, 010 

637, 638, 639, 

249.20 ...... Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified MCC PRE 

10 

008, 010 

637, 638, 639 

249.21 ...... Secondary diabetes mellitus with hyperosmolarity, uncontrolled ............................................... MCC PRE

10 

008, 010 

637, 638, 639 

249.30 ...... Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified ........ MCC PRE 

10 

008, 010 

637, 638, 639 

249.31 ...... Secondary diabetes mellitus with other coma, uncontrolled ....................................................... MCC PRE 

10 

008, 010 

637, 638, 639 

249.40 ...... Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified.N ....... PRE 

11 

008, 010 

698, 699, 700 

249.41 ...... Secondary diabetes mellitus with renal manifestations, uncontrolled ........................................ N ....... PRE 

11 

008, 010 

698, 699, 700 

249.50 ...... Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or 

unspecified.

N ....... PRE 

02 

008, 010 

124, 125 

249.51 ...... Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled ............................... N ....... PRE 

02 

008, 010 

124, 125 

249.60 ...... Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or 

unspecified.

N ....... PRE 

01 

008, 010 

073, 074 

249.61 ...... Secondary diabetes mellitus with neurological manifestations, uncontrolled ............................. N ....... PRE 

01 

008, 010 

073, 074 

249.70 ...... Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, 

or unspecified.

N ....... PRE 

05 

008, 010 

299, 300, 301 

249.71 ...... Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled ....................... N ....... PRE 

05 

008, 010 

299, 300, 301 

249.80 ...... Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, 

or unspecified.

N ....... PRE 

10 

008, 010 

637, 638, 639 

249.81 ...... Secondary diabetes mellitus with other specified manifestations, uncontrolled ......................... N ....... PRE 

10 

008, 010 

637, 638, 639 

249.90 ...... Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified.N ....... PRE 

10 

008, 010 

637, 638, 639 

249.91 ...... Secondary diabetes mellitus with unspecified complication, uncontrolled ................................. N ....... PRE

10 

008, 010 

637, 638, 639 

259.50 ...... Androgen insensitivity, unspecified ............................................................................................. N ....... 10 643, 644, 645 

259.51 ...... Androgen insensitivity syndrome ................................................................................................. N ....... 10 643, 644, 645 

259.52 ...... Partial androgen insensitivity ....................................................................................................... N ....... 10 643, 644, 645 

275.5 ........ Hungry bone syndrome ............................................................................................................... N ....... 10 640, 641 

279.50 ...... Graft-versus-host disease, unspecified ....................................................................................... CC .... 16 808, 809, 810 

279.51 ...... Acute graft-versus-host disease .................................................................................................. CC .... 16 808, 809, 810 

279.52 ...... Chronic graft-versus-host disease ............................................................................................... CC .... 16 808, 809, 810 

279.53 ...... Acute on chronic graft-versus-host disease ................................................................................ CC .... 16 808, 809, 810 

289.84 ...... Heparin-induced thrombocytopenia (HIT) ................................................................................... N ....... 15 791 2, 793 2

16 813 


jlentini on PROD1PC65 with PROPOSALS2
23842 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

25 977 

337.00 ...... Idiopathic peripheral autonomic neuropathy, unspecified ........................................................... N ....... 01 073, 074 

337.01 ...... Carotid sinus syndrome ............................................................................................................... N ....... 01 073, 074 

337.09 ...... Other idiopathic peripheral autonomic neuropathy ..................................................................... N ....... 01 073, 074 

339.00 ...... Cluster headache syndrome, unspecified ................................................................................... N ....... 01 102, 103 

339.01 ...... Episodic cluster headache .......................................................................................................... N ....... 01 102, 103 

339.02 ...... Chronic cluster headache ............................................................................................................ N ....... 01 102, 103 

339.03 ...... Episodic paroxysmal hemicrania ................................................................................................. N ....... 01 102, 103 

339.04 ...... Chronic paroxysmal hemicrania .................................................................................................. N ....... 01 102, 103 

339.05 ...... Short lasting unilateral neuralgiform headache with conjunctival injection and tearing ............. N ....... 01 102, 103 

339.09 ...... Other trigeminal autonomic cephalgias ....................................................................................... N ....... 01 102, 103 

339.10 ...... Tension type headache, unspecified ........................................................................................... N ....... 01 102, 103 

339.11 ...... Episodic tension type headache ................................................................................................. N ....... 01 102, 103 

339.12 ...... Chronic tension type headache ................................................................................................... N ....... 01 102, 103 

339.20 ...... Post-traumatic headache, unspecified ........................................................................................ N ....... 01 102, 103 

339.21 ...... Acute post-traumatic headache ................................................................................................... N ....... 01 102, 103 

339.22 ...... Chronic post-traumatic headache ............................................................................................... N ....... 01 102, 103 

339.3 ........ Drug induced headache, not elsewhere classified ..................................................................... N ....... 01 102, 103 

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 syndrome ..................................................................................... N ....... 01 102, 103 

339.81 ...... Hypnic headache ......................................................................................................................... N ....... 01 102, 103 

339.82 ...... Headache associated with sexual activity ................................................................................... N ....... 01 102, 103 

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 mention of intractable migraine with status migrainosus ............... N ....... 01 102, 103 

346.03 ...... Migraine with aura, with intractable migraine, so stated, with status migrainosus ..................... N ....... 01 102, 103 

346.12 ...... Migraine without aura, without mention of intractable migraine with status migrainosus .......... N ....... 01 102, 103

346.13 ...... Migraine without aura, with intractable migraine, so stated, with status migrainosus ................ N ....... 01 102, 103 

346.22 ...... Variants of migraine, not elsewhere classified, without mention of intractable migraine with 

status migrainosus.

N ....... 01 102, 103 

346.23 ...... Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status migrainosus.N ....... 01 102, 103 

346.30 ...... Hemiplegic migraine, without mention of intractable migraine without mention of status 

migrainosus.

N ....... 01 102, 103 

346.31 ...... Hemiplegic migraine, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

346.32 ...... Hemiplegic migraine, without mention of intractable migraine with status migrainosus ............ N ....... 01 102, 103

346.33 ...... Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus .................. N ....... 01 102, 103 

346.40 ...... Menstrual migraine, without mention of intractable migraine without mention of status 

migrainosus.

N ....... 01 102, 103 

346.41 ...... Menstrual migraine, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

346.42 ...... Menstrual migraine, without mention of intractable migraine with status migrainosus .............. N ....... 01 102, 103 

346.43 ...... Menstrual migraine, with intractable migraine, so stated, with status migrainosus .................... N ....... 01 102, 103 

346.50 ...... Persistent migraine aura without cerebral infarction, without mention of intractable migraine 

without mention of status migrainosus.

N ....... 01 102, 103 

346.51 ...... Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus.N ....... 01 102, 103 

346.52 ...... Persistent migraine aura without cerebral infarction, without mention of intractable migraine 

with status migrainosus.

N ....... 01 102, 103 

346.53 ...... Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with 

status migrainosus.

N ....... 01 102, 103 

346.60 ...... Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus.CC .... 01 102, 103 

346.61 ...... Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without 

mention of status migrainosus.

CC .... 01 102, 103 

346.62 ...... Persistent migraine aura with cerebral infarction, without mention of intractable migraine with 

status migrainosus.

CC .... 01 102, 103 

346.63 ...... Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with 

status migrainosus.

CC .... 01 102, 103 

346.70 ...... Chronic migraine without aura, without mention of intractable migraine without mention of 

status migrainosus.

N ....... 01 102, 103 

346.71 ...... Chronic migraine without aura, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

346.72 ...... Chronic migraine without aura, without mention of intractable migraine with status 

migrainosus.

N ....... 01 102, 103 

346.73 ...... Chronic migraine without aura, with intractable migraine, so stated, with status migrainosus .. N ....... 01 102, 103 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23843 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

346.82 ...... Other forms of migraine, without mention of intractable migraine with status migrainosus ....... N ....... 01 102, 103 

346.83 ...... Other forms of migraine, with intractable migraine, so stated, with status migrainosus ............ N ....... 01 102, 103 

362.20 ...... Retinopathy of prematurity, unspecified ...................................................................................... N ....... 02 124, 125 

362.22 ...... Retinopathy of prematurity, stage 0 ............................................................................................ N ....... 02 124, 125 

362.23 ...... Retinopathy of prematurity, stage 1 ............................................................................................ N ....... 02 124, 125 

362.24 ...... Retinopathy of prematurity, stage 2 ............................................................................................ N ....... 02 124, 125 

362.25 ...... Retinopathy of prematurity, stage 3 ............................................................................................ N ....... 02 124, 125 

362.26 ...... Retinopathy of prematurity, stage 4 ............................................................................................ N ....... 02 124, 125 

362.27 ...... Retinopathy of prematurity, stage 5 ............................................................................................ N ....... 02 124, 125 

364.82 ...... Plateau iris syndrome .................................................................................................................. N ....... 02 124, 125 

372.34 ...... Pingueculitis ................................................................................................................................. N ....... 02 124, 125 

414.3 ........ Coronary atherosclerosis due to lipid rich plaque ....................................................................... N ....... 05 302, 303 

511.81 ...... Malignant pleural effusion ........................................................................................................... CC .... 04 180, 181, 182 

511.89 ...... Other specified forms of effusion, except tuberculous ................................................................ CC .... 04 186, 187, 188 

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 breast implant ....................................................................................... N ....... 09 600, 601 

611.89 ...... Other specified disorders of breast ............................................................................................. N ....... 09 600, 601 

612.0 ........ Deformity of reconstructed breast ............................................................................................... N ....... 09 600, 601 

612.1 ........ Disproportion of reconstructed breast ......................................................................................... N ....... 09 600, 601 

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, unspecified as to episode of care or not applicable .................................. CC .... 14 998 

649.71 ...... Cervical shortening, delivered, with or without mention of antepartum condition ...................... CC .... 14 765, 766, 767, 

768, 774, 775 

649.73 ...... Cervical shortening, antepartum condition or complication ........................................................ CC .... 14 781, 782 

678.00 ...... Fetal hematologic conditions, unspecified as to episode of care or not applicable ................... N ....... 14 998 

678.01 ...... Fetal hematologic conditions, delivered, with or without mention of antepartum condition ....... N ....... 14 765, 766, 767, 

768, 774, 775 

678.03 ...... Fetal hematologic conditions, antepartum condition or complication ......................................... N ....... 14 781, 782 

678.10 ...... Fetal conjoined twins, unspecified as to episode of care or not applicable ............................... N ....... 14 998 

678.11 ...... Fetal conjoined twins, delivered, with or without mention of antepartum condition ................... N ....... 14 765, 766, 767, 

768, 774, 775 

678.13 ...... Fetal conjoined twins, antepartum condition or complication ..................................................... N ....... 14 781, 782 

679.00 ...... Maternal complications from in utero procedure, unspecified as to episode of care or not applicable.N ....... 14 765, 766, 767, 

768, 774, 775 

679.01 ...... Maternal complications from in utero procedure, delivered, with or without mention of 

antepartum condition.

N ....... 14 765, 766, 767, 

768, 774 

679.02 ...... Maternal complications from in utero procedure, delivered, with mention of postpartum complication.N ....... 14 765, 766, 767, 

768, 774 

679.03 ...... Maternal complications from in utero procedure, antepartum condition or complication ........... N ....... 14 781, 782 

679.04 ...... Maternal complications from in utero procedure, postpartum condition or complication ........... N ....... 14 769, 776 

679.10 ...... Fetal complications from in utero procedures, unspecified as to episode of care or not applicable.N ....... 14 998 

679.11 ...... Fetal complications from in utero procedures, delivered, with or without mention of 

antepartum condition.

N ....... 14 765, 766, 767, 

768, 774, 775 

679.12 ...... Fetal complications from in utero procedures, delivered, with mention of postpartum complication.N ....... 14 765, 766, 767, 

768, 774, 775 

679.13 ...... Fetal complications from in utero procedures, antepartum condition or complication ............... N ....... 14 781, 782 

679.14 ...... Fetal complications from in utero procedures, postpartum condition or complication ............... N ....... 14 769, 776 

695.10 ...... Erythema multiforme, unspecified ............................................................................................... N ....... 09 595, 596 

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-toxic epidermal necrolysis overlap syndrome ............................... CC .... 09 595, 596 

695.15 ...... Toxic epidermal necrolysis .......................................................................................................... CC .... 09 595, 596 

695.19 ...... Other erythema multiforme .......................................................................................................... N ....... 09 595, 596 

695.50 ...... Exfoliation due to erythematous condition involving less than 10 percent of body surface ....... N ....... 09 606, 607 


jlentini on PROD1PC65 with PROPOSALS2
23844 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

695.51 ...... Exfoliation due to erythematous condition involving 10–19 percent of body surface ................ N ....... 09 606, 607 

695.52 ...... Exfoliation due to erythematous condition involving 20–29 percent of body surface ................ N ....... 09 606, 607 

695.53 ...... Exfoliation due to erythematous condition involving 30–39 percent of body surface ................ CC .... 09 606, 607 

695.54 ...... Exfoliation due to erythematous condition involving 40–49 percent of body surface ................ CC .... 09 606, 607 

695.55 ...... Exfoliation due to erythematous condition involving 50–59 percent of body surface ................ CC .... 09 606, 607 

695.56 ...... Exfoliation due to erythematous condition involving 60–69 percent of body surface ................ CC .... 09 606, 607 

695.57 ...... Exfoliation due to erythematous condition involving 70–79 percent of body surface ................ CC .... 09 606, 607 

695.58 ...... Exfoliation due to erythematous condition involving 80–89 percent of body surface ................ CC .... 09 606, 607 

695.59 ...... Exfoliation due to erythematous condition involving 90 percent or more of body surface ......... CC .... 09 606, 607 

707.20 ...... Pressure ulcer, unspecified stage ............................................................................................... N ....... 09 573, 574, 575, 

592, 593, 594 

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, unspecified ........................................................................................... N ....... 08 555, 556 

729.91 ...... Post-traumatic seroma ................................................................................................................ N ....... 08 555, 556 

729.92 ...... Nontraumatic hematoma of soft tissue ....................................................................................... N ....... 08 555, 556 

729.99 ...... Other disorders of soft tissue ...................................................................................................... N ....... 08 555, 556 

760.61 ...... Newborn affected by amniocentesis ........................................................................................... N ....... 15 794 

760.62 ...... Newborn affected by other in utero procedure ........................................................................... N ....... 15 794 

760.63 ...... Newborn affected by other surgical operations on mother during pregnancy ............................ N ....... 15 794 

760.64 ...... Newborn affected by previous surgical procedure on mother not associated with pregnancy .. N ....... 15 794 

777.50 ...... Necrotizing enterocolitis in newborn, unspecified ....................................................................... MCC 15 791 4, 793 4

777.51 ...... Stage I necrotizing enterocolitis in newborn ............................................................................... MCC 15 791 4, 793 4

777.52 ...... Stage II necrotizing enterocolitis in newborn .............................................................................. MCC 15 791 4, 793 4

777.53 ...... Stage III necrotizing enterocolitis in newborn ............................................................................. MCC 15 791 4, 793 4

780.72 ...... Functional quadriplegia ............................................................................................................... MCC 01 052, 053 

788.91 ...... Functional urinary incontinence ................................................................................................... N ....... 11 695, 696 

788.99 ...... Other symptoms involving urinary system .................................................................................. N ....... 11 695, 696 

795.07 ...... Satisfactory cervical smear but lacking transformation zone ...................................................... N ....... 13 742, 743, 760, 

761 

795.10 ...... Abnormal glandular Papanicolaou smear of vagina ................................................................... N ....... 13 742, 743, 760, 

761 

795.11 ...... Papanicolaou smear of vagina with atypical squamous cells of undetermined significance 

(ASC–US).

N ....... 13 742, 743, 760, 

761 

795.12 ...... Papanicolaou smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC–H).N ....... 13 742, 743, 760, 

761 

795.13 ...... Papanicolaou smear of vagina with low grade squamous intraepithelial lesion (LGSIL) ........... N ....... 13 742, 743, 760, 

761 

795.14 ...... Papanicolaou smear of vagina with high grade squamous intraepithelial lesion (HGSIL) ......... N ....... 13 742, 743, 760, 

761 

795.15 ...... Vaginal high risk human papillomavirus (HPV) DNA test positive ............................................. N ....... 13 742, 743, 760, 

761 

795.16 ...... Papanicolaou smear of vagina with cytologic evidence of malignancy ...................................... N ....... 13 742, 743, 760, 

761 

795.18 ...... Unsatisfactory vaginal cytology smear ........................................................................................ N ....... 13 742, 743, 760, 

761 

795.19 ...... Other abnormal Papanicolaou smear of vagina and vaginal HPV ............................................. N ....... 13 742, 743, 760, 

761 

796.70 ...... Abnormal glandular Papanicolaou smear of anus ...................................................................... N ....... 06 393, 394, 395 

796.71 ...... Papanicolaou smear of anus with atypical squamous cells of undetermined significance 

(ASC–US).

N ....... 06 393, 394, 395 

796.72 ...... Papanicolaou smear of anus with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC–H).N ....... 06 393, 394, 395 

796.73 ...... Papanicolaou smear of anus with low grade squamous intraepithelial lesion (LGSIL) ............. N ....... 06 393, 394, 395 

796.74 ...... Papanicolaou smear of anus with high grade squamous intraepithelial lesion (HGSIL) ........... N ....... 06 393, 394, 395 

796.75 ...... Anal high risk human papillomavirus (HPV) DNA test positive .................................................. N ....... 06 393, 394, 395 

796.76 ...... Papanicolaou smear of anus with cytologic evidence of malignancy ......................................... N ....... 06 393, 394, 395 

796.77 ...... Satisfactory anal smear but lacking transformation zone ........................................................... N ....... 06 393, 394, 395 

796.78 ...... Unsatisfactory anal cytology smear ............................................................................................ N ....... 06 393, 394, 395 

796.79 ...... Other abnormal Papanicolaou smear of anus and anal HPV .................................................... N ....... 06 393, 394, 395 

997.31 ...... Ventilator associated pneumonia ................................................................................................ CC .... 04 205, 206 

15 791 2, 793 2

997.39 ...... Other respiratory complications ................................................................................................... CC .... 04 205, 206 

15 791 2, 793 2

998.30 ...... Disruption of wound, unspecified ................................................................................................ CC .... 21 919, 920, 921 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23845 

TABLE 6A.—NEW DIAGNOSIS CODES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

998.33 ...... Disruption of traumatic wound repair .......................................................................................... CC .... 21 919, 920, 921 

999.81 ...... Extravasation of vesicant chemotherapy .................................................................................... CC .... 05 314, 315, 316 

15 791 2, 793 2

999.82 ...... Extravasation of other vesicant agent ......................................................................................... CC .... 05 314, 315, 316 

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 estrogen receptor modulators (SERMs) ...................................... N ....... 23 951 

V07.52 ...... Prophylactic use of aromatase inhibitors .................................................................................... N ....... 23 951 

V07.59 ...... Prophylactic use of other agents affecting estrogen receptors and estrogen levels .................. N ....... 23 951 

V13.51 ...... Personal history of pathologic fracture ........................................................................................ N ....... 23 951 

V13.52 ...... Personal history of stress fracture .............................................................................................. N ....... 23 951 

V13.59 ...... Personal history of other musculoskeletal disorders .................................................................. N ....... 23 951 

V15.21 ...... Personal history of undergoing in utero procedure during pregnancy ....................................... N ....... 23 951 

V15.22 ...... Personal history of undergoing in utero procedure while a fetus ............................................... N ....... 23 951 

V15.29 ...... Personal history of surgery to other organs ................................................................................ N ....... 23 951 

V15.51 ...... Personal history of traumatic fracture ......................................................................................... N ....... 23 951 

V15.59 ...... Personal history of other injury ................................................................................................... N ....... 23 951 

V23.85 ...... Pregnancy resulting from assisted reproductive technology ...................................................... N ....... 14 998 

V23.86 ...... Pregnancy with history of in utero procedure during previous pregnancy ................................. N ....... 14 998 

V28.81 ...... Encounter for fetal anatomic survey ........................................................................................... N ....... 23 951 

V28.82 ...... Encounter for screening for risk of pre-term labor ...................................................................... N ....... 23 951 

V28.89 ...... Other specified antenatal screening ............................................................................................ N ....... 23 951 

V45.11 ...... Renal dialysis status .................................................................................................................... N ....... 23 951 

V45.12 ...... Noncompliance with renal dialysis .............................................................................................. N ....... 23 951 

V45.87 ...... Transplanted organ removal status ............................................................................................. N ....... 23 951 

V46.3 ........ Wheelchair dependence .............................................................................................................. N ....... 23 951 

V51.0 ........ Encounter for breast reconstruction following mastectomy ........................................................ N ....... 09 606, 607 

V51.8 ........ Other aftercare involving the use of plastic surgery ................................................................... N ....... 09 606, 607 

V87.01 ...... Contact with and (suspected) exposure to arsenic ..................................................................... N ....... 23 951 

V87.09 ...... Contact with and (suspected) exposure to other hazardous metals .......................................... N ....... 23 951 

V87.11 ...... Contact with and (suspected) exposure to aromatic amines ...................................................... N ....... 23 951 

V87.12 ...... Contact with and (suspected) exposure to benzene .................................................................. N ....... 23 951 

V87.19 ...... Contact with and (suspected) exposure to other hazardous aromatic compounds ................... N ....... 23 951 

V87.2 ........ Contact with and (suspected) exposure to other potentially hazardous chemicals ................... N ....... 23 951 

V87.31 ...... Contact with and (suspected) exposure to mold ........................................................................ N ....... 23 951 

V87.39 ...... Contact with and (suspected) exposure to other potentially hazardous substances ................. N ....... 23 951 

V87.41 ...... Personal history of antineoplastic chemotherapy ....................................................................... N ....... 23 949, 950 

V87.42 ...... Personal history of monoclonal drug therapy ............................................................................. N ....... 23 949, 950 

V87.49 ...... Personal history of other drug therapy ........................................................................................ N ....... 23 949, 950 

V88.01 ...... Acquired absence of both cervix and uterus .............................................................................. N ....... 13 742, 743, 760, 

761 

V88.02 ...... Acquired absence of uterus with remaining cervical stump ....................................................... N ....... 13 742, 743, 760, 

761 

V88.03 ...... Acquired absence of cervix with remaining uterus ..................................................................... N ....... 13 742, 743, 760, 

761 

V89.01 ...... Suspected problem with amniotic cavity and membrane not found ........................................... N ....... 23 951 

V89.02 ...... Suspected placental problem not found ...................................................................................... N ....... 23 951 

V89.03 ...... Suspected fetal anomaly not found ............................................................................................. N ....... 23 951 

V89.04 ...... Suspected problem with fetal growth not found .......................................................................... N ....... 23 951 

V89.05 ...... Suspected cervical shortening not found .................................................................................... N ....... 23 951 

V89.09 ...... Other suspected maternal and fetal condition not found ............................................................ N ....... 23 951 

1Secondary diagnosis of acute leukemia 

2Secondary diagnosis of major problem. 

3The 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. 4Principal 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 sac pressure monitoring device (intraoperative) ............................. N. 

00.59 ........ Intravascular pressure measurement of coronary arteries ......................................................... N.

00.67 ........ Intravascular pressure measurement of intrathoracic arteries .................................................... N.

00.68 ........ Intravascular pressure measurement of peripheral arteries ....................................................... N.

00.69 ........ Intravascular pressure measurement, other specified and unspecified vessels ........................ N. 


jlentini on PROD1PC65 with PROPOSALS2
23846 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6B.—NEW PROCEDURE CODES—Continued 

Procedure 

code Description O.R. MDC MS–DRG 

17.11 ........ Laparoscopic repair of direct inguinal hernia with graft or prosthesis ........................................ Y ....... 06 350, 351, 352 

17.12 ........ Laparoscopic repair of indirect inguinal hernia with graft or prosthesis ..................................... Y ....... 06 350, 351, 352 

17.13 ........ Laparoscopic repair of inguinal hernia with graft or prosthesis, not otherwise specified ........... Y ....... 06 350, 351, 352 

17.21 ........ Laparoscopic bilateral repair of direct inguinal hernia with graft or prosthesis .......................... Y ....... 06 350, 351, 352 

17.22 ........ Laparoscopic bilateral repair of indirect inguinal hernia with graft or prosthesis ....................... Y ....... 06 350, 351, 352 

17.23 ........ Laparoscopic bilateral repair of inguinal hernia, one direct and one indirect, with graft or 

prosthesis.

Y ....... 06 350, 351, 352 

17.24 ........ Laparoscopic bilateral repair of inguinal hernia with graft or prosthesis, not otherwise specified.Y ....... 06 350, 351, 352 

17.31 ........ Laparoscopic multiple segmental resection of large intestine .................................................... Y ....... 06 329, 330, 331 

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 hemicolectomy .............................................................................................. Y ....... 05 264 

06 329, 330, 331 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

17.34 ........ Laparoscopic resection of transverse colon ................................................................................ Y ....... 05 264 

06 329, 330, 331 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

17.35 ........ Laparoscopic left hemicolectomy ................................................................................................ Y ....... 05 264 

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 excision of large intestine ................................................................. Y ....... 05 264 

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 left atrial appendage (LAA) ............................................................... N. 

37.55 ........ Removal of internal biventricular heart replacement system ...................................................... Y ....... PRE 001, 002 

05 237, 238 

38.23 ........ Intravascular spectroscopy .......................................................................................................... N. 

45.81 ........ Laparoscopic total intra-abdominal colectomy ............................................................................ Y ....... 05 264 

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 colectomy ......................................................................................... Y ....... 05 264 

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 intra-abdominal colectomy .............................................................. Y ....... 05 264 

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 rectum, not otherwise specified .......................................................... Y ....... 06 332, 333, 334 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23847 

TABLE 6B.—NEW PROCEDURE CODES—Continued 

Procedure 

code Description O.R. MDC MS–DRG 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.42 ........ Laparoscopic pull-through resection of rectum ........................................................................... Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.43 ........ Open pull-through resection of rectum ........................................................................................ Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.50 ........ Abdominoperineal resection of the rectum, not otherwise specified .......................................... Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.51 ........ Laparoscopic abdominoperineal resection of the rectum ........................................................... Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.52 ........ Open abdominoperineal resection of the rectum ........................................................................ Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.59 ........ Other abdominoperineal resection of the rectum ........................................................................ Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

53.42 ........ Laparoscopic repair of umbilical hernia with graft or prosthesis ................................................ Y ....... 06 353, 354, 355 

53.43 ........ Other laparoscopic umbilical herniorrhaphy ................................................................................ Y ....... 06 353, 354, 355 

21 907, 908, 909 

24 957, 958, 959 

53.62 ........ Laparoscopic incisional hernia repair with graft or prosthesis .................................................... Y ....... 06 353, 354, 355 

21 907, 908, 909 

24 957, 958, 959 

53.63 ........ Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis .. Y ....... 06 353, 354, 355 

53.71 ........ Laparoscopic repair of diaphragmatic hernia, abdominal approach ........................................... Y ....... 04 163, 164, 165 

06 326, 327, 328 

21 907, 908, 909 

24 957, 958, 959 

53.72 ........ Other and open repair of diaphragmatic hernia, abdominal approach ....................................... Y ....... 04 163, 164, 165 

06 326, 327, 328 

21 907, 908, 909 

24 957, 958, 959 

53.75 ........ Repair of diaphragmatic hernia, abdominal approach, not otherwise specified ......................... Y ....... 04 163, 164, 165 

06 326, 327, 328 

21 907, 908, 909 

24 957, 958, 959 

53.83 ........ Laparoscopic repair of diaphragmatic hernia, with thoracic approach ....................................... Y ....... 04 163, 164, 165 

06 326, 327, 328 

21 907, 908, 909 

24 957, 958, 959 

53.84 ........ Other and open repair of diaphragmatic hernia, with thoracic approach ................................... Y ....... 04 163, 164, 165 

06 326, 327, 328 

21 907, 908, 909 

24 957, 958, 959 

80.53 ........ Repair of the anulus fibrosus with graft or prosthesis ................................................................ Y ....... 01 028, 029, 030 

08 490, 491 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

80.54 ........ Other and unspecified repair of the anulus fibrosus ................................................................... Y ....... 01 028, 029, 030 

08 490, 491 

17 820, 821, 822, 

826, 827, 828 


jlentini on PROD1PC65 with PROPOSALS2
23848 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6B.—NEW PROCEDURE CODES—Continued 

Procedure 

code Description O.R. MDC MS–DRG 

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-living amebae .................................................................................... MCC 18 867, 868, 869 

259.5 ........ Androgen insensitivity syndrome ................................................................................................. N ....... 10 643, 644, 645 

337.0 ........ Idiopathic peripheral autonomic neuropathy ............................................................................... CC .... 01 073, 074 

511.8 ........ Other specified forms of pleural effusion, except tuberculous .................................................... MCC 04 186, 187, 188 

15 791 1, 793 1

599.7 ........ Hematuria .................................................................................................................................... N ....... 11 695, 696 

15 791 1, 793 1

611.8 ........ Other specified disorders of breast ............................................................................................. N ....... 09 600, 601 

695.1 ........ Erythema multiforme ................................................................................................................... CC .... 09 595, 596 

729.9 ........ Other and unspecified disorders of soft tissue ........................................................................... N ....... 08 555, 556 

760.6 ........ Surgical operation on mother ...................................................................................................... N ....... 15 794 

777.5 ........ Necrotizing enterocolitis in fetus or newborn .............................................................................. MCC 15 791 2, 793 2

788.9 ........ Other symptoms involving urinary system .................................................................................. N ....... 11 695, 696 

795.1 ........ Nonspecific abnormal Papanicolaou smear of other site ........................................................... N ....... 04 180, 181, 182 

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 musculoskeletal disorders .................................................................. N ....... 23 951 

V15.2 ........ Personal history of surgery to other major organs ..................................................................... N ....... 23 951 

V15.5 ........ Personal history of injury ............................................................................................................. N ....... 23 951 

V28.8 ........ Encounter for other specified antenatal screening ..................................................................... N ....... 23 951 

V45.1 ........ Renal dialysis status .................................................................................................................... N ....... 23 951 

V51 ........... Aftercare involving the use of plastic surgery ............................................................................. N ....... 09 606, 607 

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 colectomy ................................................................................................. Y ....... 05 264 

06 329, 330, 331 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

48.5 .......... Abdominoperineal resection of rectum ........................................................................................ Y ....... 06 332, 333, 334 

17 820, 821, 822, 

826, 827, 828 

21 907, 908, 909 

24 957, 958, 959 

53.7 .......... Repair of diaphragmatic hernia, abdominal approach ................................................................ Y ....... 04 163, 164, 165 

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 mention of having achieved remission ............................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23849 

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

203.10 ...... Plasma cell leukemia, without mention of having achieved remission ....................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

203.80 ...... Other immunoproliferative neoplasms, without mention of having achieved remission ............. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.00 ...... Acute lymphoid leukemia, without mention of having achieved remission ................................. CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

204.10 ...... Chronic lymphoid leukemia, without mention of having achieved remission ............................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.20 ...... Subacute lymphoid leukemia, without mention of having achieved remission ........................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.80 ...... Other lymphoid leukemia, without mention of having achieved remission ................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

204.90 ...... Unspecified lymphoid leukemia, without mention of having achieved remission ....................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.00 ...... Acute myeloid leukemia, without mention of having achieved remission ................................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

205.10 ...... Chronic myeloid leukemia, without mention of having achieved remission ............................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.20 ...... Subacute myeloid leukemia, without mention of having achieved remission ............................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.30 ...... Myeloid sarcoma, without mention of having achieved remission .............................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.80 ...... Other myeloid leukemia, without mention of having achieved remission ................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

205.90 ...... Unspecified myeloid leukemia, without mention of having achieved remission ......................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.00 ...... Acute monocytic leukemia, without mention of having achieved remission ............................... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

206.10 ...... Chronic monocytic leukemia, without mention of having achieved remission ............................ CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.20 ...... Subacute monocytic leukemia, without mention of having achieved remission ......................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.80 ...... Other monocytic leukemia, without mention of having achieved remission ............................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

206.90 ...... Unspecified monocytic leukemia, without mention of having achieved remission ..................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.00 ...... Acute erythremia and erythroleukemia, without mention of having achieved remission ............ CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

207.10 ...... Chronic erythremia, without mention of having achieved remission .......................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.20 ...... Megakaryocytic leukemia, without mention of having achieved remission ................................ CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

207.80 ...... Other specified leukemia, without mention of having achieved remission ................................. CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 


jlentini on PROD1PC65 with PROPOSALS2
23850 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued 

Diagnosis 

code Description CC MDC MS–DRG 

208.00 ...... Acute leukemia of unspecified cell type, without mention of having achieved remission .......... CC .... 17 820, 821, 822, 

834, 835, 836, 

837 1, 838 1, 

839 1

208.10 ...... Chronic leukemia of unspecified cell type, without mention of having achieved remission ....... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.20 ...... Subacute leukemia of unspecified cell type, without mention of having achieved remission .... CC .... 17 820, 821, 822,

823, 824, 825, 

840, 841, 842 

208.80 ...... Other leukemia of unspecified cell type, without mention of having achieved remission .......... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

208.90 ...... Unspecified leukemia, without mention of having achieved remission ....................................... CC .... 17 820, 821, 822, 

823, 824, 825, 

840, 841, 842 

346.00 ...... Migraine with aura, without mention of intractable migraine without mention of status 

migrainosus.

N ....... 01 102, 103 

346.01 ...... Migraine with aura, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

346.10 ...... Migraine without aura, without mention of intractable migraine without mention of status 

migrainosus.

N ....... 01 102, 103 

346.11 ...... Migraine without aura, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

346.20 ...... Variants of migraine, not elsewhere classified, without mention of intractable migraine without 

mention of status migrainosus.

N ....... 01 102, 103 

346.21 ...... Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without 

mention of status migrainosus.

N ....... 01 102, 103 

346.80 ...... Other forms of migraine, without mention of intractable migraine without mention of status 

migrainosus.

N ....... 01 102, 103 

346.81 ...... Other forms of migraine, with intractable migraine, so stated, without mention of status 

migrainosus.

N ....... 01 102, 103 

386.00 ...... Me ́nie`re’s disease, unspecified ................................................................................................... N ....... 03 149 

386.01 ...... Active Me ́nie`re’s disease, cochleovestibular ............................................................................... N ....... 03 149 

386.02 ...... Active Me ́nie`re’s disease, cochlear ............................................................................................. N ....... 03 149 

386.03 ...... Active Me ́nie`re’s disease, vestibular ........................................................................................... N ....... 03 149 

386.04 ...... Inactive Me ́nie`re’s disease .......................................................................................................... N ....... 03 149 

707.00 ...... Pressure ulcer, unspecified site .................................................................................................. N 2 ..... 09 573, 574, 575, 

592, 593, 594 

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 disorder specific to newborn ............................................................ N ....... 15 794 

795.08 ...... Unsatisfactory cervical cytology smear ....................................................................................... N ....... 13 742, 743, 760, 

761 

998.31 ...... Disruption of internal operation (surgical) wound ....................................................................... CC .... 21 919, 920, 921 

V28.3 ........ Encounter for routine screening for malformation using ultrasonics .......................................... N ....... 23 951 

V45.71 ...... Acquired absence of breast and nipple ...................................................................................... N ....... 23 951 

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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23851 

TABLE 6F.—REVISED PROCEDURE CODE TITLES

Procedure 

code Description O.R. MDC MS–DRG 

37.52 ........ Implantation of internal biventricular heart replacement system ................................................ Y ....... PRE 001 1, 002 1

37.53 ........ Replacement or repair of thoracic unit of (total) replacement heart system .............................. Y ....... 05 215 

37.54 ........ Replacement or repair of other implantable component of (total) replacement heart system ... Y ....... 05 215 

45.71 ........ Open and other multiple segmental resection of large intestine ................................................ Y ....... 06 329, 330, 331 

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 hemicolectomy .......................................................................................... Y ....... 05 264 

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 transverse colon ............................................................................ Y ....... 05 264 

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 hemicolectomy ............................................................................................ Y ....... 05 264 

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 excision of large intestine ............................................................ Y ....... 05 264 

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 direct inguinal hernia .......................................................................... Y ....... 06 350, 351, 352 

53.02 ........ Other and open repair of indirect inguinal hernia ....................................................................... Y ....... 06 350, 351, 352 

53.03 ........ Other and open repair of direct inguinal hernia with graft or prosthesis .................................... Y ....... 06 350, 351, 352 

53.04 ........ Other and open repair of indirect inguinal hernia with graft or prosthesis ................................. Y ....... 06 350, 351, 352 

53.11 ........ Other and open bilateral repair of direct inguinal hernia ............................................................ Y ....... 06 350, 351, 352 

53.12 ........ Other and open bilateral repair of indirect inguinal hernia ......................................................... Y ....... 06 350, 351, 352 

53.13 ........ Other and open bilateral repair of inguinal hernia, one direct and one indirect ......................... Y ....... 06 350, 351, 352 

53.14 ........ Other and open bilateral repair of direct inguinal hernia with graft or prosthesis ...................... Y ....... 06 350, 351, 352 

53.15 ........ Other and open bilateral repair of indirect inguinal hernia with graft or prosthesis ................... Y ....... 06 350, 351, 352 

53.16 ........ Other and open bilateral repair of inguinal hernia, one direct and one indirect, with graft or 

prosthesis.

Y ....... 06 350, 351, 352 

53.41 ........ Other and open repair of umbilical hernia with graft or prosthesis ............................................ Y ....... 06 353, 354, 355 

53.49 ........ Other open umbilical herniorrhaphy ............................................................................................ Y ....... 06 353, 354, 355 

21 907, 908, 909 

24 957, 958, 959 

53.61 ........ Other open incisional hernia repair with graft or prosthesis ....................................................... Y ....... 06 353, 354, 355 

21 907, 908, 909 

24 957, 958, 959 

53.69 ........ Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis ....... Y ....... 06 353, 354, 355 

81.65 ........ Percutaneous vertebroplasty ....................................................................................................... Y ....... 08 515, 516, 517 

21 907, 908, 909 

24 957, 958, 959 

81.66 ........ Percutaneous vertebral augmentation ........................................................................................ Y ....... 08 515, 516, 517 

21 907, 908, 909 

24 957, 958, 959 

1 Note MS–DRG change. 


jlentini on PROD1PC65 with PROPOSALS2
23852 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23853 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23854 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23855 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23856 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23857 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23858 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23859 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23860 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23861 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23862 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued 

MS-DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23863 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23864 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23865 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23866 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23867 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23868 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23869 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23870 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23871 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
23872 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23873 

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR 

UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued 

MS–DRG Number of 

discharges 

Arithmetic 

mean LOS 

10th 

percentile 

25th 

percentile 

50th 

percentile 

75th 

percentile 

90th 

percentile 

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-TOCHARGE 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 ..................

TABLE 8A.—PROPOSED STATEWIDE

AVERAGE OPERATING COST-TOCHARGE RATIOS—MARCH 2008—

Continued 

State Urban Rural 

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-TOCHARGE 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 

TABLE 8B.—PROPOSED STATEWIDE

AVERAGE CAPITAL COST-TOCHARGE RATIOS—MARCH 2008—

Continued 

State Ratio 

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 


jlentini on PROD1PC65 with PROPOSALS2
23874 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

TABLE 8C.—PROPOSED STATEWIDE

AVERAGE TOTAL COST-TO-CHARGE

RATIOS FOR LTCHS—MARCH

2008—Continued 

State Urban Rural 

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 ..................

TABLE 8C.—PROPOSED STATEWIDE

AVERAGE TOTAL COST-TO-CHARGE

RATIOS FOR LTCHS—MARCH

2008—Continued 

State Urban Rural 

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 

Provider No. Geographic 

CBSA 

Reclassified 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23875 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23876 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23877 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23878 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23879 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23880 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23881 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23882 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23883 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23884 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23885 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 


jlentini on PROD1PC65 with PROPOSALS2
23886 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued 

Provider No. Geographic 

CBSA 

Reclassified 

CBSA LUGAR 

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 

Provider No. Geographic 

CBSA 

Redesignated 

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 

TABLE 9C.—HOSPITALS REDESIGNATED AS RURAL UNDER SECTION

1886(D)(8)(E) OF THE ACT—FY 

2009—Continued 

Provider No. Geographic 

CBSA 

Redesignated 

rural area 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1

MS–DRG Number of 

cases Threshold 

1 ........................ 655 $345,754 

2 ........................ 287 202,892 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23887 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 


jlentini on PROD1PC65 with PROPOSALS2
23888 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23889 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 


jlentini on PROD1PC65 with PROPOSALS2
23890 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23891 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

977 .................... 4,633 25,054 

981 .................... 25,506 78,693 

982 .................... 18,355 55,049 

983 .................... 6,144 40,105 

984 .................... 671 59,501 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

985 .................... 904 42,990 

986 .................... 732 29,607 

987 .................... 8,256 55,744 

988 .................... 11,611 37,995 

989 .................... 5,817 27,744 

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 DIAGNOSISRELATED GROUP (MS–DRG)—

MARCH 2008 1—Continued 

MS–DRG Number of 

cases Threshold 

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 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

1 ............... 1 ............... Heart transplant or implant of heart assist system w MCC 0 0.0000 0.0 0.0 

2 ............... 1 ............... Heart transplant or implant of heart assist system w/o 

MCC.

0 0.0000 0.0 0.0 

3 ............... 3 ............... ECMO or trach w MV 96+ hrs or PDX exc face, mouth & 

neck w maj O.R..

286 4.5889 66.5 55.4 

4 ............... 4 ............... Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o 

maj O.R..

1,201 2.9992 44.4 37.0 

5 ............... 5 ............... Liver transplant w MCC or intestinal transplant .................. 0 0.0000 0.0 0.0 

6 ............... 5 ............... Liver transplant w/o MCC .................................................... 0 0.0000 0.0 0.0 

7 ............... 7 ............... Lung transplant .................................................................... 0 0.0000 0.0 0.0 

8 ............... 8 ............... Simultaneous pancreas/kidney transplant ........................... 0 0.0000 0.0 0.0 

9 ............... 9 ............... Bone marrow transplant ...................................................... 0 1.2617 31.5 26.3 

10 ............. 10 ............ Pancreas transplant ............................................................. 0 0.0000 0.0 0.0 

11 ............. 11 ............ Tracheostomy for face, mouth & neck diagnoses w MCC 1 1.7509 37.9 31.6 

12 ............. 11 ............ Tracheostomy for face, mouth & neck diagnoses w CC .... 1 1.7509 37.9 31.6 

13 ............. 11 ............ Tracheostomy for face, mouth & neck diagnoses w/o CC/ 

MCC.

0 1.7509 37.9 31.6 

20 ............. 20 ............ Intracranial vascular procedures w PDX hemorrhage w 

MCC.

0 1.7509 37.9 31.6 

21 ............. 20 ............ Intracranial vascular procedures w PDX hemorrhage w 

CC.

0 1.7509 37.9 31.6 

22 ............. 20 ............ Intracranial vascular procedures w PDX hemorrhage w/o 

CC/MCC.

0 1.7509 37.9 31.6 

23 ............. 23 ............ Craniotomy w major device implant or acute complex CNS 

PDX w MCC*.

2 1.2617 31.5 26.3 

24 ............. 23 ............ Craniotomy w major device implant or acute complex CNS 

PDX w/o MCC*.

1 1.2617 31.5 26.3 

25 ............. 25 ............ Craniotomy & endovascular intracranial procedures w 

MCC.

1 1.7509 37.9 31.6 

26 ............. 25 ............ Craniotomy & endovascular intracranial procedures w CC 3 1.7509 37.9 31.6 

27 ............. 25 ............ Craniotomy & endovascular intracranial procedures w/o 

CC/MCC.

1 0.8596 25.2 21.0 

28 ............. 28 ............ Spinal procedures w MCC ................................................... 11 1.2617 31.5 26.3 

29 ............. 28 ............ Spinal procedures w CC ...................................................... 9 1.2617 31.5 26.3 

30 ............. 28 ............ Spinal procedures w/o CC/MCC ......................................... 1 1.2617 31.5 26.3 

31 ............. 31 ............ Ventricular shunt procedures w MCC ................................. 5 1.7509 37.9 31.6 

32 ............. 31 ............ Ventricular shunt procedures w CC .................................... 1 1.7509 37.9 31.6 

33 ............. 31 ............ Ventricular shunt procedures w/o CC/MCC ........................ 0 1.7509 37.9 31.6 

34 ............. 34 ............ Carotid artery stent procedure w MCC ............................... 0 1.2617 31.5 26.3 

35 ............. 34 ............ Carotid artery stent procedurew CC .................................... 0 1.2617 31.5 26.3 

36 ............. 34 ............ Carotid artery stent procedure w/o CC/MCC ...................... 0 1.2617 31.5 26.3 

37 ............. 37 ............ Extracranial procedures w MCC .......................................... 7 1.2617 31.5 26.3 

38 ............. 37 ............ Extracranial procedures w CC* ........................................... 6 1.2617 31.5 26.3 

39 ............. 37 ............ Extracranial procedures w/o CC/MCC ................................ 0 1.2617 31.5 26.3 


jlentini on PROD1PC65 with PROPOSALS2
23892 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

40 ............. 40 ............ Periph & cranial nerve & other nerv syst proc w MCC ....... 143 1.2451 34.8 29.0 

41 ............. 40 ............ Periph & cranial nerve & other nerv syst proc w CC .......... 87 1.0890 34.5 28.8 

42 ............. 40 ............ Periph & cranial nerve & other nerv syst proc w/o CC/ 

MCC*.

6 1.0890 34.5 28.8 

52 ............. 52 ............ Spinal disorders & injuries w CC/MCC ............................... 83 0.9943 31.3 26.1 

53 ............. 52 ............ Spinal disorders & injuries w/o CC/MCC ............................ 7 0.8596 25.2 21.0 

54 ............. 54 ............ Nervous system neoplasms w MCC ................................... 31 1.0109 26.7 22.3 

55 ............. 54 ............ Nervous system neoplasms w/o MCC ................................ 50 0.6542 21.6 18.0 

56 ............. 56 ............ Degenerative nervous system disorders w MCC ................ 1,180 0.8022 25.3 21.1 

57 ............. 56 ............ Degenerative nervous system disorders w/o MCC ............. 1,945 0.6033 24.0 20.0 

58 ............. 58 ............ Multiple sclerosis & cerebellar ataxia w MCC ..................... 19 0.8596 25.2 21.0 

59 ............. 58 ............ Multiple sclerosis & cerebellar ataxia w CC ........................ 23 0.6327 21.6 18.0 

60 ............. 58 ............ Multiple sclerosis & cerebellar ataxia w/o CC/MCC ............ 10 0.6327 21.6 18.0 

61 ............. 61 ............ Acute ischemic stroke w use of thrombolytic agent w MCC 0 0.8823 23.5 19.6 

62 ............. 61 ............ Acute ischemic stroke w use of thrombolytic agent w CC .. 0 0.5770 22.8 19.0 

63 ............. 61 ............ Acute ischemic stroke w use of thrombolytic agent w/o 

CC/MCC.

0 0.4824 19.6 16.3 

64 ............. 64 ............ Intracranial hemorrhage or cerebral infarction w MCC ....... 107 0.7831 24.5 20.4 

65 ............. 64 ............ Intracranial hemorrhage or cerebral infarction w CC .......... 67 0.6217 24.0 20.0 

66 ............. 64 ............ Intracranial hemorrhage or cerebral infarction w/o CC/ 

MCC.

24 0.4824 19.6 16.3 

67 ............. 67 ............ Nonspecific cva & precerebral occlusion w/o infarct w 

MCC.

4 0.4824 19.6 16.3 

68 ............. 67 ............ Nonspecific cva & precerebral occlusion w/o infarct w/o 

MCC.

4 0.4824 19.6 16.3 

69 ............. 69 ............ Transient ischemia ............................................................... 13 0.4824 19.6 16.3 

70 ............. 70 ............ Nonspecific cerebrovascular disorders w MCC .................. 87 0.8823 23.5 19.6 

71 ............. 70 ............ Nonspecific cerebrovascular disorders w CC ..................... 52 0.5770 22.8 19.0 

72 ............. 70 ............ Nonspecific cerebrovascular disorders w/o CC/MCC ......... 8 0.4824 19.6 16.3 

73 ............. 73 ............ Cranial & peripheral nerve disorders w MCC ..................... 116 0.8910 24.6 20.5 

74 ............. 73 ............ Cranial & peripheral nerve disorders w/o MCC .................. 173 0.6057 23.1 19.3 

75 ............. 75 ............ Viral meningitis w CC/MCC ................................................. 15 0.6327 21.6 18.0 

76 ............. 75 ............ Viral meningitis w/o CC/MCC .............................................. 0 0.6327 21.6 18.0 

77 ............. 77 ............ Hypertensive encephalopathy w MCC ................................ 4 1.2617 31.5 26.3 

78 ............. 77 ............ Hypertensive encephalopathy w CC ................................... 1 0.6327 21.6 18.0 

79 ............. 77 ............ Hypertensive encephalopathy w/o CC/MCC ....................... 1 0.4824 19.6 16.3 

80 ............. 80 ............ Nontraumatic stupor & coma w MCC .................................. 47 0.7859 29.2 24.3 

81 ............. 80 ............ Nontraumatic stupor & coma w/o MCC ............................... 110 0.7028 28.2 23.5 

82 ............. 82 ............ Traumatic stupor & coma, coma >1 hr w MCC .................. 9 0.8596 25.2 21.0 

83 ............. 82 ............ Traumatic stupor & coma, coma >1 hr w CC ..................... 12 0.6327 21.6 18.0 

84 ............. 82 ............ Traumatic stupor & coma, coma >1 hr w/o CC/MCC ......... 3 0.6327 21.6 18.0 

85 ............. 85 ............ Traumatic stupor & coma, coma <1 hr w MCC .................. 78 0.8652 26.1 21.8 

86 ............. 85 ............ Traumatic stupor & coma, coma <1 hr w CC ..................... 81 0.6630 24.1 20.1 

87 ............. 85 ............ Traumatic stupor & coma, coma <1 hr w/o CC/MCC ......... 15 0.4824 19.6 16.3 

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/MCC .................................................... 0 0.4824 19.6 16.3 

91 ............. 91 ............ Other disorders of nervous system w MCC ........................ 218 0.9248 25.9 21.6 

92 ............. 91 ............ Other disorders of nervous system w CC ........................... 138 0.6661 25.0 20.8 

93 ............. 91 ............ Other disorders of nervous system w/o CC/MCC ............... 43 0.6046 22.0 18.3 

94 ............. 94 ............ Bacterial & tuberculous infections of nervous system w 

MCC.

203 1.0466 29.2 24.3 

95 ............. 94 ............ Bacterial & tuberculous infections of nervous system w 

CC.

106 0.9763 28.9 24.1 

96 ............. 94 ............ Bacterial & tuberculous infections of nervous system w/o 

CC/MCC.

31 0.7559 27.6 23.0 

97 ............. 97 ............ Non-bacterial infect of nervous sys exc viral meningitis w 

MCC.

48 1.0415 26.0 21.7 

98 ............. 97 ............ Non-bacterial infect of nervous sys exc viral meningitis w 

CC.

22 0.8596 25.2 21.0 

99 ............. 97 ............ Non-bacterial infect of nervous sys exc viral meningitis w/ 

o CC/MCC.

6 0.6327 21.6 18.0 

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 CC/MCC ............................................ 1 0.8596 25.2 21.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23893 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

114 ........... 113 ........... Orbital procedures w/o CC/MCC ......................................... 0 0.8596 25.2 21.0 

115 ........... 115 ........... Extraocular procedures except orbit .................................... 0 0.4824 19.6 16.3 

116 ........... 116 ........... Intraocular procedures w CC/MCC ..................................... 1 0.8596 25.2 21.0 

117 ........... 116 ........... Intraocular procedures w/o CC/MCC .................................. 0 0.4824 19.6 16.3 

121 ........... 121 ........... Acute major eye infections w CC/MCC ............................... 10 0.6327 21.6 18.0 

122 ........... 121 ........... Acute major eye infections w/o CC/MCC ............................ 1 0.6327 21.6 18.0 

123 ........... 123 ........... Neurological eye disorders .................................................. 0 0.4824 19.6 16.3 

124 ........... 124 ........... Other disorders of the eye w MCC ..................................... 2 0.6327 21.6 18.0 

125 ........... 124 ........... Other disorders of the eye w/o MCC .................................. 8 0.4824 19.6 16.3 

129 ........... 129 ........... Major head & neck procedures w CC/MCC or major device.0 1.3344 30.2 25.2 

130 ........... 129 ........... Major head & neck procedures w/o CC/MCC ..................... 0 0.4824 19.6 16.3 

131 ........... 131 ........... Cranial/facial procedures w CC/MCC .................................. 0 1.7509 37.9 31.6 

132 ........... 131 ........... Cranial/facial procedures w/o CC/MCC ............................... 1 1.7509 37.9 31.6 

133 ........... 133 ........... Other ear, nose, mouth & throat O.R. procedures w CC/ 

MCC.

10 1.2617 31.5 26.3 

134 ........... 133 ........... Other ear, nose, mouth & throat O.R. procedures w/o CC/ 

MCC.

0 1.2617 31.5 26.3 

135 ........... 135 ........... Sinus & mastoid procedures w CC/MCC ............................ 2 0.4824 19.6 16.3 

136 ........... 135 ........... Sinus & mastoid procedures w/o CC/MCC* ........................ 1 0.4824 19.6 16.3 

137 ........... 137 ........... Mouth procedures w CC/MCC ............................................ 1 1.7509 37.9 31.6 

138 ........... 137 ........... Mouth procedures w/o CC/MCC ......................................... 0 1.7509 37.9 31.6 

139 ........... 139 ........... Salivary gland procedures ................................................... 0 1.7509 37.9 31.6 

146 ........... 146 ........... Ear, nose, mouth & throat malignancy w MCC ................... 40 1.3344 30.2 25.2 

147 ........... 146 ........... Ear, nose, mouth & throat malignancy w CC ...................... 26 0.9930 22.4 18.7 

148 ........... 146 ........... Ear, nose, mouth & throat malignancy w/o CC/MCC ......... 6 0.4824 19.6 16.3 

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 MCC .................................................. 9 0.8596 25.2 21.0 

153 ........... 152 ........... Otitis media & URI w/o MCC ............................................... 23 0.6327 21.6 18.0 

154 ........... 154 ........... Nasal trauma & deformity w MCC ....................................... 50 0.7707 22.0 18.3 

155 ........... 154 ........... Nasal trauma & deformity w CC .......................................... 47 0.7011 21.1 17.6 

156 ........... 154 ........... Nasal trauma & deformity w/o CC/MCC ............................. 13 0.6327 21.6 18.0 

157 ........... 157 ........... Dental & Oral Diseases w MCC .......................................... 12 0.6327 21.6 18.0 

158 ........... 157 ........... Dental & Oral Diseases w CC ............................................. 21 0.6327 21.6 18.0 

159 ........... 157 ........... Dental & Oral Diseases w/o CC/MCC ................................. 5 0.4824 19.6 16.3 

163 ........... 163 ........... Major chest procedures w MCC .......................................... 45 2.5063 33.5 27.9 

164 ........... 163 ........... Major chest procedures w CC ............................................. 6 1.2617 31.5 26.3 

165 ........... 163 ........... Major chest procedures w/o CC/MCC ................................. 1 0.8596 25.2 21.0 

166 ........... 166 ........... Other resp system O.R. procedures w MCC ...................... 1,506 2.4992 41.8 34.8 

167 ........... 166 ........... Other resp system O.R. procedures w CC ......................... 211 1.8587 36.2 30.2 

168 ........... 166 ........... Other resp system O.R. procedures w/o CC/MCC ............. 8 0.8596 25.2 21.0 

175 ........... 175 ........... Pulmonary embolism w MCC .............................................. 128 0.6640 21.9 18.3 

176 ........... 175 ........... Pulmonary embolism w/o MCC ........................................... 139 0.5479 20.0 16.7 

177 ........... 177 ........... Respiratory infections & inflammations w MCC .................. 3,181 0.8784 22.8 19.0 

178 ........... 177 ........... Respiratory infections & inflammations w CC ..................... 2,334 0.7414 22.1 18.4 

179 ........... 177 ........... Respiratory infections & inflammations w/o CC/MCC ......... 394 0.6225 19.4 16.2 

180 ........... 180 ........... Respiratory neoplasms w MCC ........................................... 149 0.7975 20.9 17.4 

181 ........... 180 ........... Respiratory neoplasms w CC .............................................. 109 0.6255 18.7 15.6 

182 ........... 180 ........... Respiratory neoplasms w/o CC/MCC* ................................ 11 0.6255 18.7 15.6 

183 ........... 183 ........... Major chest trauma w MCC ................................................. 1 0.4824 19.6 16.3 

184 ........... 183 ........... Major chest trauma w CC .................................................... 2 0.4824 19.6 16.3 

185 ........... 183 ........... Major chest trauma w/o CC/MCC ....................................... 1 0.4824 19.6 16.3 

186 ........... 186 ........... Pleural effusion w MCC ....................................................... 121 0.7576 20.5 17.1 

187 ........... 186 ........... Pleural effusion w CC .......................................................... 60 0.6176 20.5 17.1 

188 ........... 186 ........... Pleural effusion w/o CC/MCC* ............................................ 15 0.6176 20.5 17.1 

189 ........... 189 ........... Pulmonary edema & respiratory failure ............................... 6,586 0.9608 23.9 19.9 

190 ........... 190 ........... Chronic obstructive pulmonary disease w MCC ................. 1,652 0.7477 20.5 17.1 

191 ........... 190 ........... Chronic obstructive pulmonary disease w CC .................... 1,343 0.6220 19.4 16.2 

192 ........... 190 ........... Chronic obstructive pulmonary disease w/o CC/MCC ........ 764 0.5358 17.3 14.4 

193 ........... 193 ........... Simple pneumonia & pleurisy w MCC ................................. 1,805 0.7698 21.6 18.0 

194 ........... 193 ........... Simple pneumonia & pleurisy w CC .................................... 2,026 0.6368 20.1 16.8 

195 ........... 193 ........... Simple pneumonia & pleurisy w/o CC/MCC ....................... 382 0.5374 17.4 14.5 

196 ........... 196 ........... Interstitial lung disease w MCC ........................................... 110 0.7122 20.1 16.8 

197 ........... 196 ........... Interstitial lung disease w CC .............................................. 85 0.5716 17.6 14.7 

198 ........... 196 ........... Interstitial lung disease w/o CC/MCC .................................. 40 0.5059 15.9 13.3 


jlentini on PROD1PC65 with PROPOSALS2
23894 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

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/MCC ............................................... 5 0.4824 19.6 16.3 

202 ........... 202 ........... Bronchitis & asthma w CC/MCC ......................................... 88 0.6509 19.6 16.3 

203 ........... 202 ........... Bronchitis & asthma w/o CC/MCC ...................................... 21 0.6327 21.6 18.0 

204 ........... 204 ........... Respiratory signs & symptoms ............................................ 233 0.8315 22.8 19.0 

205 ........... 205 ........... Other respiratory system diagnoses w MCC ...................... 324 0.8236 22.3 18.6 

206 ........... 205 ........... Other respiratory system diagnoses w/o MCC ................... 171 0.7182 21.5 17.9 

207 ........... 207 ........... Respiratory system diagnosis w ventilator support 96+ 

hours.

13,186 2.0793 34.5 28.8 

208 ........... 208 ........... Respiratory system diagnosis w ventilator support <96 

hours.

1,452 1.1752 23.6 19.7 

215 ........... 215 ........... Other heart assist system implant ....................................... 0 0.8596 25.2 21.0 

216 ........... 216 ........... Cardiac valve & oth maj cardiothoracic proc w card cath w 

MMCC.

0 1.2617 31.5 26.3 

217 ........... 216 ........... Cardiac valve & oth maj cardiothoracic proc w card cath w 

MCC.

0 0.8596 25.2 21.0 

218 ........... 216 ........... Cardiac valve & oth maj cardiothoracic proc w card cath 

w/o CC/MMCC.

0 0.8596 25.2 21.0 

219 ........... 219 ........... Cardiac valve & oth maj cardiothoracic proc w/o card cath 

w MMCC.

0 1.2617 31.5 26.3 

220 ........... 219 ........... Cardiac valve & oth maj cardiothoracic proc w/o card cath 

w MCC.

0 0.8596 25.2 21.0 

221 ........... 219 ........... Cardiac valve & oth maj cardiothoracic proc w/o card cath 

w/o CC/MCC.

0 0.8596 25.2 21.0 

222 ........... 222 ........... Cardiac defib implant w cardiac cath w AMI/HF/shock w 

MMCC.

0 1.7509 37.9 31.6 

223 ........... 222 ........... Cardiac defib implant w cardiac cath w AMI/HF/shock w/o 

MMCC.

0 1.7509 37.9 31.6 

224 ........... 224 ........... Cardiac defib implant w cardiac cath w/o AMI/HF/shock w 

MMCC.

0 1.7509 37.9 31.6 

225 ........... 224 ........... Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/ 

o MMCC.

0 1.7509 37.9 31.6 

226 ........... 226 ........... Cardiac defibrillator implant w/o cardiac cath w MMCC ..... 11 1.7509 37.9 31.6 

227 ........... 226 ........... Cardiac defibrillator implant w/o cardiac cath w/o MMCC .. 9 1.7509 37.9 31.6 

228 ........... 228 ........... Other cardiothoracic procedures w MMCC ......................... 0 1.4637 33.3 27.8 

229 ........... 228 ........... Other cardiothoracic procedures w MCC ............................ 0 1.2121 28.9 24.1 

230 ........... 228 ........... Other cardiothoracic procedures w/o CC/MMCC ................ 0 0.6327 21.6 18.0 

231 ........... 231 ........... Coronary bypass w PTCA w MMCC ................................... 0 1.2617 31.5 26.3 

232 ........... 231 ........... Coronary bypass w PTCA w/o MMCC ................................ 0 0.8596 25.2 21.0 

233 ........... 233 ........... Coronary bypass w cardiac cath w MMCC ......................... 0 1.2617 31.5 26.3 

234 ........... 233 ........... Coronary bypass w cardiac cath w/o MMCC ...................... 0 0.8596 25.2 21.0 

235 ........... 235 ........... Coronary bypass w/o cardiac cath w MMCC ...................... 0 1.2617 31.5 26.3 

236 ........... 235 ........... Coronary bypass w/o cardiac cath w/o MMCC ................... 0 0.8596 25.2 21.0 

237 ........... 237 ........... Major cardiovascular procedures w MMCC ........................ 7 1.2617 31.5 26.3 

238 ........... 237 ........... Major cardiovascular procedures w/o MMCC ..................... 2 0.8596 25.2 21.0 

239 ........... 239 ........... Amputation for circ sys disorders exc upper limb & toe w 

MMCC.

163 1.5067 36.6 30.5 

240 ........... 239 ........... Amputation for circ sys disorders exc upper limb & toe w 

MCC.

83 1.1559 34.1 28.4 

241 ........... 239 ........... Amputation for circ sys disorders exc upper limb & toe w/o 

CC/MMCC.

10 0.8596 25.2 21.0 

242 ........... 242 ........... Permanent cardiac pacemaker implant w MCC* ................ 12 1.7509 37.9 31.6 

243 ........... 242 ........... Permanent cardiac pacemaker implant w MCC .................. 5 1.7509 37.9 31.6 

244 ........... 242 ........... Permanent cardiac pacemaker implant w/o CC/MMCC ..... 1 1.7509 37.9 31.6 

245 ........... 245 ........... AICD generator procedures ................................................. 0 1.7509 37.9 31.6 

246 ........... 246 ........... Percutaneous cardiovascular proc w drug-eluting stent w 

MMCC.

3 1.2617 31.5 26.3 

247 ........... 246 ........... Percutaneous cardiovascular proc w drug-eluting stent w/o 

MMCC.

1 1.2617 31.5 26.3 

248 ........... 248 ........... Percutaneous cardiovasc proc w non-drug-eluting stent w 

MMCC.

2 1.2617 31.5 26.3 

249 ........... 248 ........... Percutaneous cardiovasc proc w non-drug-eluting stent w/ 

o MCC*.

1 1.2617 31.5 26.3 

250 ........... 250 ........... Perc cardiovasc proc w/o coronary artery stent or AMI w 

MMCC.

3 1.7509 37.9 31.6 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23895 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

251 ........... 250 ........... Perc cardiovasc proc w/o coronary artery stent or AMI w/o 

MMCC.

0 1.7509 37.9 31.6 

252 ........... 252 ........... Other vascular procedures w MMCC .................................. 134 1.4637 33.3 27.8 

253 ........... 252 ........... Other vascular procedures w MCC ..................................... 51 1.2121 28.9 24.1 

254 ........... 252 ........... Other vascular procedures w/o CC/MMCC ......................... 3 0.6327 21.6 18.0 

255 ........... 255 ........... Upper limb & toe amputation for circ system disorders w 

MMCC.

61 1.2589 33.8 28.2 

256 ........... 255 ........... Upper limb & toe amputation for circ system disorders w 

MCC.

42 0.9416 30.0 25.0 

257 ........... 255 ........... Upper limb & toe amputation for circ system disorders w/o 

CC/MMCC.

1 0.4824 19.6 16.3 

258 ........... 258 ........... Cardiac pacemaker device replacement w MMCC ............. 0 1.2617 31.5 26.3 

259 ........... 258 ........... Cardiac pacemaker device replacement w/o MMCC .......... 1 1.2617 31.5 26.3 

260 ........... 260 ........... Cardiac pacemaker revision except device replacement w 

MMCC.

2 1.2617 31.5 26.3 

261 ........... 260 ........... Cardiac pacemaker revision except device replacement w 

CC*.

1 0.8596 25.2 21.0 

262 ........... 260 ........... Cardiac pacemaker revision except device replacement w/ 

o CC/MCC*.

1 0.8596 25.2 21.0 

263 ........... 263 ........... Vein ligation & stripping ....................................................... 3 0.4824 19.6 16.3 

264 ........... 264 ........... Other circulatory system O.R. procedures .......................... 608 1.0954 31.1 25.9 

265 ........... 265 ........... AICD lead procedures ......................................................... 0 1.2617 31.5 26.3 

280 ........... 280 ........... Circulatory disorders w AMI, discharged alive w MMCC .... 259 0.7832 23.0 19.2 

281 ........... 280 ........... Circulatory disorders w AMI, discharged alive w MCC ....... 110 0.5772 20.6 17.2 

282 ........... 280 ........... Circulatory disorders w AMI, discharged alive w/o CC/ 

MMCC.

35 0.5060 19.9 16.6 

283 ........... 283 ........... Circulatory disorders w AMI, expired w MMCC .................. 56 0.7924 16.1 13.4 

284 ........... 283 ........... Circulatory disorders w AMI, expired w CC* ....................... 17 0.7924 16.1 13.4 

285 ........... 283 ........... Circulatory disorders w AMI, expired w/o CC/MMCC ......... 0 0.7924 16.1 13.4 

286 ........... 286 ........... Circulatory disorders except AMI, w card cath w MMCC ... 8 1.2617 31.5 26.3 

287 ........... 286 ........... Circulatory disorders except AMI, w card cath w/o MMCC 9 0.8596 25.2 21.0 

288 ........... 288 ........... Acute & subacute endocarditis w MMCC ............................ 594 1.0060 26.1 21.8 

289 ........... 288 ........... Acute & subacute endocarditis w MCC ............................... 217 0.7920 26.1 21.8 

290 ........... 288 ........... Acute & subacute endocarditis w/o CC/MMCC .................. 48 0.6873 24.3 20.3 

291 ........... 291 ........... Heart failure & shock w MMCC ........................................... 1,728 0.7727 21.9 18.3 

292 ........... 291 ........... Heart failure & shock w MCC .............................................. 901 0.6294 21.2 17.7 

293 ........... 291 ........... Heart failure & shock w/o CC/MMCC .................................. 362 0.5168 18.8 15.7 

294 ........... 294 ........... Deep vein thrombophlebitis w CC/MMCC ........................... 6 0.6327 21.6 18.0 

295 ........... 294 ........... Deep vein thrombophlebitis w/o CC/MMCC ........................ 0 0.6327 21.6 18.0 

296 ........... 296 ........... Cardiac arrest, unexplained w MMCC ................................ 0 0.7924 16.1 13.4 

297 ........... 296 ........... Cardiac arrest, unexplained w MCC ................................... 0 0.7924 16.1 13.4 

298 ........... 296 ........... Cardiac arrest, unexplained w/o CC/MMCC ....................... 0 0.7924 16.1 13.4 

299 ........... 299 ........... Peripheral vascular disorders w MMCC .............................. 587 0.7804 23.4 19.5 

300 ........... 299 ........... Peripheral vascular disorders w MCC ................................. 751 0.5847 22.0 18.3 

301 ........... 299 ........... Peripheral vascular disorders w/o CC/MMCC ..................... 78 0.5385 20.3 16.9 

302 ........... 302 ........... Atherosclerosis w MMCC .................................................... 59 0.7597 21.8 18.2 

303 ........... 302 ........... Atherosclerosis w/o MMCC ................................................. 61 0.5692 20.1 16.8 

304 ........... 304 ........... Hypertension w MMCC ........................................................ 6 0.4824 19.6 16.3 

305 ........... 304 ........... Hypertension w/o MMCC ..................................................... 15 0.4824 19.6 16.3 

306 ........... 306 ........... Cardiac congenital & valvular disorders w MMCC .............. 59 0.8224 22.7 18.9 

307 ........... 306 ........... Cardiac congenital & valvular disorders w/o MMCC ........... 38 0.7367 22.9 19.1 

308 ........... 308 ........... Cardiac arrhythmia & conduction disorders w MMCC ........ 96 0.8384 25.0 20.8 

309 ........... 308 ........... Cardiac arrhythmia & conduction disorders w MCC ........... 107 0.5679 20.8 17.3 

310 ........... 308 ........... Cardiac arrhythmia & conduction disorders w/o CC/MCC .. 36 0.4590 19.4 16.2 

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 system diagnoses w MMCC .................... 1,305 0.8758 22.9 19.1 

315 ........... 314 ........... Other circulatory system diagnoses w MCC ....................... 285 0.6575 21.0 17.5 

316 ........... 314 ........... Other circulatory system diagnoses w/o CC/MMCC ........... 72 0.6026 21.0 17.5 

326 ........... 326 ........... Stomach, esophageal & duodenal proc w MMCC .............. 19 1.7509 37.9 31.6 

327 ........... 326 ........... Stomach, esophageal & duodenal proc w MCC ................. 3 1.2617 31.5 26.3 

328 ........... 326 ........... Stomach, esophageal & duodenal proc w/o CC/MCC* ...... 1 1.2617 31.5 26.3 

329 ........... 329 ........... Major small & large bowel procedures w MMCC ................ 31 2.2757 41.8 34.8 

330 ........... 329 ........... Major small & large bowel procedures w MCC ................... 12 1.7509 37.9 31.6 

331 ........... 329 ........... Major small & large bowel procedures w/o CC/MMCC ...... 1 1.7509 37.9 31.6 

332 ........... 332 ........... Rectal resection w MMCC ................................................... 0 1.6757 34.2 28.5 


jlentini on PROD1PC65 with PROPOSALS2
23896 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

333 ........... 332 ........... Rectal resection w MCC ...................................................... 0 1.1606 30.0 25.0 

334 ........... 332 ........... Rectal resection w/o CC/MMCC .......................................... 0 1.1606 30.0 25.0 

335 ........... 335 ........... Peritoneal adhesiolysis w MMCC ........................................ 6 1.7509 37.9 31.6 

336 ........... 335 ........... Peritoneal adhesiolysis w MCC ........................................... 0 1.7509 37.9 31.6 

337 ........... 335 ........... Peritoneal adhesiolysis w/o CC/MMCC ............................... 0 1.7509 37.9 31.6 

338 ........... 338 ........... Appendectomy w complicated principal diag w MMCC ...... 0 0.9726 25.1 20.9 

339 ........... 338 ........... Appendectomy w complicated principal diag w MCC ......... 0 0.7768 23.2 19.3 

340 ........... 338 ........... Appendectomy w complicated principal diag w/o CC/ 

MMCC.

0 0.5958 19.6 16.3 

341 ........... 341 ........... Appendectomy w/o complicated principal diag w MMCC ... 0 0.9726 25.1 20.9 

342 ........... 341 ........... Appendectomy w/o complicated principal diag w MCC ...... 0 0.7768 23.2 19.3 

343 ........... 341 ........... Appendectomy w/o complicated principal diag w/o CC/ 

MMCC.

0 0.5958 19.6 16.3 

344 ........... 344 ........... Minor small & large bowel procedures w MMCC ................ 5 1.7509 37.9 31.6 

345 ........... 344 ........... Minor small & large bowel procedures w MCC ................... 0 1.7509 37.9 31.6 

346 ........... 344 ........... Minor small & large bowel procedures w/o CC/MMCC ...... 0 1.7509 37.9 31.6 

347 ........... 347 ........... Anal & stomal procedures w MMCC ................................... 3 1.7509 37.9 31.6 

348 ........... 347 ........... Anal & stomal procedures w MCC ...................................... 3 1.2617 31.5 26.3 

349 ........... 347 ........... Anal & stomal procedures w/o CC/MMCC .......................... 0 1.2617 31.5 26.3 

350 ........... 350 ........... Inguinal & femoral hernia procedures w MMCC ................. 0 1.2617 31.5 26.3 

351 ........... 350 ........... Inguinal & femoral hernia procedures w MCC .................... 0 1.2617 31.5 26.3 

352 ........... 350 ........... Inguinal & femoral hernia procedures w/o CC/MMCC ........ 0 1.2617 31.5 26.3 

353 ........... 353 ........... Hernia procedures except inguinal & femoral w MMCC ..... 1 1.7509 37.9 31.6 

354 ........... 353 ........... Hernia procedures except inguinal & femoral w MCC ........ 1 0.6327 21.6 18.0 

355 ........... 353 ........... Hernia procedures except inguinal & femoral w/o CC/ 

MMCC.

0 0.6327 21.6 18.0 

356 ........... 356 ........... Other digestive system O.R. procedures w MMCC ............ 141 1.6757 34.2 28.5 

357 ........... 356 ........... Other digestive system O.R. procedures w MCC ............... 36 1.1606 30.0 25.0 

358 ........... 356 ........... Other digestive system O.R. procedures w/o CC/MCC* .... 4 1.1606 30.0 25.0 

368 ........... 368 ........... Major esophageal disorders w MMCC ................................ 26 0.9161 21.1 17.6 

369 ........... 368 ........... Major esophageal disorders w MCC ................................... 14 0.8596 25.2 21.0 

370 ........... 368 ........... Major esophageal disorders w/o CC/MMCC ....................... 4 0.8596 25.2 21.0 

371 ........... 371 ........... Major gastrointestinal disorders & peritoneal infections w 

MMCC.

722 0.9726 25.1 20.9 

372 ........... 371 ........... Major gastrointestinal disorders & peritoneal infections w 

MCC.

350 0.7768 23.2 19.3 

373 ........... 371 ........... Major gastrointestinal disorders & peritoneal infections w/o 

CC/MCC.

68 0.5958 19.6 16.3 

374 ........... 374 ........... Digestive malignancy w MMCC ........................................... 96 0.9011 21.5 17.9 

375 ........... 374 ........... Digestive malignancy w MCC .............................................. 90 0.7804 23.4 19.5 

376 ........... 374 ........... Digestive malignancy w/o CC/MMCC ................................. 3 0.6327 21.6 18.0 

377 ........... 377 ........... G.I. hemorrhage w MMCC .................................................. 90 0.8200 23.8 19.8 

378 ........... 377 ........... G.I. hemorrhage w MCC ..................................................... 53 0.6902 23.8 19.8 

379 ........... 377 ........... G.I. hemorrhage w/o CC/MMCC ......................................... 18 0.6327 21.6 18.0 

380 ........... 380 ........... Complicated peptic ulcer w MMCC ..................................... 22 0.8596 25.2 21.0 

381 ........... 380 ........... Complicated peptic ulcer w MCC ........................................ 17 0.6327 21.6 18.0 

382 ........... 380 ........... Complicated peptic ulcer w/o CC/MMCC ............................ 5 0.4824 19.6 16.3 

383 ........... 383 ........... Uncomplicated peptic ulcer w MMCC ................................. 0 0.8596 25.2 21.0 

384 ........... 383 ........... Uncomplicated peptic ulcer w/o MMCC .............................. 7 0.8596 25.2 21.0 

385 ........... 385 ........... Inflammatory bowel disease w MMCC ................................ 36 0.8076 23.3 19.4 

386 ........... 385 ........... Inflammatory bowel disease w MCC ................................... 37 0.7126 23.1 19.3 

387 ........... 385 ........... Inflammatory bowel disease w/o CC/MMCC ....................... 5 0.4824 19.6 16.3 

388 ........... 388 ........... G.I. obstruction w MMCC .................................................... 213 0.9486 22.5 18.8 

389 ........... 388 ........... G.I. obstruction w MCC ....................................................... 97 0.7302 20.9 17.4 

390 ........... 388 ........... G.I. obstruction w/o CC/MMCC ........................................... 17 0.6327 21.6 18.0 

391 ........... 391 ........... Esophagitis, gastroent & misc digest disorders w MMCC .. 255 0.7914 21.9 18.3 

392 ........... 391 ........... Esophagitis, gastroent & misc digest disorders w/o MMCC 292 0.6568 21.0 17.5 

393 ........... 393 ........... Other digestive system diagnoses w MMCC ...................... 779 1.0684 25.7 21.4 

394 ........... 393 ........... Other digestive system diagnoses w MCC ......................... 449 0.7872 22.6 18.8 

395 ........... 393 ........... Other digestive system diagnoses w/o CC/MMCC ............. 33 0.5783 22.1 18.4 

405 ........... 405 ........... Pancreas, liver & shunt procedures w MMCC .................... 10 1.2617 31.5 26.3 

406 ........... 405 ........... Pancreas, liver & shunt procedures w CC* ......................... 2 1.2617 31.5 26.3 

407 ........... 405 ........... Pancreas, liver & shunt procedures w/o CC/MMCC ........... 0 1.2617 31.5 26.3 

408 ........... 408 ........... Biliary tract proc except only cholecyst w or w/o c.d.e. w 

MMCC.

0 0.6327 21.6 18.0 

409 ........... 408 ........... Biliary tract proc except only cholecyst w or w/o c.d.e. w 

MCC.

1 0.6327 21.6 18.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23897 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

410 ........... 408 ........... Biliary tract proc except only cholecyst w or w/o c.d.e. w/o 

CC/MMCC.

0 0.6327 21.6 18.0 

411 ........... 411 ........... Cholecystectomy w c.d.e. w MMCC .................................... 1 1.7509 37.9 31.6 

412 ........... 411 ........... Cholecystectomy w c.d.e. w MCC ....................................... 0 1.7509 37.9 31.6 

413 ........... 411 ........... Cholecystectomy w c.d.e. w/o CC/MMCC .......................... 0 1.7509 37.9 31.6 

414 ........... 414 ........... Cholecystectomy except by laparoscope w/o c.d.e. w 

MMCC.

2 1.7509 37.9 31.6 

415 ........... 414 ........... Cholecystectomy except by laparoscope w/o c.d.e. w 

MCC.

3 1.7509 37.9 31.6 

416 ........... 414 ........... Cholecystectomy except by laparoscope w/o c.d.e. w/o 

CC/MMCC.

0 1.7509 37.9 31.6 

417 ........... 417 ........... Laparoscopic cholecystectomy w/o c.d.e. w MCC* ............ 11 1.7509 37.9 31.6 

418 ........... 417 ........... Laparoscopic cholecystectomy w/o c.d.e. w MCC .............. 5 1.7509 37.9 31.6 

419 ........... 417 ........... Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MMCC .. 0 1.7509 37.9 31.6 

420 ........... 420 ........... Hepatobiliary diagnostic procedures w MMCC ................... 0 0.8596 25.2 21.0 

421 ........... 420 ........... Hepatobiliary diagnostic procedures w MCC ...................... 0 0.8596 25.2 21.0 

422 ........... 420 ........... Hepatobiliary diagnostic procedures w/o CC/MMCC .......... 0 0.8596 25.2 21.0 

423 ........... 423 ........... Other hepatobiliary or pancreas O.R. procedures w 

MMCC.

23 1.7509 37.9 31.6 

424 ........... 423 ........... Other hepatobiliary or pancreas O.R. procedures w MCC 2 0.8596 25.2 21.0 

425 ........... 423 ........... Other hepatobiliary or pancreas O.R. procedures w/o CC/ 

MMCC.

0 0.8596 25.2 21.0 

432 ........... 432 ........... Cirrhosis & alcoholic hepatitis w MMCC ............................. 73 0.6977 20.9 17.4 

433 ........... 432 ........... Cirrhosis & alcoholic hepatitis w MCC ................................ 24 0.6327 21.6 18.0 

434 ........... 432 ........... Cirrhosis & alcoholic hepatitis w/o CC/MMCC .................... 0 0.6327 21.6 18.0 

435 ........... 435 ........... Malignancy of hepatobiliary system or pancreas w MMCC 53 0.8340 22.0 18.3 

436 ........... 435 ........... Malignancy of hepatobiliary system or pancreas w MCC ... 26 0.4904 17.2 14.3 

437 ........... 435 ........... Malignancy of hepatobiliary system or pancreas w/o CC/ 

MMCC.

4 0.4824 19.6 16.3 

438 ........... 438 ........... Disorders of pancreas except malignancy w MMCC .......... 243 1.0807 23.5 19.6 

439 ........... 438 ........... Disorders of pancreas except malignancy w MCC ............. 144 0.7533 22.0 18.3 

440 ........... 438 ........... Disorders of pancreas except malignancy w/o CC/MMCC 24 0.6327 21.6 18.0 

441 ........... 441 ........... Disorders of liver except malig,cirr,alc hepa w MMCC ....... 123 0.8206 23.1 19.3 

442 ........... 441 ........... Disorders of liver except malig,cirr,alc hepa w MCC .......... 62 0.7145 21.7 18.1 

443 ........... 441 ........... Disorders of liver except malig,cirr,alc hepa w/o CC/ 

MMCC.

14 0.4824 19.6 16.3 

444 ........... 444 ........... Disorders of the biliary tract w MMCC ................................ 104 0.8334 22.7 18.9 

445 ........... 444 ........... Disorders of the biliary tract w MCC ................................... 35 0.6140 20.7 17.3 

446 ........... 444 ........... Disorders of the biliary tract w/o CC/MCC* ......................... 8 0.6140 20.7 17.3 

453 ........... 453 ........... Combined anterior/posterior spinal fusion w MMCC ........... 0 1.7509 37.9 31.6 

454 ........... 453 ........... Combined anterior/posterior spinal fusion w MCC .............. 0 1.7509 37.9 31.6 

455 ........... 453 ........... Combined anterior/posterior spinal fusion w/o CC/MMCC 0 1.7509 37.9 31.6 

456 ........... 456 ........... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions 

w MMCC.

1 1.7509 37.9 31.6 

457 ........... 456 ........... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions 

w MCC.

3 1.7509 37.9 31.6 

458 ........... 456 ........... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions 

w/o CC/MMCC.

0 1.7509 37.9 31.6 

459 ........... 459 ........... Spinal fusion except cervical w MMCC ............................... 1 1.7509 37.9 31.6 

460 ........... 459 ........... Spinal fusion except cervical w/o MMCC ............................ 0 1.7509 37.9 31.6 

461 ........... 461 ........... Bilateral or multiple major joint procs of lower extremity w 

MMCC.

0 1.7509 37.9 31.6 

462 ........... 461 ........... Bilateral or multiple major joint procs of lower extremity w/ 

o MMCC.

0 0.8596 25.2 21.0 

463 ........... 463 ........... Wnd debrid & skn grft exc hand, for musculo-conn tiss dis 

w MMCC.

526 1.4126 38.7 32.3 

464 ........... 463 ........... Wnd debrid & skn grft exc hand, for musculo-conn tiss dis 

w MCC.

311 1.0643 34.0 28.3 

465 ........... 463 ........... Wnd debrid & skn grft exc hand, for musculo-conn tiss dis 

w/o CC/MCC.

61 0.9863 34.0 28.3 

466 ........... 466 ........... Revision of hip or knee replacement w MMCC .................. 3 1.2617 31.5 26.3 

467 ........... 466 ........... Revision of hip or knee replacement w MCC ..................... 4 1.2617 31.5 26.3 

468 ........... 466 ........... Revision of hip or knee replacement w/o CC/MMCC ......... 1 0.4824 19.6 16.3 

469 ........... 469 ........... Major joint replacement or reattachment of lower extremity 

w MCC*.

3 1.7509 37.9 31.6 

470 ........... 469 ........... Major joint replacement or reattachment of lower extremity 

w/o MMCC.

3 1.7509 37.9 31.6 


jlentini on PROD1PC65 with PROPOSALS2
23898 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

471 ........... 471 ........... Cervical spinal fusion w MMCC .......................................... 2 0.8596 25.2 21.0 

472 ........... 471 ........... Cervical spinal fusion w MCC ............................................. 1 0.8596 25.2 21.0 

473 ........... 471 ........... Cervical spinal fusion w/o CC/MMCC ................................. 0 0.8596 25.2 21.0 

474 ........... 474 ........... Amputation for musculoskeletal sys & conn tissue dis w 

MMCC.

91 1.5642 38.4 32.0 

475 ........... 474 ........... Amputation for musculoskeletal sys & conn tissue dis w 

MCC.

67 1.1116 33.9 28.3 

476 ........... 474 ........... Amputation for musculoskeletal sys & conn tissue dis w/o 

CC/MMCC.

4 0.8596 25.2 21.0 

477 ........... 477 ........... Biopsies of musculoskeletal system & connective tissue w 

MMCC.

22 1.7509 37.9 31.6 

478 ........... 477 ........... Biopsies of musculoskeletal system & connective tissue w 

MCC.

12 1.2617 31.5 26.3 

479 ........... 477 ........... Biopsies of musculoskeletal system & connective tissue w/ 

o CC/MMCC.

0 1.2617 31.5 26.3 

480 ........... 480 ........... Hip & femur procedures except major joint w MMCC ........ 21 1.7509 37.9 31.6 

481 ........... 480 ........... Hip & femur procedures except major joint w MCC ........... 11 1.2617 31.5 26.3 

482 ........... 480 ........... Hip & femur procedures except major joint w/o CC/MMCC 2 0.8596 25.2 21.0 

483 ........... 483 ........... Major joint & limb reattachment proc of upper extremity w 

CC/MMCC.

0 1.7509 37.9 31.6 

484 ........... 483 ........... Major joint & limb reattachment proc of upper extremity w/ 

o CC/MMCC.

0 0.8596 25.2 21.0 

485 ........... 485 ........... Knee procedures w pdx of infection w MMCC .................... 10 1.2617 31.5 26.3 

486 ........... 485 ........... Knee procedures w pdx of infection w MCC ....................... 10 1.2617 31.5 26.3 

487 ........... 485 ........... Knee procedures w pdx of infection w/o CC/MCC* ............ 2 1.2617 31.5 26.3 

488 ........... 488 ........... Knee procedures w/o pdx of infection w CC/MMCC .......... 1 1.7509 37.9 31.6 

489 ........... 488 ........... Knee procedures w/o pdx of infection w/o CC/MMCC ....... 1 0.6327 21.6 18.0 

490 ........... 490 ........... Back & neck procedures except spinal fusion w CC/MCC 

or disc devices.

8 1.2617 31.5 26.3 

491 ........... 490 ........... Back & neck procedures except spinal fusion w/o CC/ 

MMCC.

0 1.2617 31.5 26.3 

492 ........... 492 ........... Lower extrem & humer proc except hip, foot, femur w 

MMCC.

10 1.2617 31.5 26.3 

493 ........... 492 ........... Lower extrem & humer proc except hip, foot, femur w 

MCC.

10 1.2617 31.5 26.3 

494 ........... 492 ........... Lower extrem & humer proc except hip, foot, femur w/o 

CC/MMCC.

1 0.8596 25.2 21.0 

495 ........... 495 ........... Local excision & removal int fix devices exc hip & femur w 

MMCC.

42 1.2616 36.9 30.8 

496 ........... 495 ........... Local excision & removal int fix devices exc hip & femur w 

CC*.

20 1.2616 36.9 30.8 

497 ........... 495 ........... Local excision & removal int fix devices exc hip & femur 

w/o CC/MCC*.

5 1.2616 36.9 30.8 

498 ........... 498 ........... Local excision & removal int fix devices of hip & femur w 

CC/MCC.

9 1.7509 37.9 31.6 

499 ........... 498 ........... Local excision & removal int fix devices of hip & femur w/o 

CC/MCC.

0 1.7509 37.9 31.6 

500 ........... 500 ........... Soft tissue procedures w MMCC ......................................... 68 1.3427 36.7 30.6 

501 ........... 500 ........... Soft tissue procedures w MCC ............................................ 28 1.0746 33.3 27.8 

502 ........... 500 ........... Soft tissue procedures w/o CC/MMCC ............................... 4 0.8596 25.2 21.0 

503 ........... 503 ........... Foot procedures w MMCC .................................................. 15 1.2617 31.5 26.3 

504 ........... 503 ........... Foot procedures w MCC ..................................................... 22 0.8596 25.2 21.0 

505 ........... 503 ........... Foot procedures w/o CC/MMCC ......................................... 3 0.8596 25.2 21.0 

506 ........... 506 ........... Major thumb or joint procedures ......................................... 0 1.2617 31.5 26.3 

507 ........... 507 ........... Major shoulder or elbow joint procedures w CC/MMCC ..... 1 1.7509 37.9 31.6 

508 ........... 507 ........... Major shoulder or elbow joint procedures w/o CC/MMCC .. 0 1.7509 37.9 31.6 

509 ........... 509 ........... Arthroscopy .......................................................................... 0 0.8596 25.2 21.0 

510 ........... 510 ........... Shoulder, elbow or forearm proc, exc major joint proc w 

MCC*.

1 0.8596 25.2 21.0 

511 ........... 510 ........... Shoulder, elbow or forearm proc, exc major joint proc w 

CC*.

2 0.8596 25.2 21.0 

512 ........... 510 ........... Shoulder, elbow or forearm proc, exc major joint proc w/o 

CC/MCC.

0 0.8596 25.2 21.0 

513 ........... 513 ........... Hand or wrist proc, except major thumb or joint proc w 

CC/MMCC.

6 1.2617 31.5 26.3 

514 ........... 513 ........... Hand or wrist proc, except major thumb or joint proc w/o 

CC/MCC*.

1 1.2617 31.5 26.3 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23899 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

515 ........... 515 ........... Other musculoskelet sys & conn tiss O.R. proc w MMCC 60 1.3728 31.5 26.3 

516 ........... 515 ........... Other musculoskelet sys & conn tiss O.R. proc w MCC .... 27 0.9133 28.0 23.3 

517 ........... 515 ........... Other musculoskelet sys & conn tiss O.R. proc w/o CC/ 

MMCC.

0 0.9133 28.0 23.3 

533 ........... 533 ........... Fractures of femur w MMCC ............................................... 3 0.6327 21.6 18.0 

534 ........... 533 ........... Fractures of femur w/o MMCC ............................................ 6 0.6327 21.6 18.0 

535 ........... 535 ........... Fractures of hip & pelvis w MMCC ..................................... 16 0.8596 25.2 21.0 

536 ........... 535 ........... Fractures of hip & pelvis w/o MMCC .................................. 25 0.6130 26.9 22.4 

537 ........... 537 ........... Sprains, strains, & dislocations of hip, pelvis & thigh w 

CC/MMCC.

1 0.4824 19.6 16.3 

538 ........... 537 ........... Sprains, strains, & dislocations of hip, pelvis & thigh w/o 

CC/MCC.

0 0.4824 19.6 16.3 

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/MMCC .............................................. 227 0.6901 27.1 22.6 

542 ........... 542 ........... Pathological fractures & musculoskelet & conn tiss malig 

w MMCC.

23 0.8596 25.2 21.0 

543 ........... 542 ........... Pathological fractures & musculoskelet & conn tiss malig 

w MCC.

42 0.5682 20.5 17.1 

544 ........... 542 ........... Pathological fractures & musculoskelet & conn tiss malig 

w/o CC/MMCC.

17 0.4824 19.6 16.3 

545 ........... 545 ........... Connective tissue disorders w MMCC ................................ 50 0.9093 23.5 19.6 

546 ........... 545 ........... Connective tissue disorders w MCC ................................... 38 0.8478 25.5 21.3 

547 ........... 545 ........... Connective tissue disorders w/o CC/MMCC ....................... 5 0.4824 19.6 16.3 

548 ........... 548 ........... Septic arthritis w MMCC ...................................................... 172 0.8843 26.1 21.8 

549 ........... 548 ........... Septic arthritis w MCC ......................................................... 200 0.7080 26.9 22.4

550 ........... 548 ........... Septic arthritis w/o CC/MMCC ............................................. 73 0.6067 24.2 20.2 

551 ........... 551 ........... Medical back problems w MMCC ........................................ 83 0.8867 26.5 22.1 

552 ........... 551 ........... Medical back problems w/o MMCC ..................................... 156 0.6146 24.2 20.2 

553 ........... 553 ........... Bone diseases & arthropathies w MMCC ........................... 15 0.6327 21.6 18.0 

554 ........... 553 ........... Bone diseases & arthropathies w/o MMCC ........................ 59 0.5022 21.3 17.8 

555 ........... 555 ........... Signs & symptoms of musculoskeletal system & conn tissue w MMCC.3 0.8596 25.2 21.0 

556 ........... 555 ........... Signs & symptoms of musculoskeletal system & conn tissue w/o MCC.8 0.4824 19.6 16.3 

557 ........... 557 ........... Tendonitis, myositis & bursitis w MMCC ............................. 84 0.8284 24.6 20.5 

558 ........... 557 ........... Tendonitis, myositis & bursitis w/o MMCC .......................... 134 0.6519 23.0 19.2 

559 ........... 559 ........... Aftercare, musculoskeletal system & connective tissue w 

MMCC.

1,368 0.8146 26.1 21.8 

560 ........... 559 ........... Aftercare, musculoskeletal system & connective tissue w 

MCC.

1,613 0.6469 24.7 20.6 

561 ........... 559 ........... Aftercare, musculoskeletal system & connective tissue w/o 

CC/MMCC.

730 0.5579 22.8 19.0 

562 ........... 562 ........... Fx, sprn, strn & disl except femur, hip, pelvis & thigh w 

MMCC.

5 0.8596 25.2 21.0 

563 ........... 562 ........... Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o 

MMCC.

9 0.4824 19.6 16.3 

564 ........... 564 ........... Other musculoskeletal sys & connective tissue diagnoses 

w MMCC.

307 0.8803 24.2 20.2 

565 ........... 564 ........... Other musculoskeletal sys & connective tissue diagnoses 

w MCC.

199 0.6473 22.7 18.9 

566 ........... 564 ........... Other musculoskeletal sys & connective tissue diagnoses 

w/o CC/MMCC.

60 0.6236 22.5 18.8 

573 ........... 573 ........... Skin graft &/or debrid for skn ulcer or cellulitis w MMCC ... 1,814 1.3944 38.2 31.8 

574 ........... 573 ........... Skin graft &/or debrid for skn ulcer or cellulitis w MCC ...... 1,761 1.0779 36.0 30.0 

575 ........... 573 ........... Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/ 

MMCC.

200 0.9033 30.1 25.1 

576 ........... 576 ........... Skin graft &/or debrid exc for skin ulcer or cellulitis w 

MMCC.

27 1.7840 37.6 31.3 

577 ........... 576 ........... Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC 28 0.8093 27.3 22.8 

578 ........... 576 ........... Skin graft &/or debrid exc for skin ulcer or cellulitis w/o 

CC/MMCC.

11 0.6327 21.6 18.0 

579 ........... 579 ........... Other skin, subcut tiss & breast proc w MMCC .................. 476 1.3648 36.5 30.4 

580 ........... 579 ........... Other skin, subcut tiss & breast proc w MCC ..................... 398 1.0585 33.5 27.9 

581 ........... 579 ........... Other skin, subcut tiss & breast proc w/o CC/MMCC ......... 34 0.8032 30.1 25.1 

582 ........... 582 ........... Mastectomy for malignancy w CC/MMCC .......................... 1 1.7509 37.9 31.6 

583 ........... 582 ........... Mastectomy for malignancy w/o CC/MMCC ....................... 0 1.7509 37.9 31.6 


jlentini on PROD1PC65 with PROPOSALS2
23900 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

584 ........... 584 ........... Breast biopsy, local excision & other breast procedures w 

CC/MMCC.

2 0.6327 21.6 18.0 

585 ........... 584 ........... Breast biopsy, local excision & other breast procedures w/ 

o CC/MMCC.

0 0.6327 21.6 18.0 

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/MMCC .................................................. 435 0.6109 24.8 20.7 

595 ........... 595 ........... Major skin disorders w MMCC ............................................ 28 0.8138 25.3 21.1 

596 ........... 595 ........... Major skin disorders w/o MMCC ......................................... 39 0.6547 22.4 18.7 

597 ........... 597 ........... Malignant breast disorders w MMCC .................................. 7 1.2617 31.5 26.3 

598 ........... 597 ........... Malignant breast disorders w MCC ..................................... 7 0.8596 25.2 21.0 

599 ........... 597 ........... Malignant breast disorders w/o CC/MCC* .......................... 1 0.8596 25.2 21.0 

600 ........... 600 ........... Non-malignant breast disorders w CC/MMCC .................... 17 0.8596 25.2 21.0 

601 ........... 600 ........... Non-malignant breast disorders w/o CC/MMCC ................. 6 0.4824 19.6 16.3 

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, subcut tiss & breast w MMCC ............ 29 0.8236 24.4 20.3 

605 ........... 604 ........... Trauma to the skin, subcut tiss & breast w/o MMCC ......... 53 0.6053 23.8 19.8 

606 ........... 606 ........... Minor skin disorders w MMCC ............................................ 63 0.8273 24.5 20.4 

607 ........... 606 ........... Minor skin disorders w/o MMCC ......................................... 93 0.5599 20.7 17.3 

614 ........... 614 ........... Adrenal & pituitary procedures w CC/MMCC ...................... 0 1.0449 32.5 27.1 

615 ........... 614 ........... Adrenal & pituitary procedures w/o CC/MMCC ................... 0 0.8596 25.2 21.0 

616 ........... 616 ........... Amputat of lower limb for endocrine, nutrit,& metabol dis 

w MMCC.

70 1.4804 38.4 32.0 

617 ........... 616 ........... Amputat of lower limb for endocrine, nutrit,& metabol dis 

w MCC.

132 1.1478 33.1 27.6 

618 ........... 616 ........... Amputat of lower limb for endocrine, nutrit,& metabol dis 

w/o CC/MMCC.

2 0.4824 19.6 16.3 

619 ........... 619 ........... O.R. procedures for obesity w MMCC ................................ 1 1.7509 37.9 31.6 

620 ........... 619 ........... O.R. procedures for obesity w MCC ................................... 0 1.7509 37.9 31.6 

621 ........... 619 ........... O.R. procedures for obesity w/o CC/MMCC ....................... 0 1.7509 37.9 31.6 

622 ........... 622 ........... Skin grafts & wound debrid for endoc, nutrit & metab dis 

w MCC.

171 1.2978 35.7 29.8 

623 ........... 622 ........... Skin grafts & wound debrid for endoc, nutrit & metab dis 

w MCC.

357 1.0065 30.9 25.8 

624 ........... 622 ........... Skin grafts & wound debrid for endoc, nutrit & metab dis 

w/o CC/MMCC.

21 0.6327 21.6 18.0 

625 ........... 625 ........... Thyroid, parathyroid & thyroglossal procedures w MMCC 1 1.2617 31.5 26.3 

626 ........... 625 ........... Thyroid, parathyroid & thyroglossal procedures w MCC .... 1 0.8596 25.2 21.0 

627 ........... 625 ........... Thyroid, parathyroid & thyroglossal procedures w/o CC/ 

MMCC.

0 0.8596 25.2 21.0 

628 ........... 628 ........... Other endocrine, nutrit & metab O.R. proc w MMCC ......... 48 1.3769 32.3 26.9 

629 ........... 628 ........... Other endocrine, nutrit & metab O.R. proc w MCC ............ 110 1.0449 32.5 27.1 

630 ........... 628 ........... Other endocrine, nutrit & metab O.R. proc w/o CC/MMCC 2 0.8596 25.2 21.0 

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 metabolic disorders w MMCC ................ 638 0.8424 23.1 19.3 

641 ........... 640 ........... Nutritional & misc metabolic disorders w/o MMCC ............. 548 0.6217 21.5 17.9 

642 ........... 642 ........... Inborn errors of metabolism ................................................ 5 0.4824 19.6 16.3 

643 ........... 643 ........... Endocrine disorders w MMCC ............................................. 30 0.6833 24.0 20.0 

644 ........... 643 ........... Endocrine disorders w MCC ................................................ 28 0.5393 21.1 17.6 

645 ........... 643 ........... Endocrine disorders w/o CC/MCC ...................................... 1 0.4824 19.6 16.3 

652 ........... 652 ........... Kidney transplant ................................................................. 0 0.0000 0.0 0.0 

653 ........... 653 ........... Major bladder procedures w MCC ...................................... 2 1.7509 37.9 31.6 

654 ........... 653 ........... Major bladder procedures w MCC ...................................... 0 1.7509 37.9 31.6 

655 ........... 653 ........... Major bladder procedures w/o CC/MMCC .......................... 0 1.7509 37.9 31.6 

656 ........... 656 ........... Kidney & ureter procedures for neoplasm w MMCC .......... 1 1.7509 37.9 31.6 

657 ........... 656 ........... Kidney & ureter procedures forneoplasm w MCC .............. 0 1.7509 37.9 31.6 

658 ........... 656 ........... Kidney & ureter procedures for neoplasm w/o CC/MMCC 0 1.7509 37.9 31.6 

659 ........... 659 ........... Kidney & ureter procedures for non-neoplasm w MMCC ... 6 1.2617 31.5 26.3 

660 ........... 659 ........... Kidney & ureter procedures for non-neoplasm w MCC ...... 6 1.2617 31.5 26.3 

661 ........... 659 ........... Kidney & ureter procedures for non-neoplasm w/o CC/ 

MMCC.

1 0.6327 21.6 18.0 

662 ........... 662 ........... Minor bladder procedures w MMCC ................................... 2 1.7509 37.9 31.6 

663 ........... 662 ........... Minor bladder procedures w MCC ...................................... 2 0.6327 21.6 18.0 

664 ........... 662 ........... Minor bladder procedures w/o CC/MCC ............................. 0 0.6327 21.6 18.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23901 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

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/MMCC ............................................. 0 0.8596 25.2 21.0 

668 ........... 668 ........... Transurethral procedures w MMCC .................................... 4 0.8596 25.2 21.0 

669 ........... 668 ........... Transurethral procedures w MCC ....................................... 3 0.6327 21.6 18.0 

670 ........... 668 ........... Transurethral procedures w/o CC/MMCC ........................... 0 0.6327 21.6 18.0 

671 ........... 671 ........... Urethral procedures w CC/MMCC ....................................... 1 0.6327 21.6 18.0 

672 ........... 671 ........... Urethral procedures w/o CC/MMCC .................................... 0 0.6327 21.6 18.0 

673 ........... 673 ........... Other kidney & urinary tract procedures w MMCC ............. 227 1.4418 33.8 28.2 

674 ........... 673 ........... Other kidney & urinary tract procedures w MCC ................ 67 1.1430 29.1 24.3 

675 ........... 673 ........... Other kidney & urinary tract procedures w/o CC/MMCC .... 0 1.1430 29.1 24.3 

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/MMCC ............................................... 91 0.6647 20.6 17.2 

685 ........... 685 ........... Admit for renal dialysis ........................................................ 32 0.8341 25.1 20.9

686 ........... 686 ........... Kidney & urinary tract neoplasms w MMCC ....................... 15 0.8596 25.2 21.0 

687 ........... 686 ........... Kidney & urinary tract neoplasms w MCC .......................... 18 0.8596 25.2 21.0 

688 ........... 686 ........... Kidney & urinary tract neoplasms w/o CC/MMCC .............. 3 0.6327 21.6 18.0 

689 ........... 689 ........... Kidney & urinary tract infections w MMCC ......................... 868 0.6712 22.6 18.8 

690 ........... 689 ........... Kidney & urinary tract infections w/o MMCC ...................... 782 0.5266 20.5 17.1 

691 ........... 691 ........... Urinary stones w esw lithotripsy w CC/MMCC ................... 0 0.4824 19.6 16.3 

692 ........... 691 ........... Urinary stones w esw lithotripsy w/o CC/MMCC ................ 0 0.4824 19.6 16.3 

693 ........... 693 ........... Urinary stones w/o esw lithotripsy w MMCC ....................... 3 0.8596 25.2 21.0 

694 ........... 693 ........... Urinary stones w/ot esw lithotripsy w/o MMCC ................... 5 0.4824 19.6 16.3 

695 ........... 695 ........... Kidney & urinary tract signs & symptoms w MMCC ........... 4 1.2617 31.5 26.3 

696 ........... 695 ........... Kidney & urinary tract signs & symptoms w/o MMCC ........ 7 0.6327 21.6 18.0 

697 ........... 697 ........... Urethral stricture .................................................................. 0 0.6327 21.6 18.0 

698 ........... 698 ........... Other kidney & urinary tract diagnoses w MMCC ............... 285 0.9527 23.5 19.6 

699 ........... 698 ........... Other kidney & urinary tract diagnoses w MCC .................. 142 0.6606 22.0 18.3 

700 ........... 698 ........... Other kidney & urinary tract diagnoses w/o CC/MMCC ..... 33 0.5695 21.1 17.6 

707 ........... 707 ........... Major male pelvic procedures w CC/MMCC ....................... 0 1.2617 31.5 26.3 

708 ........... 707 ........... Major male pelvic procedures w/o CC/MMCC .................... 0 0.6327 21.6 18.0 

709 ........... 709 ........... Penis procedures w CC/MMCC .......................................... 15 1.7509 37.9 31.6 

710 ........... 709 ........... Penis procedures w/o CC/MMCC ....................................... 0 1.7509 37.9 31.6 

711 ........... 711 ........... Testes procedures w CC/MMCC ......................................... 6 1.2617 31.5 26.3 

712 ........... 711 ........... Testes procedures w/o CC/MMCC ...................................... 0 1.2617 31.5 26.3 

713 ........... 713 ........... Transurethral prostatectomy w CC/MMCC ......................... 2 1.7509 37.9 31.6 

714 ........... 713 ........... Transurethral prostatectomy w/o CC/MMCC ...................... 0 1.7509 37.9 31.6 

715 ........... 715 ........... Other male reproductive system O.R. proc for malignancy 

w CC/MMCC.

0 1.2617 31.5 26.3 

716 ........... 715 ........... Other male reproductive system O.R. proc for malignancy 

w/o CC/MMCC.

0 1.2617 31.5 26.3 

717 ........... 717 ........... Other male reproductive system O.R. proc exc malignancy 

w CC/MMCC.

11 1.2617 31.5 26.3 

718 ........... 717 ........... Other male reproductive system O.R. proc exc malignancy 

w/o CC/MMCC.

0 1.2617 31.5 26.3 

722 ........... 722 ........... Malignancy, male reproductive system w MMCC ............... 15 0.6327 21.6 18.0 

723 ........... 722 ........... Malignancy, male reproductive system w MCC .................. 15 0.4824 19.6 16.3 

724 ........... 722 ........... Malignancy, male reproductive system w/o CC/MMCC ...... 0 0.4824 19.6 16.3 

725 ........... 725 ........... Benign prostatic hypertrophy w MMCC ............................... 1 0.8596 25.2 21.0 

726 ........... 725 ........... Benign prostatic hypertrophy w/o MMCC ............................ 2 0.4824 19.6 16.3 

727 ........... 727 ........... Inflammation of the male reproductive system w MMCC ... 27 0.7907 23.1 19.3 

728 ........... 727 ........... Inflammation of the male reproductive system w/o MMCC 51 0.5259 20.4 17.0 

729 ........... 729 ........... Other male reproductive system diagnoses w CC/MMCC 49 0.8878 26.2 21.8 

730 ........... 729 ........... Other male reproductive system diagnoses w/o CC/MMCC 8 0.4824 19.6 16.3 

734 ........... 734 ........... Pelvic evisceration, rad hysterectomy & rad vulvectomy w 

CC/MMCC.

0 1.2617 31.5 26.3 

735 ........... 734 ........... Pelvic evisceration, rad hysterectomy & rad vulvectomy w/ 

o CC/MMCC.

0 1.2617 31.5 26.3 

736 ........... 736 ........... Uterine & adnexa proc for ovarian or adnexal malignancy 

w MMCC.

0 1.2617 31.5 26.3 

737 ........... 736 ........... Uterine & adnexa proc for ovarian or adnexal malignancy 

w MCC.

0 0.8596 25.2 21.0 

738 ........... 736 ........... Uterine & adnexa proc for ovarian or adnexal malignancy 

w/o CC/MMCC.

0 0.4824 19.6 16.3 

739 ........... 739 ........... Uterine,adnexa proc for non-ovarian/adnexal malig w 

MMCC.

1 1.2617 31.5 26.3 


jlentini on PROD1PC65 with PROPOSALS2
23902 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

740 ........... 739 ........... Uterine,adnexa proc for non-ovarian/adnexal malig w 

MCC.

0 1.2617 31.5 26.3 

741 ........... 739 ........... Uterine,adnexa proc for non-ovarian/adnexal malig w/o 

CC/MMCC.

0 1.2617 31.5 26.3 

742 ........... 742 ........... Uterine & adnexa proc for non-malignancy w CC/MMCC .. 0 0.8596 25.2 21.0 

743 ........... 742 ........... Uterine & adnexa proc for non-malignancy w/o CC/MMCC 0 0.4824 19.6 16.3 

744 ........... 744 ........... D&C, conization, laparascopy & tubal interruption w CC/ 

MMCC.

1 0.8596 25.2 21.0 

745 ........... 744 ........... D&C, conization, laparascopy & tubal interruption w/o CC/ 

MMCC.

0 0.8596 25.2 21.0 

746 ........... 746 ........... Vagina, cervix & vulva procedures w CC/MMCC ............... 1 1.7509 37.9 31.6 

747 ........... 746 ........... Vagina, cervix & vulva procedures w/o CC/MMCC ............ 0 1.7509 37.9 31.6 

748 ........... 748 ........... Female reproductive system reconstructive procedures ..... 0 1.2617 31.5 26.3 

749 ........... 749 ........... Other female reproductive system O.R. procedures w CC/ 

MMCC.

4 1.2617 31.5 26.3 

750 ........... 749 ........... Other female reproductive system O.R. procedures w/o 

CC/MMCC.

0 1.2617 31.5 26.3 

754 ........... 754 ........... Malignancy, female reproductive system w MMCC ............ 22 1.2617 31.5 26.3 

755 ........... 754 ........... Malignancy, female reproductive system w MCC ............... 21 0.8596 25.2 21.0 

756 ........... 754 ........... Malignancy, female reproductive system w/o CC/MMCC ... 1 0.4824 19.6 16.3 

757 ........... 757 ........... Infections, female reproductive system w MCC* ................ 52 0.7580 23.7 19.8 

758 ........... 757 ........... Infections, female reproductive system w CC* ................... 27 0.7580 23.7 19.8 

759 ........... 757 ........... Infections, female reproductive system w/o CC/MCC* ....... 5 0.7580 23.7 19.8 

760 ........... 760 ........... Menstrual & other female reproductive system disorders w 

CC/MMCC.

0 0.8596 25.2 21.0 

761 ........... 760 ........... Menstrual & other female reproductive system disorders 

w/o CC/MMCC.

0 0.8596 25.2 21.0 

765 ........... 765 ........... Cesarean section w CC/MMCC .......................................... 0 0.8596 25.2 21.0 

766 ........... 765 ........... Cesarean section w/o CC/MMCC ....................................... 0 0.8596 25.2 21.0 

767 ........... 767 ........... Vaginal delivery w sterilization &/or D&C ............................ 0 0.8596 25.2 21.0 

768 ........... 768 ........... Vaginal delivery w O.R. proc except steril &/or D&C .......... 0 0.8596 25.2 21.0 

769 ........... 769 ........... Postpartum & post abortion diagnoses w O.R. procedure 0 0.8596 25.2 21.0 

770 ........... 770 ........... Abortion w D&C, aspiration curettage or hysterotomy ........ 0 0.8596 25.2 21.0 

774 ........... 774 ........... Vaginal delivery w complicating diagnoses ......................... 0 0.8596 25.2 21.0 

775 ........... 775 ........... Vaginal delivery w/o complicating diagnoses ...................... 0 0.8596 25.2 21.0 

776 ........... 776 ........... Postpartum & post abortion diagnoses w/o O.R. procedure 0 0.8596 25.2 21.0 

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 diagnoses w medical complications ....... 1 0.4824 19.6 16.3 

782 ........... 782 ........... Other antepartum diagnoses w/o medical complications .... 0 0.4824 19.6 16.3 

789 ........... 789 ........... Neonates, died or transferred to another acute care facility 0 0.4824 19.6 16.3 

790 ........... 790 ........... Extreme immaturity or respiratory distress syndrome, 

neonate.

0 0.4824 19.6 16.3 

791 ........... 791 ........... Prematurity w major problems ............................................. 0 0.4824 19.6 16.3 

792 ........... 792 ........... Prematurity w/o major problems .......................................... 0 0.4824 19.6 16.3 

793 ........... 793 ........... Full term neonate w major problems ................................... 0 0.4824 19.6 16.3 

794 ........... 794 ........... Neonate w other significant problems ................................. 0 0.4824 19.6 16.3 

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/MMCC ............................................... 0 0.8596 25.2 21.0 

802 ........... 802 ........... Other O.R. proc of the blood & blood forming organs w 

MMCC.

4 1.2617 31.5 26.3 

803 ........... 802 ........... Other O.R. proc of the blood & blood forming organs w 

MCC.

0 1.2617 31.5 26.3 

804 ........... 802 ........... Other O.R. proc of the blood & blood forming organs w/o 

CC/MMCC.

0 1.2617 31.5 26.3 

808 ........... 808 ........... Major hematol/immun diag exc sickle cell crisis & coagul 

w MMCC.

17 1.2617 31.5 26.3 

809 ........... 808 ........... Major hematol/immun diag exc sickle cell crisis & coagul 

w MCC.

11 0.8596 25.2 21.0 

810 ........... 808 ........... Major hematol/immun diag exc sickle cell crisis & coagul 

w/o CC/MMCC.

1 0.4824 19.6 16.3 

811 ........... 811 ........... Red blood cell disorders w MMCC ...................................... 43 0.7905 22.8 19.0 

812 ........... 811 ........... Red blood cell disorders w/o MMCC ................................... 58 0.5349 20.4 17.0 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23903 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

813 ........... 813 ........... Coagulation disorders .......................................................... 55 0.8402 23.2 19.3 

814 ........... 814 ........... Reticuloendothelial & immunity disorders w MMCC ........... 16 0.8596 25.2 21.0 

815 ........... 814 ........... Reticuloendothelial & immunity disorders w MCC .............. 7 0.6327 21.6 18.0 

816 ........... 814 ........... Reticuloendothelial & immunity disorders w/o CC/MMCC .. 1 0.4824 19.6 16.3 

820 ........... 820 ........... Lymphoma & leukemia w major O.R. procedure w MMCC 0 1.2617 31.5 26.3 

821 ........... 820 ........... Lymphoma & leukemia w major O.R. procedure w MCC ... 0 0.8596 25.2 21.0 

822 ........... 820 ........... Lymphoma & leukemia w major O.R. procedure w/o CC/ 

MMCC.

0 0.8596 25.2 21.0 

823 ........... 823 ........... Lymphoma & non-acute leukemia w other O.R. proc w 

MMCC.

11 1.2617 31.5 26.3 

824 ........... 823 ........... Lymphoma & non-acute leukemia w other O.R. proc w 

MCC.

4 0.8596 25.2 21.0 

825 ........... 823 ........... Lymphoma & non-acute leukemia w other O.R. proc w/o 

CC/MMCC.

0 0.8596 25.2 21.0 

826 ........... 826 ........... Myeloprolif disord or poorly diff neopl w maj O.R. proc w 

MMCC.

1 1.7509 37.9 31.6 

827 ........... 826 ........... Myeloprolif disord or poorly diff neopl w maj O.R. proc w 

MCC.

1 1.7509 37.9 31.6 

828 ........... 826 ........... Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o 

CC/MMCC.

0 1.7509 37.9 31.6 

829 ........... 829 ........... Myeloprolif disord or poorly diff neopl w other O.R. proc w 

CC/MMCC.

7 1.7509 37.9 31.6 

830 ........... 829 ........... Myeloprolif disord or poorly diff neopl w other O.R. proc w/ 

o CC/MMCC.

0 1.7509 37.9 31.6 

834 ........... 834 ........... Acute leukemia w/o major O.R. procedure w MMCC ......... 14 0.8596 25.2 21.0 

835 ........... 834 ........... Acute leukemia w/o major O.R. procedure w CC* .............. 14 0.8596 25.2 21.0 

836 ........... 834 ........... Acute leukemia w/o major O.R. procedure w/o CC/MCC* 2 0.8596 25.2 21.0 

837 ........... 837 ........... Chemo w acute leukemia as sdx or w high dose chemo 

agent w MMCC.

0 1.7509 37.9 31.6 

838 ........... 837 ........... Chemo w acute leukemia as sdx or w high dose chemo 

agent w MCC.

0 1.7509 37.9 31.6 

839 ........... 837 ........... Chemo w acute leukemia as sdx or w high dose chemo 

agent w/o CC/MMCC.

0 1.7509 37.9 31.6 

840 ........... 840 ........... Lymphoma & non-acute leukemia w MMCC ....................... 133 0.9227 23.1 19.3 

841 ........... 840 ........... Lymphoma & non-acute leukemia w MCC .......................... 63 0.7247 19.7 16.4 

842 ........... 840 ........... Lymphoma & non-acute leukemia w/o CC/MMCC ............. 7 0.6327 21.6 18.0 

843 ........... 843 ........... Other myeloprolif dis or poorly diff neopl diag w MMCC .... 20 0.8596 25.2 21.0 

844 ........... 843 ........... Other myeloprolif dis or poorly diff neopl diag w MCC ....... 11 0.6327 21.6 18.0 

845 ........... 843 ........... Other myeloprolif dis or poorly diff neopl diag w/o CC/ 

MMCC.

3 0.6327 21.6 18.0 

846 ........... 846 ........... Chemotherapy w/o acute leukemia as secondary diagnosis w MMCC.49 1.4778 30.0 25.0 

847 ........... 846 ........... Chemotherapy w/o acute leukemia as secondary diagnosis w MCC.43 1.0877 23.8 19.8 

848 ........... 846 ........... Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MMCC.0 1.0877 23.8 19.8 

849 ........... 849 ........... Radiotherapy ........................................................................ 141 0.7949 21.6 18.0 

853 ........... 853 ........... Infectious & parasitic diseases w O.R. procedure w 

MMCC.

837 1.7864 37.3 31.1 

854 ........... 853 ........... Infectious & parasitic diseases w O.R. procedure w MCC 104 1.1703 33.0 27.5 

855 ........... 853 ........... Infectious & parasitic diseases w O.R. procedure w/o CC/ 

MCC*.

5 1.1703 33.0 27.5 

856 ........... 856 ........... Postoperative or post-traumatic infections w O.R. proc w 

MMCC.

301 1.5591 36.7 30.6 

857 ........... 856 ........... Postoperative or post-traumatic infections w O.R. proc w 

MCC.

213 1.0707 32.6 27.2 

858 ........... 856 ........... Postoperative or post-traumatic infections w O.R. proc w/o 

CC/MMCC.

32 0.8943 26.8 22.3 

862 ........... 862 ........... Postoperative & post-traumatic infections w MMCC ........... 1,163 0.9629 25.3 21.1 

863 ........... 862 ........... Postoperative & post-traumatic infections w/o MMCC ........ 1,231 0.7018 23.8 19.8 

864 ........... 864 ........... Fever of unknown origin ...................................................... 11 0.4824 19.6 16.3 

865 ........... 865 ........... Viral illness w MMCC .......................................................... 36 0.7998 22.2 18.5 

866 ........... 865 ........... Viral illness w/o MMCC ....................................................... 14 0.6327 21.6 18.0 

867 ........... 867 ........... Other infectious & parasitic diseases diagnoses w MMCC 357 1.1296 23.4 19.5 

868 ........... 867 ........... Other infectious & parasitic diseases diagnoses w MCC ... 86 0.7458 22.6 18.8 

869 ........... 867 ........... Other infectious & parasitic diseases diagnoses w/o CC/ 

MMCC.

7 0.4824 19.6 16.3 


jlentini on PROD1PC65 with PROPOSALS2
23904 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

870 ........... 870 ........... Septicemia w MV 96+ hours ............................................... 894 2.2127 33.0 27.5 

871 ........... 871 ........... Septicemia w/o MV 96+ hours w MMCC ............................ 4,507 0.8713 23.4 19.5 

872 ........... 871 ........... Septicemia w/o MV 96+ hours w/o MMCC ......................... 1,608 0.6584 21.8 18.2 

876 ........... 876 ........... O.R. procedure w principal diagnoses of mental illness ..... 12 0.6327 21.6 18.0 

880 ........... 880 ........... Acute adjustment reaction & psychosocial dysfunction ...... 11 0.4824 19.6 16.3 

881 ........... 881 ........... Depressive neuroses ........................................................... 14 0.6327 21.6 18.0 

882 ........... 882 ........... Neuroses except depressive ............................................... 16 0.4824 19.6 16.3 

883 ........... 883 ........... Disorders of personality & impulse control .......................... 12 0.8596 25.2 21.0 

884 ........... 884 ........... Organic disturbances & mental retardation ......................... 146 0.5159 25.4 21.2 

885 ........... 885 ........... Psychoses ............................................................................ 1,218 0.4206 23.9 19.9 

886 ........... 886 ........... Behavioral & developmental disorders ................................ 18 0.4824 19.6 16.3 

887 ........... 887 ........... Other mental disorder diagnoses ........................................ 0 0.6327 21.6 18.0 

894 ........... 894 ........... Alcohol/drug abuse or dependence, left ama ..................... 0 0.6327 21.6 18.0 

895 ........... 895 ........... Alcohol/drug abuse or dependence w rehabilitation therapy.2 0.4824 19.6 16.3 

896 ........... 896 ........... Alcohol/drug abuse or dependence w/o rehabilitation therapy w MMCC.7 1.2617 31.5 26.3 

897 ........... 896 ........... Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MMCC.17 0.4824 19.6 16.3 

901 ........... 901 ........... Wound debridements for injuries w MMCC ........................ 217 1.5251 35.9 29.9 

902 ........... 901 ........... Wound debridements for injuries w MCC ........................... 129 1.0552 30.1 25.1 

903 ........... 901 ........... Wound debridements for injuries w/o CC/MMCC ............... 23 0.8596 25.2 21.0 

904 ........... 904 ........... Skin grafts for injuries w CC/MMCC ................................... 78 1.3404 35.6 29.7 

905 ........... 904 ........... Skin grafts for injuries w/o CC/MMCC ................................ 6 0.8596 25.2 21.0 

906 ........... 906 ........... Hand procedures for injuries ............................................... 1 1.7509 37.9 31.6 

907 ........... 907 ........... Other O.R. procedures for injuries w MMCC ...................... 91 1.6273 37.5 31.3 

908 ........... 907 ........... Other O.R. procedures for injuries w MCC ......................... 63 1.1167 34.0 28.3 

909 ........... 907 ........... Other O.R. procedures for injuries w/o CC/MCC* .............. 6 1.1167 34.0 28.3 

913 ........... 913 ........... Traumatic injury w MMCC ................................................... 37 0.7480 24.8 20.7 

914 ........... 913 ........... Traumatic injury w/o MMCC ................................................ 66 0.6073 21.8 18.2 

915 ........... 915 ........... Allergic reactions w MMCC ................................................. 0 0.4824 19.6 16.3 

916 ........... 915 ........... Allergic reactions w/o MMCC .............................................. 0 0.4824 19.6 16.3 

917 ........... 917 ........... Poisoning & toxic effects of drugs w MMCC ....................... 8 0.4824 19.6 16.3 

918 ........... 917 ........... Poisoning & toxic effects of drugs w/o MMCC .................... 9 0.4824 19.6 16.3 

919 ........... 919 ........... Complications of treatment w MMCC .................................. 1,235 1.0924 26.9 22.4 

920 ........... 919 ........... Complications of treatment w MCC ..................................... 841 0.8582 26.0 21.7 

921 ........... 919 ........... Complications of treatment w/o CC/MMCC ........................ 117 0.6163 20.1 16.8 

922 ........... 922 ........... Other injury, poisoning & toxic effect diag w MMCC .......... 7 0.8596 25.2 21.0 

923 ........... 922 ........... Other injury, poisoning & toxic effect diag w/o MMCC ....... 11 0.6327 21.6 18.0 

927 ........... 927 ........... Extensive burns or full thickness burns w MV 96+ hrs w 

skin graft.

1 1.7509 37.9 31.6 

928 ........... 928 ........... Full thickness burn w skin graft or inhal inj w CC/MMCC .. 9 1.2617 31.5 26.3 

929 ........... 928 ........... Full thickness burn w skin graft or inhal inj w/o CC/MMCC 2 0.6327 21.6 18.0 

933 ........... 933 ........... Extensive burns or full thickness burns w MV 96+ hrs w/o 

skin graft.

10 1.2617 31.5 26.3 

934 ........... 934 ........... Full thickness burn w/o skin grft or inhal inj ........................ 40 0.7755 24.2 20.2 

935 ........... 935 ........... Non-extensive burns ............................................................ 46 0.7815 24.5 20.4 

939 ........... 939 ........... O.R. proc w diagnoses of other contact w health services 

w MCC.

267 1.3463 34.1 28.4 

940 ........... 939 ........... O.R. proc w diagnoses of other contact w health services 

w MCC.

135 0.9993 30.6 25.5 

941 ........... 939 ........... O.R. proc w diagnoses of other contact w health services 

w/o CC/MMCC.

15 0.8596 25.2 21.0 

945 ........... 945 ........... Rehabilitation w CC/MMCC ................................................. 2,220 0.6154 22.1 18.4 

946 ........... 945 ........... Rehabilitation w/o CC/MMCC .............................................. 428 0.4311 18.9 15.8 

947 ........... 947 ........... Signs & symptoms w MMCC ............................................... 57 0.6548 22.2 18.5 

948 ........... 947 ........... Signs & symptoms w/o MMCC ............................................ 69 0.5737 22.2 18.5 

949 ........... 949 ........... Aftercare w CC/MMCC ........................................................ 3,802 0.7034 22.5 18.8 

950 ........... 949 ........... Aftercare w/o CC/MMCC ..................................................... 546 0.5002 19.2 16.0 

951 ........... 951 ........... Other factors influencing health status ................................ 28 1.2726 27.0 22.5 

955 ........... 955 ........... Craniotomy for multiple significant trauma .......................... 0 1.7509 37.9 31.6 

956 ........... 956 ........... Limb reattachment, hip & femur proc for multiple significant trauma.0 0.8596 25.2 21.0 

957 ........... 957 ........... Other O.R. procedures for multiple significant trauma w 

MMCC.

1 1.2617 31.5 26.3 

958 ........... 957 ........... Other O.R. procedures for multiple significant trauma w 

MCC.

1 0.4824 19.6 16.3 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23905 

TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE

LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued 

Proposed 

MS–LTC–

DRG 

Proposed 

base MS–

LTC–DRG 

Proposed MS–LTC–DRG title FY 2007 

LTCH cases 

Proposed 

relative 

weight 

Proposed 

geometric 

average 

length of 

stay 

Proposed 

short-stay 

outlier 

(SSO) 

threshold 1

959 ........... 957 ........... Other O.R. procedures for multiple significant trauma w/o 

CC/MMCC.

0 0.4824 19.6 16.3 

963 ........... 963 ........... Other multiple significant trauma w MMCC ......................... 15 0.8596 25.2 21.0 

964 ........... 963 ........... Other multiple significant trauma w MCC ............................ 5 0.6327 21.6 18.0 

965 ........... 963 ........... Other multiple significant trauma w/o CC/MMCC ............... 3 0.4824 19.6 16.3 

969 ........... 969 ........... HIV w extensive O.R. procedure w MMCC ......................... 13 1.2617 31.5 26.3 

970 ........... 969 ........... HIV w extensive O.R. procedure w/o MCC* ....................... 3 1.2617 31.5 26.3 

974 ........... 974 ........... HIV w major related condition w MMCC ............................. 196 1.0056 21.9 18.3 

975 ........... 974 ........... HIV w major related condition w MCC ................................ 85 0.6433 18.3 15.3 

976 ........... 974 ........... HIV w major related condition w/o CC/MMCC .................... 16 0.6327 21.6 18.0 

977 ........... 977 ........... HIV w or w/o other related condition ................................... 45 0.6975 19.0 15.8 

981 ........... 981 ........... Extensive O.R. procedure unrelated to principal diagnosis 

w MMCC.

1,143 2.3516 43.1 35.9 

982 ........... 981 ........... Extensive O.R. procedure unrelated to principal diagnosis 

w MCC.

290 1.4645 35.2 29.3 

983 ........... 981 ........... Extensive O.R. procedure unrelated to principal diagnosis 

w/o CC/MMCC.

26 1.1662 31.9 26.6 

984 ........... 984 ........... Prostatic O.R. procedure unrelated to principal diagnosis 

w MMCC.

16 1.2617 31.5 26.3 

985 ........... 984 ........... Prostatic O.R. procedure unrelated to principal diagnosis 

w MCC.

9 1.2617 31.5 26.3 

986 ........... 984 ........... Prostatic O.R. procedure unrelated to principal diagnosis 

w/o CC/MMCC.

0 1.2617 31.5 26.3 

987 ........... 987 ........... Non-extensive O.R. proc unrelated to principal diagnosis 

w MMCC.

419 1.7561 36.4 30.3 

988 ........... 987 ........... Non-extensive O.R. proc unrelated to principal diagnosis 

w MCC.

218 1.1596 33.9 28.3 

989 ........... 987 ........... Non-extensive O.R. proc unrelated to principal diagnosis 

w/o CC/MMCC.

10 0.8596 25.2 21.0 

998 ........... 998 ........... Ungroupable ........................................................................ 0 0.0000 0.0 0.0

999 ........... 999 ........... Principal diagnosis invalid as discharge diagnosis ............. 0 0.0000 0.0 0.0 

1The proposed SSO Threshold is calculated as 5⁄6th of the geometric average length of stay of the proposed MS–LTC–DRG (as specified at 

§ 412.529 in conjunction with § 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 


jlentini on PROD1PC65 with PROPOSALS2
23906 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 casemix 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 capitalrelated costs encompass most general shortterm, 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 Medicareparticipating 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 

§ 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 costbased 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 § 403.752(a) of the 

regulations, RNHCIs are paid under § 413.40, 

which also uses section 1886(b)(3)(B)(ii) of 

the Act to update target amounts by the rateof-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 costbased 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 costbased 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 rateof-increase limits since their base period, the 

major effect is on the level of incentive 

payments these hospitals and hospital units 

receive. Conversely, for excluded hospitals 

and hospital units with per-case cost 

increases above the cumulative update in 

their rate-of-increase limits, the major effect 

is the amount of excess costs that will not be 

reimbursed. 

We note that, under § 413.40(d)(3), an 

excluded hospital or unit whose costs exceed 

110 percent of its rate-of-increase limit 

receives its rate-of-increase limit plus 50 

percent of the difference between its 

reasonable costs and 110 percent of the limit, 

not to exceed 110 percent of its limit. In 

addition, under the various provisions set 

forth in § 413.40, certain excluded hospitals 

and hospital units can obtain payment 

adjustments for justifiable increases in 

operating costs that exceed the limit. 

VI. Quantitative Effects of the Proposed 

Policy Changes Under the IPPS for 

Operating Costs 

A. Basis and Methodology of Estimates 

In this proposed rule, we are announcing 

proposed policy changes and 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: 

• 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, 

• 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. 

• 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. 

• The effects of geographic 

reclassifications by the MGCRB that will be 

effective in FY 2009. 

• 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. 

• The effects of the proposal to apply the 

imputed rural floor budget neutrality 

adjustment to the wage index at the Statelevel, rather than applying it to the 

standardized amount at the national level. 

• The effects of section 505 of Pub. L. 108–

173, which provides for an increase in a 

hospital’s wage index if the hospital qualifies 

by meeting a threshold percentage of 

residents of the county where the hospital is 

located who commute to work at hospitals in 

counties with higher wage indexes. 

• The 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. 

• 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 rateof-increase for FY 2009 at this time. 

Each policy change, statutorily or 

otherwise, is then added incrementally to 


jlentini on PROD1PC65 with PROPOSALS2
23908 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

Number of 

hospitals 1

Proposed 

FY 2009 

cost based 

DRG 

Weights & 

MS–DRG 

changes 2

Proposed 

FY 2009 

wage 

data 3

Proposed 

FY 2009 

DRG, rel. 

wts. and 

wage 

index 

changes 4

FY 2009 

MGCRB 

Reclassifications 5

Application 

of proposed rural 

floor and 

imputed 

rural floor, 

including 

proposed 

within state 

budget 

neutrality 6

Proposed 

FY 2009 

out-migration adjustment 7

All proposed FY 

2009 

changes 

w/CMI adjustment 

prior to estimated 

CMI 

growth 8

All proposed FY 

2009 

changes 

w/CMI adjustment 

and estimated CMI 

growth 9

(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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23909 

TABLE I.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009—Continued 

Number of 

hospitals 1

Proposed 

FY 2009 

cost based 

DRG 

Weights & 

MS–DRG 

changes 2

Proposed 

FY 2009 

wage 

data 3

Proposed 

FY 2009 

DRG, rel. 

wts. and 

wage 

index 

changes 4

FY 2009 

MGCRB 

Reclassifications 5

Application 

of proposed rural 

floor and 

imputed 

rural floor, 

including 

proposed 

within state 

budget 

neutrality 6

Proposed 

FY 2009 

out-migration adjustment 7

All proposed FY 

2009 

changes 

w/CMI adjustment 

prior to estimated 

CMI 

growth 8

All proposed FY 

2009 

changes 

w/CMI adjustment 

and estimated CMI 

growth 9

(1) (2) (3) (4) (5) (6) (7) (8) (9) 

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 Full 

Year FY 2009 ................................... 360 ¥0.7 0 ¥0.7 3.3 ¥0 0 1.8 3.7 

Rural Nonreclassified Hospitals Full 

Year FY 2009 ................................... 565 ¥1.5 ¥0 ¥1.6 ¥0.4 ¥0.1 0.3 1 2.8 


jlentini on PROD1PC65 with PROPOSALS2
23910 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE I.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009—Continued 

Number of 

hospitals 1

Proposed 

FY 2009 

cost based 

DRG 

Weights & 

MS–DRG 

changes 2

Proposed 

FY 2009 

wage 

data 3

Proposed 

FY 2009 

DRG, rel. 

wts. and 

wage 

index 

changes 4

FY 2009 

MGCRB 

Reclassifications 5

Application 

of proposed rural 

floor and 

imputed 

rural floor, 

including 

proposed 

within state 

budget 

neutrality 6

Proposed 

FY 2009 

out-migration adjustment 7

All proposed FY 

2009 

changes 

w/CMI adjustment 

prior to estimated 

CMI 

growth 8

All proposed FY 

2009 

changes 

w/CMI adjustment 

and estimated CMI 

growth 9

(1) (2) (3) (4) (5) (6) (7) (8) (9) 

All Section 401 Reclassified Hospitals 29 ¥1.3 ¥0.2 ¥1.6 0.6 0 0 1.6 3.5 

Other Reclassified Hospitals (Section 

1886(d)(8)(B)) ................................... 61 ¥1 ¥0.2 ¥1.3 3.2 ¥0.2 0.1 1 2.8 

Specialty Hospitals 

Cardiac specialty Hospitals .................. 20 ¥2.2 ¥0.1 ¥2.4 ¥0.7 0.1 0 0 1.8 

1Because 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. 2This 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. 3This column displays the payment impact of updating the wage index data to the FY 2005 cost report data. 

4This 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. 5Shown 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. 6This column displays the effects of the rural floor and the imputed rural floor, including the proposal to apply the budget neutrality adjustment within State. 7This 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. 8This 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. 9This 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 CostBased 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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. 

Percentage change in area wage index values 

Number of hospitals 

Urban Rural 

Increase more than 10 percent ....................................................................................................................................... 5 0 

Increase more than 5 percent and less than 10 percent ................................................................................................ 32 0 

Increase or decrease less than 5 percent ....................................................................................................................... 2,420 972 

Decrease more than 5 percent and less than 10 percent .............................................................................................. 18 0 

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 postreclassification 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 


jlentini on PROD1PC65 with PROPOSALS2
23912 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 casemix. 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 casemix 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. 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 Statespecific 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] 

Number of 

hospitals 

Average FY 

2008 payment per 

case 1

Average 

proposed 

FY 2009 

payment per 

case 1

All proposed 

FY 2009 

changes 

(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 


jlentini on PROD1PC65 with PROPOSALS2
23914 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE II.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009 OPERATING PROSPECTIVE PAYMENT SYSTEM—

Continued 

[Payments per case] 

Number of 

hospitals 

Average FY 

2008 payment per 

case 1

Average 

proposed 

FY 2009 

payment per 

case 1

All proposed 

FY 2009 

changes 

(1) (2) (3) (4) 

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 

1These 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

Year 

Savings 

(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 § 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 

§ 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 § 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 addon 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 


jlentini on PROD1PC65 with PROPOSALS2
23916 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 oncall physicians in hospital emergency 

departments. We are proposing to delete the 

provision relating to maintaining a list of oncall physicians from the regulations referring 

to EMTALA at § 489.24(j)(1) because a 

provision addressing the on-call physician 

list is already included in the regulations 

relating to provider agreements at 

§ 489.20(r)(2). We are proposing to 

incorporate the language of § 489.24(j)(1) as 

replacement language for the existing 

§ 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 physicianowned 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 § 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 

§ 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 physicianowned 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 


jlentini on PROD1PC65 with PROPOSALS2
23918 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 hospitalspecific rate (see § 412.340). Under the holdharmless methodology, unless a hospital 

elected payment based on 100 percent of the 

capital Federal rate, hospitals were paid 85 

percent of reasonable costs for old capital 

costs (100 percent for SCHs) plus an amount 

for new capital costs based on a proportion 

of the capital Federal rate (see § 412.344). As 

we state in section V. of the preamble of this 

proposed rule, with the 10-year transition 

period ending with hospital cost reporting 

periods beginning on or after October 1, 2001 

(FY 2002), beginning in FY 2002 capital 

prospective payment system payments for 

most hospitals are based solely on the capital 

Federal rate. Therefore, we no longer include 

information on obligated capital costs or 

projections of old capital costs and new 

capital costs, which were factors needed to 

calculate payments during the transition 

period, for our impact analysis. 

The basic methodology for determining a 

capital PPS payment is set forth at § 412.312. 

The basic methodology for calculating capital 

IPPS payments in FY 2009 would be as 

follows: (Standard Federal Rate) × (DRG 

weight) × (GAF) × (COLA for hospitals 

located in Alaska and Hawaii) × (1 + 

Disproportionate Share Adjustment Factor + 

IME Adjustment Factor, if applicable). 

We note that, in accordance with 

§ 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 casemix 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 §§ 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 § 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: 

• 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.) 

• 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. 

• 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. 

• 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. 

• 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 casemix 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 (§ 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] 

Number of 

hospitals 

Average FY 

2008 payments/case 

Average FY 

2009 payments/case Change 

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: 


jlentini on PROD1PC65 with PROPOSALS2
23920 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

TABLE III.—COMPARISON OF TOTAL CAPITAL PAYMENTS PER CASE—Continued 

[FY 2008 payments compared to FY 2009 payments] 

Number of 

hospitals 

Average FY 

2008 payments/case 

Average FY 

2009 payments/case Change 

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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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 Ricospecific 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 hospitalspecific rates applicable to SCHs and MDHs 

equal to the rate set forth in section 

1886(b)(3)(B)(i) of the Act (that is, the same 

update factor as for all other hospitals subject 

to the IPPS, or the rate-of-increase in the 

market basket). Therefore, the update to the 

hospital-specific rates applicable to SCHs 

and MDHs is estimated to be 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 § 403.752(a) of 

the regulations, RNHCIs are paid under 

§ 413.40, which also uses section 

1886(b)(3)(B)(ii) of the Act to update the 

percentage increase in the rate-of-increase 

limits. Section 1886(j)(3)(C) of the Act 

addresses the increase factor for the Federal 

prospective payment rate of IRFs. Section 

123 of Pub. L. 106–113, as amended by 

section 307(b) of Pub. L. 106–554, provides 

the statutory authority for updating payment 

rates under the LTCH PPS. As discussed 

below, for cost reporting periods beginning 

on or after October 1, 2006, LTCHs that are 

not defined as new under § 412.23(e)(4), and 

that had not elected to be paid under 100 

percent of the Federal rate are paid 100 

percent of the adjusted Federal PPS rate. 

Therefore, because no portion of LTCHs’

prospective payments will be based on 

reasonable cost concepts for cost reporting 

periods beginning on or after October 1, 

2006, we are not proposing a rate-of-increase 

percentage to the reasonable cost portion for 

FY 2009 for LTCHs to be used under 

§ 413.40. In addition, section 124 of Pub. L. 

106–113 provides the statutory authority for 

updating all aspects of the payment rates for 

IPFs. Under this broad authority, IPFs that 

are not defined as new under § 412.426(c) 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 


jlentini on PROD1PC65 with PROPOSALS2
23922 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

January 1, 2008, we are not proposing a rateof-increase percentage to the reasonable cost 

portion for FY 2009 for IPFs to be used under 

§ 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 § 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 casemix 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 § 412.426(c)) are 

paid based on a blend of the reasonable costbased 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 § 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 Ricospecific 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 costbased 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 casemix 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 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: 

• 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. 

• 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. 

• 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 SelfReferral, 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 

HOSPITALDISCLOSURE@cms.hhs.gov. In 

the subject line, please include the title 

‘‘Exception to Disclosure Report.’’

General Instructions for DFRR 

• 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. 

• 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. 

• The terms, ‘‘physician-owner’’ and 

‘‘physician-investor’’ are used 

interchangeably throughout this report. 

• 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.). 

• Where supporting documentation or an 

explanation is requested, please include the 

name of the physician-owner or physicianinvestor, and his/her NPI. 

• 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. 

• If a particular question does not apply to 

the hospital, please type 

‘‘N/A.’’

• 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. 

• 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 

HOSPITALDISCLOSURE@cms.hhs.gov. 

• 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: 

• Cover Sheet—(Certification Page) 

• Worksheet 1—Hospital Characteristics 

• Worksheet 2—Direct Ownership in 

Hospital 

• Worksheet 3—Indirect Ownership in 

Hospital 

• Worksheet 4—Payments Made to 

Hospital by Direct Owners 

• Worksheet 5—Payments Made to 

Hospital by Indirect Owners 

• Worksheet 6—Investment Reconciliation 

• Worksheet 7—Compensation 

Arrangements—Rentals, Personal Service 

Arrangements, and Recruitment (See 42 CFR 

411.357) 

• 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, sonin-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). 


jlentini on PROD1PC65 with PROPOSALS2
23924 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

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 

• Please include month, date, and year for 

the beginning and end of your cost reporting 

period(s). 

Worksheet 2—Direct Ownership in Hospital 

• Identify the class of stock (if applicable) 

and list all owners of that class within the 

same grouping on the Worksheet. 

• If the direct owner is the physician, enter 

‘‘Self’’ in Column B. 

• 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. 

• 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. 

• One hundred percent of ownership 

should be identified for each individual class 

of stock. 

Worksheet 3—Indirect Ownership in 

Hospital 

• Report only indirect ownership interests 

of physicians and immediate family members 

on this Worksheet. 

• 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. 

• List each investor-owner of the group 

entity in Column D. Indicate if the investorowner 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. 

• Column E should indicate each investorowner’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. 

• To calculate the percent of indirect 

ownership in Column H for each investorowner of the entity, multiply the percentage 

in Column C by the percentage in Column E. 

Worksheet 4—Payments Made to Hospital by 

Direct Owners 

• Report only payments to the hospital by 

direct physician-owners and immediate 

family member owners on this Worksheet. 

• 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. 

• 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. 

• 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 

• Report only payments made by indirect 

physician-owners and immediate family 

member owners on this Worksheet. 

• 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. 

• 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. 

• For immediate family members, enter the 

relationship to and name of, the physician 

family member in Column C. 

• 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 

• Please complete a separate Worksheet for 

each physician-owner or immediate family 

member owner. 

• Please provide the owner’s Social 

Security Number (SSN) or NPI as 

appropriate. 

• If a physician owns more than one class 

of stock/equity, a separate worksheet must be 

completed for each class of stock/equity. 

• 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. 

• 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). 

• 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. 

• Line 17 must reflect all other capital 

assessments that occurred during the cost 

reporting period(s) ending in 2006. 

• 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. 

• 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) 

• 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. 

• 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. 

• The information requested in columns A 

and B must include compensation 

arrangements that occur in either direction 

(i.e., rentals to/from physicians). 

• Please indicate in the appropriate 

column the number of compensation 

arrangements that pertain to the physician 

for the reporting period(s) ending in 2006. 

• 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. 

• Personal Service Arrangements (PSA—

Column C) 

Æ For each physician listed, please 

indicate the number of PSAs in effect for the 

cost reporting period(s) ending in 2006. 

Æ 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 


jlentini on PROD1PC65 with PROPOSALS2
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23925 

one copy will satisfy the supporting 

documentation requirement for all 

physicians who entered into a uniform PSA 

with the hospital. 

Æ 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. 

Æ 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) 

• This Worksheet addresses other 

compensation arrangements exceptions that 

are found at 42 CFR 411.357. 

• Please note that you may be required to 

furnish an explanation or additional 

documentation depending on the answer to 

each question. 

• 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: DFRRQuestions@cms.hhs.gov. 

BILLING CODE 4120–01–P 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.022</GPH>
23926 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.023</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23927 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.024</GPH>
23928 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.025</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23929 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.026</GPH>
23930 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.027</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23931 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.028</GPH>
23932 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.029</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23933 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.030</GPH>
23934 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.031</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23935 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.032</GPH>
23936 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.033</GPH>
Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23937 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.035</GPH>
23938 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 

[FR Doc. 08–1135 Filed 4–14–08; 9:19 am] 

BILLING CODE 4120–01–C 


jlentini on PROD1PC65 with PROPOSALS2EP30AP08.036</GPH>