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Code · REGISTER · 2002-05-09 · Centers for Medicare & Medicaid Services (CMS), HHS · Presidential Documents

Presidential Documents. Proposed rule

200,107 words·~910 min read·/register/2002/05/09/02-11290

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Billing code 3195-01-P 67 90 Thursday, May 9, 2002 CORRECTIONS !!!Michele DEPARTMENT OF TRANSPORTATION Federal Aviation Administration 14 CFR Part 13 [Docket No. FAA-2000-7554; Amendment No. 13-30] RIN 2120-AF04 Flight Operational Quality Assurance Program Correction In rule document 01-27273 beginning on page 55042, in the issue of Wednesday, October 31, 2001, make the following correction: § 13.401 [Corrected] On page 55048, in the third column, § 13.401, paragraph (e), in the third line, “for” should read “or”. [FR Doc.
C1-27273 Filed 5-8-02; 8:45 am] BILLING CODE 1505-01-D 67 90 Thursday, May 9, 2002 Proposed Rules Part II Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 405, 412 et al. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2003 Rates; Proposed Rule DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405, 412, 413, 482, 485, and 489 [CMS-1203-P] RIN 0938-AL23 Medicare Program;
Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2003 Rates AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: We are proposing to revise the Medicare acute care hospital inpatient prospective payment systems for operating and capital costs to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs.
These changes would be applicable to discharges occurring on or after October 1, 2002. We also are setting forth proposed rate-of-increase limits as well as proposed policy changes for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment systems. In addition, we are proposing changes to other hospital payment policies, which include policies governing: payments to hospitals for the direct and indirect costs of graduate medical education; pass-through payments for the services of nonphysician anesthetists in some rural hospitals; clinical requirements for swing-bed services in critical access hospitals (CAHs); payments to provider-based entities; and implementation of the Emergency Medical Treatment and Active Labor Act (EMTALA).
DATES: Comments will be considered if received at the appropriate address, as provided below, no later than 5 p.m. on July 8, 2002. ADDRESSES: Mail written comments (an original and three copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1203-P, P.O. Box 8010, Baltimore, MD 21244-1850. If you prefer, you may deliver, by hand or courier, your written comments (an original and three copies) to one of the following addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201, or Room C5-14-03, Central Building, 7500 Security Boulevard, Baltimore, MD 21244-1850. (Because access to the interior of the Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for commenters who wish to retain proof of filing by stamping in and keeping an extra copy of the comments being filed.
) Comments mailed to those addresses specified as appropriate for courier delivery may be delayed and could be considered late. Because of staffing and resource limitations, we cannot accept comments by facsimile
(FAX)transmission. In commenting, please refer to file code CMS-1203-P. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. For comments that relate to information collection requirements, mail a copy of comments to the following addresses: Centers for Medicare & Medicaid Services, Office of Information Services, Security and Standards Group, Division of CMS Enterprise Standards, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Attn: John Burke, CMS-1203-P; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 3001, New Executive Office Building, Washington, DC 20503, Attn: Allison Herron Eydt, CMS Desk Officer. FOR FURTHER INFORMATION CONTACT: Stephen Phillips,
(410)786-4548, Operating Prospective Payments, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology, Hospital Geographic Reclassifications, and Postacute Transfer Issues. Tzvi Hefter,
(410)786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education, Provider-Based Entities, Critical Access Hospital (CAH), EMTALA Issues. Stephen Heffler,
(410)786-1211, Hospital Market Basket Rebasing. Jeannie Miller,
(410)786-3164, Clinical Standards for CAHs. Tom Hutchinson,
(410)786-8953, Hospital Communication with Medicare+Choice Organizations. SUPPLEMENTARY INFORMATION: Inspection of Public Comments Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, in Room C5-12-08 of the Centers for Medicare & Medicaid Services, 7500 Security Blvd., Baltimore, MD, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. Please call
(410)786-7197 to schedule an appointment to view public comments. Availability of Copies and Electronic Access *Copies:* To order copies of the **Federal Register** containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at
(202)512-1800 or by faxing to
(202)512-2250. The cost for each copy is $9.00. As an alternative, you can view and photocopy the **Federal Register** document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the **Federal Register** . 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.access.gpo.gov/nara_docs/,* 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). I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System 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. Under these prospective payment systems, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor share is adjusted by a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight. If the hospital is recognized as serving a disproportionate share of low-income patients, it receives a percentage add-on payment for each case paid through the acute care hospital inpatient prospective payment system. This percentage varies, depending on several factors which include the percentage of low-income patients served. It is applied to the DRG-adjusted base payment rate, plus any outlier payments received. If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid through the acute care hospital inpatient prospective payment system. This percentage varies, depending on the ratio of residents to beds. 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. Although payments to most hospitals under the acute care hospital inpatient prospective payment system are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of Federal fiscal year
(FY)1982, FY 1987, or FY 1996) or the prospective payment system rate based on the standardized amount. For example, sole community hospitals
(SCHs)are the sole source of care in their areas, and Medicare-dependent, small rural hospitals
(MDHs)are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries (although MDHs receive only 50 percent of the difference between the prospective payment system rate and their hospital-specific rates, if the hospital-specific rate is higher than the prospective payment system rate). The existing regulations governing payments to hospitals under the acute care hospital inpatient prospective payment system are located in 42 CFR part 412, Subparts A through M. 2. Hospitals and Hospital Units Excluded From the Acute Care Hospital Inpatient Prospective Payment System Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the acute care hospital inpatient prospective payment system. These hospitals and units are: psychiatric hospitals and units; rehabilitation hospitals and units; long-term care hospitals; children's hospitals; and cancer hospitals. Various sections of the Balanced Budget Act of 1997 (Public Law 105-33), the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (Public Law 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554) provide for the implementation of prospective payment systems for rehabilitation hospitals and units, psychiatric hospitals and units, and long-term care hospitals, as discussed below. Children's hospitals and cancer hospitals will continue to be paid on a cost-based reimbursement basis. The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR parts 412 and 413. Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units are being transitioned from a blend of reasonable cost-based reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and Federal prospective payments for cost reporting periods beginning January 1, 2002 through September 30, 2002, to payment on a fully Federal prospective rate effective for cost reporting periods beginning on or after October 1, 2002 (66 FR 41316, August 7, 2001). The statute also provides that IRFs may elect to receive the full prospective payment instead of a blended payment. The existing regulations governing payment under the inpatient rehabilitation facility prospective payment system (for rehabilitation hospitals and units) are located in 42 CFR part 412, subpart P. Under the broad authority conferred to the Secretary by section 123 of Public Law 106-113 and section 307(b) of Public Law 106-554, we are proposing to transition long-term care hospitals from payments based on reasonable cost-based reimbursement under section 1886(b) of the Act to fully Federal prospective rates during a 5-year period. For cost reporting periods beginning on or after October 1, 2006, we are proposing to pay long-term care hospitals under the fully Federal prospective payment rate. (See the proposed rule issued in the **Federal Register** on March 22, 2002 (67 FR 13416).) Under the proposed rule, long-term care hospitals would also be permitted to elect to be paid based on full Federal prospective rates. The proposed regulations governing payments under the long-term care hospital prospective payment system would be located in 42 CFR part 412, subpart O. Sections 124(a) and
(c)of Public Law 106-113 provide for the development of a per diem prospective payment system for payment for inpatient hospital services furnished by psychiatric hospitals and units under the Medicare program, effective for cost reporting periods beginning on or after October 1, 2002. This system must include an adequate patient classification system that reflects the differences in patient resource use and costs among these hospitals and must maintain budget neutrality. We are in the process of developing a proposed rule, to be followed by a final rule, to implement the prospective payment system for psychiatric hospitals and units. 3. Critical Access Hospitals 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 on a reasonable cost basis. 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 Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education
(GME)programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year. The existing regulations governing GME payments are located in 42 CFR part 413. B. Major Contents of This Proposed Rule In this proposed rule, we are setting forth proposed changes to the Medicare hospital inpatient prospective payment systems for operating costs and for capital-related costs in FY 2003. We also are proposing changes relating to payments for GME costs; payments to excluded hospitals and units; policies implementing EMTALA; clinical requirements for swing beds in CAHs; and other hospital payment policy changes. The proposed changes would be effective for discharges occurring on or after October 1, 2002. The following is a summary of the major changes that we are proposing to make: 1. Proposed Changes to the DRG Reclassifications and Recalibrations of Relative Weights As required by section 1886(d)(4)(C) of the Act, we adjust the DRG classifications and relative weights annually. Based on analyses of Medicare claims data, we are proposing to establish a number of new DRGs and to make changes to the designation of diagnosis and procedure codes under other existing DRGs. Our proposed changes for FY 2003 are set forth in section II. of this preamble. Among the proposed changes discussed are: • Revisions of DRG 1 (Craniotomy Age >17 Except for Trauma) and DRG 2 (Craniotomy for Trauma Age >17) to reflect the current assignment of cases involving head trauma patients with other significant injuries to MDC 24; • Reconfiguration of DRG 14 (Specific Cerebrovascular Disorders Except Transient Ischemic Attack) and DRG 15 (Transient Ischemic Attack and Precerebral Occlusions) and creation of a new DRG 524 (Transient Ischemia); • Creation of a new DRG for heart assist devices; • Reassignment of the diagnosis code for rheumatic heart failure with cardiac catheterization; • Assignment of new, and reassignment of existing, cystic fibrosis principal diagnosis codes; • Designation of a code for insertion of totally implantable vascular access device (VAD); • Changes in the DRG assignment for the bladder reconstruction procedure code. • Changes in DRG and MDC assignments for numerous newborn and neonate diagnosis codes; and • Changes in DRG assignment for cases of tracheostomy and continuous mechanical ventilation greater than 96 hours. We also are presenting our analysis of applicants for add-on payments for high-cost new medical technologies. 2. Proposed Changes to the Hospital Wage Index In section III. of this preamble, we discuss proposed revisions to the wage index and the annual update of the wage data. Specific issues addressed in this section include the following: • The FY 2003 wage index update, using FY 1999 wage data. • Exclusion from the wage index of Part A physician wage costs that are teaching-related, as well as resident and Part A certified registered nurse anesthetist
(CRNA)costs. • Collection of data for contracted administrative and general, housekeeping, and dietary services. • Revisions to the wage index based on hospital redesignations and reclassifications by the Medicare Geographic Classification Review Board (MGCRB). • Requests for wage data corrections, including clarification of our policies on mid-year corrections. 3. Revision and Rebasing of the Hospital Market Basket In section IV. of this preamble, we discuss issues relating to our proposed rebasing and revision of the hospital market basket in developing the recommended FY 2003 update factor for the operating prospective payment rates and the excluded hospital rate-of-increase limits. We also set forth the data sources used to determine the proposed revised market basket relative weights and choice of price proxies. 4. Other Decisions and Proposed Changes to the Prospective Payment System for Inpatient Operating and Graduate Medical Education Costs In section V. of this preamble, we discuss several provisions of the regulations in 42 CFR Parts 412 and 413 and set forth certain proposed changes concerning the following: • Options for expanding the postacute care transfer policy. • Refinement of the application of a hospital bed-count policy that would more accurately reflect the size of a hospital's operations. • Clarification of the application of the statutory provisions on the calculation of hospital-specific rates for SCHs. • Technical change regarding additional payments for outlier cases. • Rural referral centers proposed case-mix index values for FY 2003. • Changes relating to the IME adjustment, including resident-to-bed ratio caps and counting beds for IME and DSH adjustments. • Clarification and codification of classification requirements for MDHs and intermediary evaluations of cost reports for these hospitals. • Changes to policies on pass-through payments for the costs of nonphysician anesthetists in some rural hospitals. • Clarification of policies relating to implementing 3-year reclassifications of hospitals and other policies related to hospital reclassifications decisions made by the MGCRB. • Changes relating to payment for the direct costs of GME. • Changes related to emergency medical conditions in hospital emergency department under the EMTALA provisions. • Criteria for and payments to provider-based entities. • CMS-directed reopening of intermediary determinations and hearing decisions on provider reimbursements. 5. Prospective Payment System for Capital-Related Costs In section VI. of this preamble, we specify the proposed payment requirements for capital-related costs which include: • Capital-related costs for new hospitals. • Additional payments for extraordinary circumstances. • Restoration of the 2.1 percent reduction to the standard Federal capital prospective payment system rate. • Clarification of the special exceptions payment policy. 6. Proposed Changes for Hospitals and Hospital Units Excluded From the Prospective Payment Systems In section VII. of this preamble, we discuss the following proposals concerning excluded hospitals and hospital units and CAHs: • Payments for existing excluded hospitals and hospital units for FY 2003. • Updated caps for new excluded hospitals and hospital units. • Revision of criteria for exclusion of satellite facilities from the acute care hospital inpatient prospective payment system. • The prospective payment systems for inpatient rehabilitation hospitals and units and long-term care hospitals. • Changes in the advance notification period for CAHs electing the optional payment methodology. • Removal of the requirement on CAHs to use a State resident assessment instrument
(RAI)for patient assessments for swing-bed patients. 7. Determining 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 2003 prospective payment rates for operating costs and capital-related costs. We also establish the proposed threshold amounts for outlier cases. In addition, we address update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2003 for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system. 8. Impact Analysis In Appendix A, we set forth an analysis of the impact that the proposed changes described in this proposed rule would have on affected entities. 9. Report to Congress on the Update Factor for Hospitals Under the Prospective Payment System and Hospitals and Units Excluded From the Prospective Payment System Section 1886(e)(3) of the Act requires the Secretary to report to Congress on our initial estimate of a recommended update factor for FY 2003 for payments to hospitals included in the acute care hospital inpatient prospective payment system, and hospitals excluded from this prospective payment system. This report is included as Appendix B to this proposed rule. 10. Proposed Recommendation of Update Factor for Hospital Inpatient Operating Costs As required by sections 1886(e)(4) and (e)(5) of the Act, appendix C provides our recommendation of the appropriate percentage change for FY 2003 for the following: • Large urban area and other area average standardized amounts (and hospital-specific rates applicable to SCHs and MDHs) for hospital inpatient services paid under the prospective payment system for operating costs. • Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system. 11. Discussion of Medicare Payment Advisory Commission Recommendations Under section 1805(b) of the Act, the Medicare Payment Advisory Commission (MedPAC) is required to submit a report to Congress, not later than March 1 of each year, that reviews and makes recommendations on Medicare payment policies. This annual report makes recommendations concerning hospital inpatient payment policies. In section VIII. of this preamble, we discuss the MedPAC recommendations and any actions we are proposing to take with regard to them (when an action is recommended). For further information relating specifically to the MedPAC March 1 report or to obtain a copy of the report, contact MedPAC at
(202)653-7220 or visit MedPAC's website at: *www.medpac.gov.* II. Proposed Changes to DRG Classifications and Relative Weights A. Background Under the acute care hospital inpatient prospective payment system, 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. The proposed changes to the DRG classification system and the proposed recalibration of the DRG weights for discharges occurring on or after October 1, 2002 are discussed below. B. DRG Reclassification 1. General Cases are classified into DRGs for payment under the acute care hospital inpatient prospective payment system based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). For FY 2002, cases are assigned to one of 506 DRGs in 25 major diagnostic categories (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. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). In general, cases are assigned to an MDC based on the patients' principal diagnosis before assignment to a DRG. However, for FY 2002, there are eight DRGs to which cases are directly assigned on the basis of ICD-9-CM procedure codes. These are the DRGs for heart, liver, bone marrow, lung transplants, simultaneous pancreas/kidney, and pancreas transplants (DRGs 103, 480, 481, 495, 512, and 513, respectively) and the two DRGs for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs before classification to an MDC. Within most MDCs, cases are then 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. Some surgical and medical DRGs are further differentiated based on the presence or absence of complications or comorbidities (CC). Generally, nonsurgical procedures and minor surgical procedures not usually performed in an operating room are not treated as O.R. procedures. However, there are a few non-O.R. procedures that do affect DRG assignment for certain principal diagnoses, such as extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones. Patients' diagnosis, procedure, discharge status, and demographic information is fed into the Medicare claims processing systems and subjected to a series of automated screens called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before classification into a DRG. After screening through the MCE and any further development of the claims, cases are classified into the appropriate DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and, for a limited number of DRGs, demographic information (that is, sex, age, and discharge status). The GROUPER is used both to classify current cases for purposes of determining payment and to classify past cases in order to measure relative hospital resource consumption to establish the DRG weights. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights. However, in the July 30, 1999 final rule (64 FR 41500), we discussed a process for considering non-MedPAR data in the recalibration process. In order for the use of particular data to be feasible, 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 data submitted. Generally, however, a significant sample of the data should be submitted by mid-October, so that we can test the data and make a preliminary assessment as to the feasibility of using the data. Subsequently, a complete database should be submitted no later than December 1 for consideration in conjunction with next year's proposed rule. The major changes we are proposing to the DRG classification system for FY 2003 GROUPER version 20.0 and to the methodology to recalibrate the DRG weights are set forth below. Unless otherwise noted, our DRG analysis is based on data from 100 percent of the FY 2001 MedPAR file, which contains hospital bills received through May 31, 2001, for discharges in FY 2001. 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Proposed Revisions of DRGs 1 and 2 Currently, adult craniotomy patients are assigned to either DRG 1 (Craniotomy Age >17 Except for Trauma) or DRG 2 (Craniotomy for Trauma Age >17). The trauma distinction recognizes that head trauma patients requiring a craniotomy often have multiple injuries affecting other body parts. However, we note that the structure of these DRGs predates the creation in FY 1991 of MDC 24 (Multiple Significant Trauma). The creation of MDC 24 resulted in head trauma patients with other significant injuries being assigned to MDC 24 and removed from DRG 2. In FY 1990, there was a 16-percent difference in the DRG weights for DRG l and DRG 2. In FY 1992, after the creation of MDC 24, the percentage difference in the DRG weights for DRG 1 and DRG 2 had declined to 1.2 percent. The FY 2002 payment weight for DRG 1 is 3.2713 and for DRG 2 is 3.3874, a 3.5 percent difference. For FY 2003, we reevaluated the GROUPER logic for DRGs 1 and 2 by combining the patients assigned to these DRGs and examining the impact of other patient attributes on patient charges. The presence or absence of a CC was found to have a substantial impact on patient charges. Cases in DRGs 1 and 2 Number of patients Average charges With CC 19,012 $49,659 Without CC 9,618 26,824 Thus, there is an 85.1 percent difference in average charges for the groups with and without CC for the combined DRGs 1 and 2. On this basis, we are proposing to redefine and retitle DRGs 1 and 2 as follows: DRG 1 (Craniotomy Age >17 with CC); and DRG 2 (Craniotomy Age >17 without CC). b. Proposed Revisions of DRGs 14 and 15 To assess the appropriate classification of patients with stroke symptoms, we evaluated the assignment of cases to DRGs 14 (Specific Cerebrovascular Disorders Except Transient Ischemic Attack
(TIA)and DRG 15 (Transient Ischemic Attack and Precerebral Occlusions). Our data review indicated that the cases in DRGs 14 and 15 fell into three discrete groups. The first group included cases in which the patients were very sick, with severe intracranial lesions or subarachnoid hemorrhage and severe consequences. The second group included cases in which patients had not suffered a debilitating stroke but instead may have experienced a transient ischemic attack. The patients in the second group had one half of the average length of stay in the hospital as the first group. The third group of cases included patients who appeared to suffer strokes with minor consequences, as well as those having occluded vessels without having a full-blown stroke. We found that patients who have intracranial hemorrhage and patients who have infarction are similar in severity. These cases are more frequent in occurrence than cases with patients who have subarachnoid hemorrhage. Therefore, we are proposing to continue to group patients with intracranial hemorrhage and infarction together. These types of cases are different from patients with, for example, an occlusive carotid artery without infarction. In this common group of cases, patients are not as severely ill because they typically have lesser degrees of functional status deficits. Our analysis indicates that we can improve the clinical and resource cohesiveness of DRGs 14 and 15 by reassigning several specific ICD-9-CM codes. For example, code 436 (Acute, but ill-defined, cerebrovascular disease) is not a specific code and contains patients with a wide range of deficits and anatomic problems. Our data show that these cases consume fewer resources and have shorter lengths of stay than other cases in DRG 14. Therefore, we are proposing to remove code 436 from DRG 14 and reassign it to DRG 15. We also are proposing to create a third new DRG to further identify these cases. The proposed revised or new DRG titles are as follows: DRG 14 (Intracranial Hemorrhage and Stroke with Infarction); DRG 15 (Nonspecific Cerebrovascular and Precerebral Occlusion without Infarction); and DRG 524 (Transient Ischemia). The following table represents a proposed reconfiguration of DRGs 14 and 15 and the creation of a new DRG 524 reflecting these three categorizations: Proposed DRG and title Number of cases Average length of stay
(days)Average charge Revised DRG 14 (Intracranial Hemorrhage and Stroke with Infarction) 164,786 6.1 $15,643 Revised DRG 15 (Nonspecific Cerebrovascular and Precerebral Occlusion without Infarction) 70,866 4.9 11,595 New DRG 524 (Transient Ischemia) 92,835 3.3 8,633 The proposed reconfiguration of DRGs 14 and 15 would result in the following codes being designated as principal diagnosis codes in proposed revised DRG 14: • 430, Subarachnoid hemorrhage • 431, Intracerebral hemorrhage • 432.0, Nontraumatic extradural hemorrhage • 432.1, Subdural hemorrhage • 432.9, Unspecified intracranial hemorrhage • 433.01, Occlusion and stenosis of basilar artery, with cerebral infarction • 433.11, Occlusion and stenosis of carotid artery, with cerebral infarction • 433.21, Occlusion and stenosis of vertebral artery, with cerebral infarction • 433.31, Occlusion and stenosis of multiple and bilateral arteries, with cerebral infarction • 433.81, Occlusion and stenosis of other specified precerebral artery, with cerebral infarction • 433.91, Occlusion and stenosis of unspecified precerebral artery, with cerebral infarction • 434.01, Cerebral thrombosis with cerebral infarction • 434.11, Cerebral embolism with cerebral infarction • 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction In addition, we are proposing that the following two codes be moved from DRG 14 to DRG 34 (Other Disorders of Nervous System with CC) and DRG 35 (Other Disorders of Nervous System without CC): Code 437.3 (Cerebral aneurysm, nonruptured) and Code 784.3 (Aphasia). These codes do not represent acute conditions. Aphasia, for example, could result from a cerebral infarction, but if it does, the infarction should be correctly coded as the principal diagnosis. The proposed redefined DRG 15 would contain the following principal diagnosis codes: • 433.00, Occlusion and stenosis of basilar artery, without mention of cerebral infarction • 433.10, Occlusion and stenosis of carotid artery, without mention of cerebral infarction • 433.20, Occlusion and stenosis of vertebral artery, without mention of cerebral infarction • 433.30, Occlusion and stenosis of multiple and bilateral arteries, without mention of cerebral infarction • 433.80, Occlusion and stenosis of other specified precerebral artery, without mention of cerebral infarction • 433.90, Occlusion and stenosis of unspecified precerebral artery, without mention of cerebral infarction • 434.00, Cerebral thrombosis without mention of cerebral infarction • 434.10, Cerebral embolism without mention of cerebral infarction • 434.90, Cerebral artery occlusion, unspecified, without mention of cerebral infarction • 436, Acute, but ill-defined, cerebrovascular disease In addition, we are proposing to remove the following codes from the existing DRG 15 and place them in the proposed newly created DRG 524: • 435.0, Basilar artery syndrome • 435.1, Vertebral artery syndrome • 435.2, Subclavian steal syndrome • 435.3, Vertebrobasilar artery syndrome • 435.8, Other specified transient cerebral ischemias • 435.9, Unspecified transient cerebral ischemia We are proposing to move code 437.1 (Other generalized ischemic cerebrovascular disease) from DRG 16 (Nonspecific Cerebrovascular Disorders with CC) and DRG 17 (Nonspecific Cerebrovascular Disorders without CC) and add it to the proposed new DRG 524. This proposed change represents a modification to improve clinical coherence and seems to be a logical change for the construction of the proposed new DRG 524. 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Heart Assist Systems Heart failure is typically caused by persistent high blood pressure (hypertension), heart attack, valve disease, other forms of heart disease, or birth defects. It is a chronic condition in which the lower chambers of the heart (ventricles) cannot pump sufficient amounts of blood to the body. This causes the organs of the body to progressively fail, resulting in numerous medical complications and frequently death. DRG 127 (Heart Failure and Shock), to which heart failure cases are assigned, is the single most common DRG in the Medicare population, and represents the medical, not surgical, treatment options for this group of patients. In many cases, heart transplantation would be the treatment of choice. However, the low number of donor hearts limits this treatment option. Circulatory support devices, also known as heart assist systems or left ventricular assist devices (LVADs), offer a surgical alternative for end-stage heart failure patients. This type of device is often implanted near a patient's native heart and assumes the pumping function of the weakened heart's left ventricle. Studies are currently underway to evaluate LVADs as permanent support for end-stage heart failure patients. We have reviewed the payment and DRG assignment of this type of device in the past. Originally, these cases were assigned to DRG 110 (Major Cardiovascular Procedures with CC) and DRG 111 (Major Cardiovascular Procedures without CC) in the September 1, 1994 final rule (59 FR 45345). A more specific procedure code, 37.66 (Implant of an implantable, pulsatile heart assist system) was made effective for use with hospital discharges occurring on or after October 1, 1995. In the August 29, 1997 final rule (62 FR 45973), we reassigned these cases to DRG 108 (Other Cardiothoracic Procedures), because it was the most clinically similar DRG with the best match in resource consumption according to our data. In the July 31, 1998 final rule (63 FR 40956), we again reviewed our data and discovered that the charges for implantation of an LVAD were increasing at a greater rate than the average charges for DRG 108. The length of stay for cases with code 37.66 was approximately 32 days, or three times as long as all other DRG 108 cases. Therefore, we decided to move LVAD cases from DRG 108 to DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization) and DRG 105 (Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization). We continued to review our data and discuss this topic in the FY 1999 and FY 2000 annual final rules: July 30, 1999 (64 FR 41498) and August 1, 2000 (65 FR 47058). In the August 1, 2001 final rule (66 FR 39838), we remodeled MDC 5 to add five new DRGs. We also added procedure codes 37.62 (Implant of other heart assist system), 37.63 (Replacement and repair of heart assist system), and 37.65 (Implant of an external, pulsatile heart assist system) to DRGs 104 and 105. We removed defibrillator cases from DRGs 104 and 105 and assigned them to DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization) to make these DRGs more clinically coherent. This also increased the relative weights for DRGs 104 and 105, as the defibrillator cases had lower average charges than other cases in those two DRGs. In the FY 2001 MedPAR data file, we found 185 LVAD cases in DRG 104 and 90 cases in DRG 105, for a total of 275 cases. These cases represent 1.3 percent of the total cases in DRG 104, and approximately 0.5 percent of the total cases in DRG 105. However, the average charges for these cases are approximately $36,000 and $85,000 higher than the average charges for cases in DRGs 104 and 105, respectively. This situation presents a dilemma, in that the technology has been available since 1995 and is gradually increasing in utilization, while LVAD cases involving the technology remain a small part of the total cases in these two DRGs. In fact, removing LVAD cases from the calculation of the average charge changes the average by only -0.4 percent and -0.5 percent for DRGs 104 and 105, respectively. Therefore, despite the dramatically higher average charges for LVADs compared to the DRG averages, the relative volume is insufficient to affect the average to any great degree. Therefore, we are proposing to create a new DRG 525 (Heart Assist System Implant), which would contain these cases. The proposed FY 2003 relative weight for proposed new DRG 525 is 11.3787. The new DRG would consist of any principal diagnosis in MDC 5, plus one of the following surgical procedures: • 37.62, Implant of other heart assist system • 37.63, Replacement and repair of heart assist system • 37.65, Implant of an external, pulsatile heart assist system • 37.66, Implant of an implantable, pulsatile heart assist system Cases in which a subsequent heart transplant occurs during the hospitalization episode would continue to be assigned to DRG 103 (Heart Transplant) because cases involving procedure codes 336 (Combined heart/lung transplant) and 375 (Heart transplant) are assigned to DRG 103, regardless of other codes included on the bill. We reiterate a discussion we included in the August 1, 2000 final rule (65 FR 47058) regarding placement of code 37.66 in the MCE screening software as a noncovered procedure. The default designation for that code will continue to be “noncovered” because of the stringent conditions that must be met by hospitals in order to receive payment for implantation of the device. Section 65-15 of the Medicare Coverage Issues Manual (Artificial Hearts and Relative Devices) provides the national coverage determination regarding Medicare coverage of these devices. This section may be accessed online at *www.hcfa.gov/pubforms/06_cim/ci00.htm.* b. Moving Diagnosis Code 398.91 (Rheumatic Heart Failure) From DRG 125 to DRG 124 DRG 124 (Circulatory Disorders Except Acute Myocardial Infarction (AMI), with Cardiac Catheterization and Complex Diagnosis) and DRG 125 (Circulatory Disorders Except Acute Myocardial Infarction
(AMI)with Cardiac Catheterization without Complex Diagnosis) have a somewhat complex DRG logic. In order to be assigned to DRG 124 or 125, the patient must first have a circulatory disorder, which would be one of the diagnoses included in MDC 5. However, these DRGs exclude acute myocardial infarctions. Therefore, these DRGs are comprised of cases with a diagnosis from MDC 5, excluding acute myocardial infarction, but also with a cardiac catheterization during the stay. DRGs 124 and 125 are then further defined by whether or not the patient had a complex diagnosis. If the patient had a complex diagnosis, the case is assigned to DRG 124. If the patient does not have a complex diagnosis, the case is assigned to DRG 125. A list of diagnoses that comprise complex diagnoses is identified within DRG 124. These diagnoses can be listed as either a principal or secondary diagnosis. We have received correspondence regarding the current assignment of diagnosis code 398.91 (Rheumatic heart failure). The correspondent pointed out that, while other forms of heart failure are listed as complex diagnoses under DRG 124, rheumatic heart failure is not included as a complex diagnosis within that DRG. Currently, if a patient with rheumatic heart failure receives a cardiac catheterization, the case is assigned to DRG 125. The correspondent had conducted a study and found that patients with rheumatic heart failure who receive a cardiac catheterization have lengths of stay that are significantly longer than patients with other forms of heart failure who receive a cardiac catheterization and who are assigned to DRG 125. The correspondent found that these patients have lengths of stay more similar to those cases assigned to DRG 124 (which have other forms of heart failure), and recommended that diagnosis code 398.91 be added to the list of complex diagnoses within DRG 124. Within our claims data, we found 439 cases of patients in DRG 125 with rheumatic heart failure who received a cardiac catheterization. The average charges for these rheumatic heart failure cases were almost twice as much as for other cardiac patients in DRG 125 who received a cardiac catheterization and who did not have a diagnosis of rheumatic heart failure. We also conferred with our medical consultants and they agree that rheumatic heart failure with cardiac catheterization is a complex diagnosis and should be assigned to DRG 124 along with the other complex forms of heart failure cases involving cardiac catheterization. We are proposing to add code 398.91 to DRG 124 as a complex diagnosis. As a result, catheterization cases with rheumatic heart disease would no longer be assigned to DRG 125. c. Radioactive Element Implant In the August 1, 2001 final rule, we created DRG 517 (Percutaneous Cardiovascular Procedure without Acute Myocardial Infarction
(AMI)with Coronary Artery Stent Implant) as a result of the overall DRG splits based on the presence of AMI (66 FR 39839). We assigned code 92.27 (Implantation or insertion of radioactive elements) to DRG 517 because we believed that code 92.27 would always accompany cases involving a percutaneous cardiovascular procedure and intravascular radiation treatment. We have since determined that code 92.27 can also be present as a stand-alone code in other types of cases. When cases with code 92.27 do not meet the criteria for DRG 517, they are currently directed into DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis). Because DRG 468 is for cases in which the O.R. procedure is unrelated to the principal diagnosis, rather than assign cases with code 92.27 that would otherwise be assigned to MDC 5 to DRG 468 because they do not meet the criteria for assignment to DRG 517, we are proposing to assign these cases to DRG 120 (Other Circulatory System O.R. Procedures). 4. MDC 10 (Endocrine, Nutritional, and Metabolic Diseases and Disorders) Currently, when ICD-9-CM code 277.00 (Cystic Fibrosis without mention of meconium ileus) is reported as the principal diagnosis, it is assigned to the following DRG series in MDC 10: DRG 296 (Nutritional and Metabolic Disease, Age >17 with CC); DRG 297 (Nutritional and Metabolic Disease, Age >17 without CC); and DRG 298 (Nutritional and Metabolic Disease, Age 0-17). As part of our annual review of DRG assignments and based on correspondence that we have received, we examined claims relating to cases involving code 277.00 as a principal diagnosis in DRGs 296, 297, and 298. Our analysis of the average charges for cases in which code 277.00 was the principal diagnosis in DRGs 296, 297, and 298 indicates that resource utilization for these cases is quite different from resource utilization for other cases in the three DRGs. We believe that this difference in resource utilization is due to the fact it is not uncommon for cystic fibrosis patients to be admitted with pulmonary complications. Our findings on the number of cases and the average charges in the three DRGs when code 277.00 is assigned as the principal diagnosis, and our findings for all cases in the three DRGs, are indicated in the charts below. Cases in DRG 296, 297, and 298 With Code 277.00 as the Principal Diagnosis DRG and description Number of cases Average charges DRG 296 (Nutritional & Metabolic Disease Age >17 with CC) 271 $34,111 DRG 297 (Nutritional & Metabolic Disease Age >17 with CC) 133 21,998 DRG 298 (Nutritional & Metabolic Disease Age 0-17) 0 All Cases in DRG 296, 297, 298 DRG and description Number of cases Average charges DRG 296 (Nutritional & Metabolic Disease Age >17 with CC) 169,768 $10,480 DRG 297 (Nutritional & Metabolic Disease Age >17 without CC) 31,560 6,190 DRG 298 (Nutritional & Metabolic Disease Age 0-17) 17 8,603 Based on the results of our analysis, we are proposing that three new cystic fibrosis principal diagnosis codes be assigned to specific DRGs and MDCs, and that other changes be made to DRG and MDC assignments of existing cystic fibrosis codes, as discussed below. We are proposing to create the following three new principal diagnosis codes: • 277.02 (Cystic fibrosis with pulmonary manifestations) • 277.03 (Cystic fibrosis with gastrointestinal manifestations) • 277.09 (Cystic fibrosis with other manifestations) We are proposing that existing code 277.01 (Cystic fibrosis with mention of meconium ileus) would continue to be assigned to DRG 387 (Prematurity with Major Problems) and DRG 389 (Full Term Neonate with Major Problems) in MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period), since it is a newborn diagnosis code. Because proposed new code 277.02 would identify those patients with cystic fibrosis who have pulmonary manifestations, we are proposing to assign cases in which the principal diagnosis is the proposed new code 277.02 to DRG 79 (Respiratory Infection and Inflammations Age >17 with CC), DRG 80 (Respiratory Infections and Inflammations Age >17 without CC), or DRG 81 (Respiratory Infections and Inflammations Age 0-17) in MDC 4 (Diseases and Disorders of the Respiratory System). We are proposing that proposed new code 277.03 would be assigned to DRG 188 (Other Digestive System Diagnoses Age >17 with CC), DRG 189 (Other Digestive System Diagnoses Age >17 without CC), and DRG 190 (Other Digestive System Diagnoses Age 0-17) in MDC 6 (Diseases and Disorders of the Digestive System), because of its specific relationship to the digestive system. Since proposed new code 277.09 could involve a number of manifestations (excluding pulmonary and gastrointestinal), we are proposing to assign this proposed new code to DRGs 296, 297, and 298 in MDC 10, where we are retaining the current assignment of existing code 277.00. The following chart summarizes our proposed DRG and MDC assignments for new and existing cystic fibrosis principal diagnosis codes: Principal diagnosis code and description Proposed MDC assignment Proposed DRG assignments Existing 277.00 (Cystic fibrosis without mention of meconium ileus) 10 296, 297, 298 Existing 277.01 (Cystic fibrosis with mention of meconium ileus) 15 387, 389 Proposed new 277.02 (Cystic fibrosis with pulmonary manifestations) 4 79, 80, 81 Proposed new 277.03 (Cystic fibrosis with gastrointestinal manifestations) 6 188, 189, 190 Proposed new 277.09 (Cystic fibrosis with other manifestations) 10 296, 297, 298 5. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract) a. Insertion of Totally Implantable Vascular Access Device
(VAD)In the August 1, 2001 final rule (66 FR 39844), we discussed our review of the DRG assignment of code 86.07 (Insertion of totally implantable vascular access device (VAD)). Code 86.07 is considered a nonoperative procedure when it occurs in MDC 11. Therefore, patients in renal (kidney) failure requiring implantation of this device for dialysis are grouped to medical DRG 316 (Renal Failure). We examined whether implantation of this device should be removed from DRG 316 and placed into surgical DRG 315 (Other Kidney and Urinary Tract O.R. Procedures). Implantation of a VAD into the chest wall and blood vessels of a patient's upper body allows access to a patient's vessels via an implanted valve and cannula. Two devices are implanted during one operative session. One system is implanted arterially (the “draw”), while the other is implanted venously (the “return”). Typically, the VAD allows access to the patient's blood for hemodialysis purposes when other sites in the body have been exhausted. The device is usually inserted in the outpatient setting. Operative time is approximately 1 to 1.5 hours. In the FY 2002 final rule (66 FR 39844-39845), we pointed out that cases where the VAD was inserted as an inpatient procedure also involved other complications, leading to higher average charges. Therefore, we indicated that we were not assigning code 86.07 to DRG 315 at that time, but we would consider other alternative adjustments to DRGs 315 and 316. For FY 2003, we explored whether DRG 315 should be split based on existence or nonexistence of CCs. However, during our consideration of this alternative, we discovered that DRG 315 does not lend itself to a CC split due to the high occurrence of cases in this DRG that already have complications identified on the CC list. Therefore, we reexamined cases in DRGs 315 and 316 in the FY 2001 MedPAR file. The results are reflected in the chart below: With Code 86.07 Without Code 86.07 DRG 315 (surgical): Number of Cases 354 21,089. Average Length of Stay 12.6 days 6.7 days. Average Charges $47,251 $25,622. DRG 316 (Medical): Number of Cases 887 76,676. Average Length of Stay 10.3 6.6 days. Average Charges $31,904 $16,934. These results are similar to the findings included in the FY 2002 final rule that were based on data from the FY 2000 MedPAR file (66 FR 39845). We found that the average length of stay in DRG 315 for patients not receiving the VAD is 6.7 days, while those patients who received the VAD had an average length of stay of 12.6 days. We found the average charges in DRG 315 for patients not receiving the VAD were approximately $25,622, while the average charges for those patients who received the VAD were $47,251. We found that the cases receiving the VAD as an inpatient procedure are significantly more costly than other cases in DRG 316. Therefore, we are proposing to designate code 86.07 as an O.R. procedure under MDC 11. Specifically, code 86.07 would be recognized as an O.R. procedure code in MDC 11 and assigned to DRG 315 when combined with the following principal diagnosis codes from DRG 316: • 403.01, Malignant hypertensive renal disease with renal failure • 403.11, Benign hypertensive renal disease with renal failure • 403.91, Unspecified hypertensive renal disease with renal failure • 404.02, Malignant hypertensive heart and renal disease with renal failure • 404.12, Malignant hypertensive heart and renal disease with renal failure • 404.92, Unspecified hypertensive heart and renal disease with renal failure • 584.5, Acute renal failure with lesion of tubular necrosis • 584.6, Acute renal failure with lesion of renal cortical necrosis • 584.7, Acute renal failure with lesion of renal medullary (papillary) necrosis • 584.8, Acute renal failure with other specified pathological lesion in kidney • 584.9, Acute renal failure, unspecified • 585, Chronic renal failure • 586, Renal failure, unspecified • 788.5, Oliguria and anuria • 958.5, Traumatic anuria b. Bladder Reconstruction We received correspondence regarding the current classification of procedure code 57.87 (Reconstruction of urinary bladder) as a minor bladder procedure and the assignment of the code under DRG 308 (Minor Bladder Procedures with CC) and DRG 309 (Minor Bladder Procedures without CC). The correspondent believed that bladder reconstruction is not a minor procedure, submitted individual hospital charges to support this contention, and recommended that the code be classified as a major procedure and assigned to a higher weighted DRG. Our clinical advisors indicated that reconstruction of the bladder is a more extensive procedure than the other minor bladder procedures in DRGs 308 and 309. They agree that the bladder reconstruction procedure is as complex as the procedures under code 57.79 (Total cystectomy) and the other major bladder procedures in DRGs 303 through 305. As indicated in the chart below, we found that the average charges for bladder reconstruction are significantly higher than the average charges for other minor procedures within DRGs 308 and 309: With Code 57.87 Without Code 57.87 DRG 308 (minor bladder procedure with CC): Number of Cases 64 5,066 Average Charges $36,560 $19,923 DRG 309 (minor bladder procedures without CC): Number of Cases 25 3,021 Average Charges $23,390 $11,200 We found that procedure code 57.87 may be more appropriately placed in DRG 303 (Kidney, Ureter and Major Bladder Procedures for Neoplasm), 304 (Kidney, Ureter and Major Bladder Procedures for Nonneoplasm with CC), and DRG 305 (Kidney, Ureter and Major Bladder Procedures for Nonneoplasm without CC), based on average charges for procedures in these three DRGS as indicated in the following chart: DRG Number of cases Average charges 303 (Kidney, Ureter and Major Bladder Procedures for Neoplasm) 14,116 $30,691 304 (Kidney, Ureter and Major Bladder Procedures for Nonneoplasm with CC) 8,060 30,577 305 (Kidney, Ureter and Major Bladder Procedures for Nonneoplasm without CC) 2,029 15,492 Based on the results of our analysis and the advice of our medical consultants discussed above, we are proposing to classify code 57.87 as a major bladder procedure and to assign it to DRGs 303, 304, and 305. 6. MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period) The primary focus of updates to the Medicare DRG classification system is for changes relating to the Medicare patient population, not the pediatric or neonatal patient populations. However, the Medicare DRGs are sometimes used to classify other patient populations. Over the years, we have received comments about aspects of the Medicare newborn DRGs that appear problematic, and we have responded to these on an individual basis. Some correspondents have requested that we take a closer overall look at the DRGs within MDC 15. To respond to this request relating to review of MDC 15, we contacted the National Association of Children's Hospitals and Related Institutions (NACHRI), along with our own medical advisors, to obtain proposals for possible revisions of the existing DRG categories in MDC 15. The focus of the requested proposals was to refine category definitions within the framework of the existing seven broadly defined neonatal DRGs. The proposals also were to take advantage of the new, more specific neonatal diagnosis codes to be adopted, effective October 1, 2002, to assist with refinements to the existing DRG category definitions. In preparing these proposed changes to MDC 15, we have considered comments and suggestions previously received, including suggestions from NACHRI on how to make improvements within the existing framework of seven very broadly defined neonatal DRGs. In the future, we may consider broader changes to MDC 15. a. Definition of MDC 15 The existing diagnosis definitions for MDC 15 include certain diagnoses that may be present at the time of birth but may also continue beyond the perinatal period. These diagnoses are basically congenital anomalies, and even though they may continue beyond the perinatal period, they are assigned to MDC 15 which is specific to newborns and neonates. The diagnosis codes assigned to the DRGs under MDC 15 have been a source of confusion because older children and adults can be admitted with these principal diagnoses and assigned to newborn or neonate DRGs in MDC 15 as if they were newborns. Our medical consultants and NACHRI have reviewed the listing of diagnosis codes and identified those that should not be routinely classified under MDC 15. As a result of this review, we are proposing that the following list of diagnosis codes be removed from MDC 15: • 758.9, Conditions due to anomaly of unspecified chromosome • 759.4, Conjoined twins • 759.7, Multiple congenital anomalies, so described • 759.81, Prader-Willi Syndrome • 759.83, Fragile X Syndrome • 759.89, Other specified anomalies • 759.9, Congenital anomaly, unspecified • 779.7, Periventricular leukomalacia • 795.2, Nonspecific abnormal findings on chromosomal analysis We are proposing to assign the nine diagnosis codes listed above to the following MDCs and DRGs (if medical): Diagnosis code Title Proposed MDC assignment Proposed DRG assignment 758.9 Conditions due to anomaly of unspecified chromosome 23 467 (Other Factors Influencing Health Status). 759.4 Conjoined twins 6 188, 189, 190 (Other Digestive System Diagnoses, age >17 with CC, Age >17 without CC, and Age 0-17, respectively). 759.7 Multiple congenital anomalies, so described 8 256 (Other Musculoskeletal System and Connective Tissue Diagnoses). 759.81 Prader-Willi Syndrome 8 256 (Other Musculoskeletal System and Connective Tissue Diagnoses). 759.83 Fragile x Syndrome 19 429 (Organic Disturbances and Mental Retardation) 759.89 Other specified anomalies 8 256 (Other Musculoskeletal System and Connective Tissue Diagnoses). 759.9 Congenital anomaly, unspecified 23 467 (Other Factors Influencing Health Status). 779.7 Periventricular leukomalacia 1 34, 35 (Other Disorders of the Nervous System with CC and without CC, respectively). 795.2 Nonspecific abnormal findings on chromosomal analysis 23 467 (Other Factors Influencing Health Status). The following three specific 4-digit diagnosis codes have been determined invalid by the ICD-9-CM Coordination and Maintenance Committee, effective October 1, 2002, and we are proposing to remove them from MDC 15. • 770.8, Other newborn respiratory problems • 771.8, Other infection specific to the perinatal period • 779.8, Other specified conditions originating in the perinatal period The above three codes are being replaced by 5-digit codes to capture more detail. These new 5-digit codes are assigned to DRGs within MDC 15 and are listed among the codes in Table 6A—New Diagnosis Codes in the Addendum of this proposed rule. In addition, the ICD-9-CM Coordination and Maintenance Committee created a number of new codes, effective October 1, 2002, to capture newborn and neonatal conditions. Therefore, we are proposing to add the following new 23 diagnosis codes to MDC 15: • 747.83, Persistent fetal circulation • 765.20, Unspecified weeks of gestation • 765.21, Less than 24 completed weeks of gestation • 765.22, 24 completed weeks of gestation • 765.23, 25-26 completed weeks of gestation • 765.24, 27-28 completed weeks of gestation • 765.25, 29-30 completed weeks of gestation • 765.26, 31-32 completed weeks of gestation • 765.27, 33-34 completed weeks of gestation • 765.28, 35-36 completed weeks of gestation • 765.29, 37 or more completed weeks of gestation • 770.81, Primary apnea of newborn • 770.82, Other apnea of newborn • 770.83, Cyanotic attacks of newborn • 770.84, Respiratory failure of newborn • 770.89, Other respiratory problems after birth • 771.81, Septicemia [sepsis] of newborn • 771.82, Urinary tract infection of newborn • 771.83, Bacteremia of newborn • 771.89, Other infections specific to the perinatal period • 779.81, Neonatal bradycardia • 779.82, Neonatal tachycardia • 779.89, Other specified conditions originating in perinatal period b. DRG 386 (Extreme Immaturity or Respiratory Distress Syndrome, Neonate) The existing DRG 386 is defined by the presence of one of the ICD-9-CM extreme prematurity codes (765.01 through 765.05) with the fifth digit indicating birthweight less than 1,500 grams (3.3 pounds). NACHRI has identified two weaknesses in the use of the fifth digit to define prematurity. One weakness relates to determining extreme immaturity, which, in part, is limited by the existing ICD-9-CM diagnosis codes. The existing ICD-9-CM definition for the extreme immaturity codes “usually implies birthweight less than 1,000 grams (2.2 pounds) or gestational age less than 28 completed weeks,” or both. The fifth digit provides range values for birthweight but gives no information on gestational age. A specific and distinct set of ICD-9-CM diagnosis codes for gestational age is to be introduced effective October 1, 2002. These new codes will provide a clearer basis for differentiating extreme immaturity or gestational age, or both. The second weakness is that diagnosis code 769 (Respiratory distress syndrome in newborn) is currently only associated with DRG 386, which requires extreme prematurity, but respiratory distress syndrome in newborns can occur with all levels of prematurity. Therefore, we believe that code 769 should not be used to classify a diagnosis under DRG 386. The proposed revision to DRG 386 would reflect the upcoming new ICD-9-CM diagnosis codes. We are proposing to redefine DRG 386 to include those newborns whose preterm birthweight is less than 1,000 grams or gestational age is less than 27-28 completed weeks, or both. Therefore, we would remove diagnosis code 769 from DRG 386, as this code is associated with all levels of prematurity, not just extreme immaturity. In addition, we are proposing to revise the title of DRG 386 to read “Extreme Immaturity”. Because birthweight for neonates varies at all gestational ages, some neonates will meet the DRG 386 criteria for preterm extremely low birthweight (less than 1,000 grams) but not the DRG 386 criteria for extremely short gestation age (less than 27-28 completed weeks). The reverse may also occur, where a neonate meets the DRG 386 criteria for extremely short gestational age (less than 27-28 completed weeks) but not for preterm extremely low birthweight (less than 1,000 grams). In either situation, the neonate would be assigned to the proposed retitled DRG 386 (Extreme Immaturity). NACHRI provided the following information on the measurement of gestational age and its use in the definition of Medicare neonatal DRGs. First, they noted that gestational age can be as powerful a predictor of a newborn's hospitalization course as birthweight and corresponds more directly to organ system immaturity. Second, while gestational age can be identified with a reasonable level of accuracy, it cannot be measured as precisely as birthweight. These two considerations led NACHRI to recommend the inclusion of gestational age in the definition of the Medicare neonatal DRGs, but in a conservative manner. Specifically, extremely short gestational age, as identified earlier, usually implies gestational age less than 28 weeks. The proposed new definition of DRG 386 includes only the gestational age codes for less than 27 to 28 completed weeks. Thus, there is a 1-week conservative bias in the use of the new gestational age codes for DRG 386. It is also important to note that the existing DRG 386 definition includes existing codes 765.01 through 765.05, which include extreme immaturity without a specific identification of gestational age and birthweight up to 1,499 grams (3.3 pounds). Thus, the proposed revised definition of DRG 386 is actually somewhat more stringent as well as more specific. To implement these changes, we are proposing to remove the following diagnosis codes from the list of “principal or secondary diagnosis” under DRG 386: • 765.04, Extreme immaturity, 1,000-1,249 grams • 765.05, Extreme immaturity, 1,250-1,499 grams • 769, Respiratory distress syndrome in newborn Note, as explained above, while we are proposing to remove diagnosis codes 765.04, 765.05, and 769 from the list of principal or secondary diagnosis under DRG 386, a neonate would still be assigned to DRG 386 if there is a diagnosis of gestational age less than 27 to 28 completed weeks reported (765.21 through 765.23). We are proposing to add the following diagnosis codes to the list of “principal or secondary diagnosis” under DRG 386: • 765.11, Other preterm infants, less than 500 grams • 765.12, Other preterm infants, 500-749 grams • 765.13, Other preterm infants, 750-999 grams • 765.21, Less than 24 completed weeks of gestation • 765.22, 24 completed weeks of gestation • 765.23, 25-26 completed weeks of gestation c. DRG 387 (Prematurity With Major Problems) The existing definition of DRG 387 has the following three components:
(1)Principal or secondary diagnosis of prematurity;
(2)Principal or secondary diagnosis of major problem (these are diagnoses that define MDC 15); or
(3)secondary diagnosis of major problem (these are diagnoses that do not define MDC 15 so they can only be secondary diagnosis codes for patients assigned to MDC 15). We are proposing changes for each component of the definition for DRG 387. We are proposing to revise the definition for the first component of DRG 387, “principal or secondary diagnosis of prematurity”, to include all preterm low birthweight codes with fifth digit range code values indicating birthweight between 1,000 grams (2.2 pounds) and 2,499 grams (5.5 pounds), or gestational age between 27 to 28 and 35 to 36 completed weeks, or both. This would include all of the preterm low birthweight and gestational age codes except those assigned to the proposed revised DRG 386 and except for the following four preterm and gestational age codes: 765.10, 765.19, 765.20, and 765.29. It is possible for a neonate to be premature and greater than 2,500 grams (5.5 pounds). In this instance, one of the new gestational age codes that specifically identifies the newborn to be less than 37 completed weeks of gestation would need to be present to meet the criteria for inclusion in DRG 387. This is not a conceptual change for DRG 387, in that diagnosis codes 765.10 and 765.19 should both refer to newborns less than 37 completed weeks of gestation. Therefore, we are proposing to take into consideration the new ICD-9-CM codes that require a more specific affirmation that the newborn is less than 37 completed weeks of gestation. Because DRG 387 is a broadly defined category (1,000-2,499 grams or 27-36 completed weeks of gestation), NACHRI recommends that it is important to require specific information for inclusion of patients at the high end of the birthweight/gestational age range. We are proposing to remove the following diagnosis codes from the list of diagnoses defined as “principal or secondary diagnosis of prematurity” for DRG 387: • 765.10, Other preterm infants, unspecified (weight) • 765.11, Other preterm infants, less than 500 grams • 765.12, Other preterm infants, 500-749 grams • 765.13, Other preterm infants, 750-999 grams • 765.19, Other preterm infants, 2,500+ grams We are proposing to add the following diagnosis codes to the list of diagnoses defined as “principal or secondary diagnosis of prematurity” for DRG 387: • 765.04, Extreme immaturity, 1000-1249 grams • 765.05, Extreme immaturity, 1250-1499 grams • 765.24, 27-28 completed weeks of gestation • 765.25, 29-30 completed weeks of gestation • 765.26, 31-32 completed weeks of gestation • 765.27, 33-34 completed weeks of gestation • 765.28, 35-36 completed weeks of gestation We are proposing to revise the definition for the second component of DRG 387, “principal or secondary diagnosis of major problem”, to remove certain diagnosis codes and to add other diagnosis codes. We are proposing to remove three groups of diagnosis codes. The first group of diagnosis codes that we are proposing to remove includes the fetal malnutrition codes for the birthweight ranges less than 2500 grams. NACHRI indicates that these newborns are not necessarily more complicated than preterm infants of the same birthweight range. These newborns have fewer problems related to organ system immaturity and often demonstrate excellent catch-up growth after delivery. Some of the fetal malnutrition diagnosis neonates may have serious problems. Therefore, it is best for the classification system to look for other more specific, major problem diagnoses than to include all of these newborns in DRG 387. We are proposing to remove the following diagnosis codes from DRG 387. • 764.11, “Light-for-dates” with signs of fetal malnutrition, less than 500 grams • 764.12, “Light-for-dates” with signs of fetal malnutrition, 500-749 grams • 764.13, “Light-for-dates” with signs of fetal malnutrition, 750-999 grams • 764.14, “Light-for-dates” with signs of fetal malnutrition, 1,000-1,249 grams • 764.15, “Light-for-dates” with signs of fetal malnutrition, 1,250-1,499 grams • 764.16, “Light-for-dates” with signs of fetal malnutrition, 1,500-1,749 grams • 764.17, “Light-for-dates” with signs of fetal malnutrition, 1,750-1,999 grams • 764.18, “Light-for-dates” with signs of fetal malnutrition, 2,000-2,499 grams • 764.21, Fetal malnutrition without mention of “light-for-dates”, less than 500 grams • 764.22, Fetal malnutrition without mention of “light-for-dates”, 500-749 grams • 764.23, Fetal malnutrition without mention of “light-for-dates”, 750-999 grams • 764.24, Fetal malnutrition without mention of “light-for-dates”, 1,000-1,249 grams • 764.25, Fetal malnutrition without mention of “light-for-dates”, 1,250-1,499 grams • 764.26, Fetal malnutrition without mention of “light-for-dates”, 1,500-1,749 grams • 764.27, Fetal malnutrition without mention of “light-for-dates”, 1,750-1,999 grams • 764.28, Fetal malnutrition without mention of “light-for-dates”, 2,000-2,499 grams The second group of codes we are proposing to remove from the list of “principal or secondary diagnosis of major problems” under DRG 387 consists of the following 13 diagnosis codes. The majority of these diagnosis codes do not represent a major problem for a newborn at or shortly after birth. NACHRI believes that costs associated with newborns with these conditions are similar to costs associated with neonates without a major problem. • 763.4, Cesarean delivery affecting fetus or newborn • 770.1, Meconium aspiration syndrome • 770.8, Other newborn respiratory problems • 771.8, Other infection specific to the perinatal period • 772.0, Fetal blood loss • 773.2, Hemolytic disease due to other and unspecified isoimmunization of fetus or newborn • 773.5, Late anemia due to isoimmunization of fetus or newborn • 775.5, Other transitory neonatal electrolyte disturbances • 775.6, Neonatal hypoglycemia • 776.0, Hemorrhagic disease of newborn • 776.6, Anemia of prematurity • 777.1, Meconium obstruction in fetus or newborn • 777.2, Intestinal obstruction due to inspissated milk in newborn We note that diagnosis code 770.8 (Other newborn respiratory problems) and diagnosis code 771.8 (Other infection specific to the perinatal period) are 4-digit codes that are being replaced by a series of more specific 5-digit codes, effective October 1, 2002. (See Table 6C in the Addendum of this proposed rule.) The listing of the codes on the second group above includes some of these new 5-digit codes. The third group of diagnosis codes that we are proposing to remove from the list of diagnosis defined as “principal or secondary diagnosis of major problem” under DRG 387 includes the following two diagnosis codes. These codes are no longer assigned to MDC 15 when they are the principal diagnosis. • 759.4, Conjoined twins • 779.7, Periventricular leukomalacia We are proposing to add the following nine new and existing diagnosis codes to the list of “principal or secondary diagnosis of major problem” that defines DRG 387. These nine diagnosis codes generally represent major problems at the time of birth and have costs more similar to those of neonates with major problems than neonates without major problems. Many of these diagnosis codes are related to congenital anomaly conditions. • 747.83, Persistent fetal circulation (new code) • 769, Respiratory distress syndrome in newborn • 770.84, Respiratory failure of newborn (new code) • 771.3, Tetanus neonatorum • 771.81, Septicemia of newborn (new code) • 771.82, Neonatal urinary tract infection (new code) • 771.83, Bacteremia of newborn (new code) • 771.89, Other infections specific to perinatal period (new code) • 776.7, Transient neonatal neutropenia Of special note is the handling of diagnosis code 769 (Respiratory distress syndrome in newborn). Earlier in this preamble, we discussed the proposed removal of this diagnosis code from the definition of proposed retitled DRG 386 (Extreme Immaturity) because, even though it is usually associated with prematurity, it may occur with all levels of prematurity. We are proposing to add respiratory distress syndrome (which was previously assigned to existing DRG 386) to the list of diagnoses that define “principal or secondary diagnosis of major problem” for DRG 387. We are not proposing to add it to the list of diagnoses that define “principal or secondary diagnosis of prematurity” for DRG 387. The rationale for not adding code 769 as a prematurity diagnosis is that it occurs in only a small subset of neonates in the birthweight range of 1,000 to 2,499 grams (2.2 to 5.5 pounds), and the vast majority of occurrences is in the upper end of this birthweight range. Respiratory distress syndrome might not be indicative of a major problem for neonates at the low end of this range (for example, those closer to 1,000 to 1,249 grams), because these neonates will most likely have multiple significant problems. Therefore, we are proposing that respiratory distress syndrome be classified as a major problem and included among the list of “principal or secondary diagnosis of major problem” for DRG 387. In addition, we are proposing to revise the definition for the third defining component of DRG 387, “secondary diagnosis of major problem”. This list of major problem diagnoses can only be secondary diagnoses because they are not among the list of principal diagnoses that defines MDC 15 for the Medicare DRG classification system. Based on NACHRI's recommendations, we are proposing to add and remove diagnoses from this list on the same basis as previously described for the list of “principal or secondary diagnosis of major problems” for DRG 387. That is, diagnoses are removed if, in the majority of instances, the condition does not represent a major problem for a newborn at or shortly after birth, and on average exhibits costs similar to the costs associated with neonates without a major problem. In addition, we are proposing to remove the asthma with status asthmaticus diagnosis codes, as these diagnosis codes pertain to newborns or other conditions arising in the perinatal period. We are proposing to remove the following diagnosis codes from the list of “secondary diagnosis of major problem” for DRG 387: • 276.5, Volume depletion • 349.0, Reaction to spinal or lumbar puncture • 457.2, Lymphangitis • 493.01, Extrinsic asthma with status asthmaticus • 493.11, Intrinsic asthma with status asthmaticus • 493.91, Asthma, unspecified type, with status asthmaticus • 578.1, Blood in stool • 683, Acute lymphadenitis • 693.0, Dermatitis due to drugs and medicines taken internally • 695.0, Toxic erythema • 708.0, Allergic urticaria • 745.4, Ventricular septal defect • 785.0, Tachycardia, unspecified • 995.2, Unspecified adverse effect of drug, medicinal and biological substance, not elsewhere classified • 999.5, Other serum reaction, not elsewhere classified • 999.6, ABO incompatibility reaction, not elsewhere classified • 999.7, Rh incompatibility reaction, not elsewhere classified • 999.8, Other transfusion reaction, not elsewhere classified We are proposing to add the following 65 diagnosis codes to the list of “secondary diagnosis of major problem” for DRG 387: • 416.0, Primary pulmonary hypertension • 416.8, Other chronic pulmonary heart diseases • 425.3, Endocardial fibroelastosis • 425.4, Other primary cardiomyopathies • 427.0, Paroxysmal supraventricular tachycardia • 427.1, Paroxysmal ventricular tachycardia • 466.11, Acute bronchiolitis due to respiratory syncytial virus
(RSV)• 466.19, Acute bronchiolitis due to other infectious organisms • 478.74, Stenosis of larynx • 480.0, Pneumonia due to adenovirus • 480.1, Pneumonia due to respiratory syncytial virus • 480.2, Pneumonia due to parainfluenza virus • 480.8, Pneumonia due to other virus not elsewhere classified • 480.9, Viral pneumonia, unspecified • 745.0, Common truncus • 745.10, Complete transposition of great vessels • 745.11, Double outlet right ventricle • 745.12, Corrected transposition of great vessels • 745.19, Other transposition of great vessels • 745.2, Tetralogy of Fallot • 745.3, Common ventricle • 745.60, Endocardial cushion defect, unspecified type • 745.61, Ostium primum defect • 745.69, Other endocardial cushion defects • 746.01, Atresia of pulmonary valve, congenital • 746.1, Tricuspid atresia and stenosis, congenital • 746.2, Ebstein's anomaly • 746.7, Hypoplastic left heart syndrome • 746.81, Subaortic stenosis, congenital • 746.82, Cor triatriatum • 746.84, Obstructive anomalies of heart, congenital, not elsewhere classified • 746.86, Congenital heart block • 747.10, Coarctation of aorta (preductal) (postductal) • 747.11, Interruption of aortic arch • 747.41, Total anomalous pulmonary venous connection • 747.81, Anomalies of cerebrovascular system, congenital • 748.3, Other congenital anomalies of larynx, trachea, and bronchus • 748.4, Cystic lung, congenital • 748.5, Agenesis, hypoplasia, and dysplasia of lung, congenital • 750.3, Tracheoesophageal fistula, esophageal atresia and stenosis, congenital • 751.1, Atresia and stenosis of small intestine, congenital • 751.2, Atresia and stenosis of large intestine, rectum, and anal canal, congenital • 751.3, Hirschsprung's disease and other congenital functional disorders of colon • 751.4, Anomalies of intestinal fixation, congenital • 751.62, Congenital cystic disease of liver • 751.69, Other congenital anomalies of gall bladder, bile ducts, and liver • 751.7, Anomalies of pancreas, congenital • 753.0, Renal agenesis and dysgenesis • 753.5, Exstrophy of urinary bladder • 756.51, Osteogenesis imperfecta • 756.6, Anomalies of diaphragm, congenital • 756.70, Congenital anomaly of abdominal wall, unspecified • 756.71, Prune belly syndrome • 756.79, Other congenital anomalies of abdominal wall • 758.1, Patau's Syndrome • 758.2, Edwards' Syndrome • 758.3, Autosomal deletion syndromes • 759.4, Conjoined twins • 759.7, Multiple congenital anomalies, so described • 759.81, Prader-Willi Syndrome • 759.89, Other specified anomalies • 7797, Periventricular leukomalacia • 785.51, Cardiogenic shock • 785.59, Other shock without mention of trauma • 789.5, Ascites d. DRG 388 (Prematurity Without Major Problems) We are proposing to revise the definition for prematurity for DRG 388 ((Prematurity without Major Problems) in the same manner that we proposed to revise the definition of prematurity for DRG 387 (Prematurity with Major Problems). We are proposing to remove the following five diagnosis codes from the list of codes pertaining to the “principal or secondary diagnosis of prematurity” for DRG 388: • 765.10, Other preterm infants unspecified (weight) • 765.11, Other preterm infants, less than 500 grams • 765.12, Other preterm infants, 500-749 grams • 765.13, Other preterm infants, 750-999 grams • 765.19, Other preterm infants, 2,500+ grams We are proposing to add the following seven diagnosis codes to the definition of principal or secondary diagnosis of prematurity for DRG 388: • 765.04, Extreme immaturity, 1000-1249 grams • 765.05, Extreme immaturity, 1250-1499 grams • 765.24, 27-28 completed weeks of gestation • 765.25, 29-30 completed weeks of gestation • 765.26, 31-32 completed weeks of gestation • 765.27, 33-34 completed weeks of gestation • 765.28, 35-36 completed weeks of gestation e. DRG 389 (Full Term Neonate With Major Problem) We are proposing to revise the definition of “principal or secondary diagnosis of major problem” for DRG 389 (Full Term Neonate with Major Problem) in the same manner that we proposed to revise the definition for DRG 387 (Prematurity with Major Problem). f. DRG 390 (Neonate With Other Significant Problems) DRG 390 is defined as patients with “principal or secondary diagnosis of newborn or neonate, with other significant problems, not assigned to DRG 385 through 389, 391, or 469 (principal diagnosis invalid as discharge diagnosis). As a result of our proposed changes to other neonatal DRGs, we are proposing to make conforming changes related to diagnosis codes assigned to DRG 390. g. DRG 391 (Normal Newborn) DRG 391 (Normal Newborn) is defined by a list of principal diagnoses (for example, V30, Newborn codes plus certain minor newborn problems) and no secondary diagnoses or only certain secondary diagnoses (that is, minor problem diagnoses). NACHRI recommended that the definition of DRG 391 be modified to expand the number of minor problem newborn diagnoses included in both the list of principal diagnoses and the list of only certain secondary diagnoses that define DRG 391. The diagnoses that we are proposing to add to DRG 391 are conditions that NACHRI has identified as occurring with some frequency in the newborn population and having costs more similar to that of DRG 391 than DRG 390 (Neonates with Other Significant Problems). We are proposing to add the following diagnosis codes to the list of “principal diagnosis” that defines DRG 391: • 764.00, “Light-for-dates” without mention of fetal malnutrition, unspecified (weight) • 764.90, Fetal growth retardation unspecified (weight) • 765.10, Other preterm infants unspecified (weight) • 765.19, Other preterm infants, 2,500+ grams • 765.20, Unspecified weeks of gestation • 765.29, 37 or more completed weeks of gestation We also are proposing to add the above six diagnosis codes to the list of “only certain secondary diagnosis” that defines DRG 391, as indicated below. Of these diagnosis codes, NACHRI indicates that the highest volume diagnosis code is 765.19 (Other preterm infants, 2,500+ grams). NACHRI notes that when this diagnosis code is recorded and no major problem or significant problem diagnosis is recorded, these patients have costs that are not much different than those for other normal newborns. We are proposing to add the following codes to the list of “only certain secondary diagnosis” that defines DRG 391: • 216.0, Benign neoplasm of skin of lip • 216.1, Benign neoplasm of eyelid, including canthus • 216.2, Benign neoplasm of ear and external auditory canal • 216.3, Benign neoplasm of skin of other and unspecified parts of face • 216.4, Benign neoplasm of scalp and skin of neck • 216.5, Benign neoplasm of skin of trunk, except scrotum • 216.6, Benign neoplasm of skin of upper limb, including shoulder • 216.7, Benign neoplasm of skin of lower limb, including hip • 216.8, Benign neoplasm of other specified sites of skin • 216.9, Benign neoplasm of skin, site unspecified • 228.00, Hemangioma of unspecified site • 228.01, Hemangioma of skin and subcutaneous tissue • 228.1, Lymphangioma, any site • 379.8, Other specified disorders of eye and adnexa • 379.90, Disorder of eye, unspecified • 379.92, Swelling or mass of eye • 379.93, Redness or discharge of eye • 379.99, Other ill-defined disorders of eye • 427.60, Premature beats, unspecified • 427.61, Supraventricular premature beats • 427.9, Cardiac dysrhythmia, unspecified • 528.4, Cysts of oral soft tissues • 553.1, Umbilical hernia without mention of obstruction or gangrene • 603.8, Other specified types of hydrocele • 603.9, Hydrocele, unspecified • 607.89, Other specified disorders of penis • 607.9, Unspecified disorder of penis and perineum • 624.9, Unspecified noninflammatory disorder of vulva and perineum • 692.9, Contact dermatitis and other eczema unspecified cause • 701.1, Keratoderma, acquired • 701.3, Striae atrophicae • 701.8, Other specified hypertrophic and atrophic conditions of skin • 701.9, Unspecified hypertrophic and atrophic conditions of skin • 702.8, Other specified dermatoses • 705.1, Prickly heat • 706.1, Other acne • 706.2, Sebaceous cyst • 709.8, Other specified disorders of skin • 709.9, Unspecified disorder of skin and subcutaneous tissue • 719.61, Other symptoms referable to joint of shoulder region • 719.65, Other symptoms referable to joint of pelvic region and thigh • 755.00, Polydactyly, unspecified digits • 755.01, Polydactyly of fingers • 755.02, Polydactyly of toes • 755.10, Syndactyly of multiple and unspecified sites • 755.11, Syndactyly of fingers without fusion of bone • 755.12, Syndactyly of fingers with fusion of bone • 755.13, Syndactyly of toes without fusion of bone • 755.14, Syndactyly of toes with fusion of bone • 755.66, Other congenital anomalies of toes • 755.67, Anomalies of foot, congenital, not elsewhere classified • 755.9, Unspecified congenital anomaly of unspecified limb • 757.2, Dermatoglyphic anomalies • 757.32, Vascular hamartomas • 757.39, Other specified congenital anomalies of skin • 757.4, Specified congenital anomalies of hair • 757.5, Specified congenital anomalies of nails • 757.6, Specified congenital anomalies of breast • 757.8, Other specified congenital anomalies of the integument • 757.9, Unspecified congenital anomaly of the integument • 760.0, Maternal hypertensive disorders affecting fetus or newborn • 760.1, Maternal renal and urinary tract diseases affecting fetus or newborn • 760.2, Maternal infections affecting fetus or newborn • 760.3, Other chronic maternal circulatory and respiratory diseases affecting fetus or newborn • 760.4, Maternal nutritional disorders affecting fetus or newborn • 760.5, Maternal injury affecting fetus or newborn • 760.6, Surgical operation on mother affecting fetus or newborn • 760.70, Unspecified noxious substance affecting fetus or newborn via placenta or breast milk • 760.74, Anti-infectives affecting fetus or newborn via placenta or breast milk • 760.76, Diethylstilbestrol
(DES)exposure affecting fetus or newborn via placenta or breast milk • 760.79, Other noxious influences affecting fetus or newborn via placenta or breast milk • 760.8, Other specified maternal conditions affecting fetus or newborn • 760.9, Unspecified maternal condition affecting fetus or newborn • 761.0, Incompetent cervix affecting fetus or newborn • 761.1, Premature rupture of membranes affecting fetus or newborn • 761.5, Multiple pregnancy affecting fetus or newborn • 761.7, Malpresentation before labor affecting fetus or newborn • 761.8, Other specified maternal complications of pregnancy affecting fetus or newborn • 761.9, Unspecified maternal complication of pregnancy affecting fetus or newborn • 762.8, Other specified abnormalities of chorion and amnion affecting fetus or newborn • 762.9, Unspecified abnormality of chorion and amnion affecting fetus or newborn • 763.4, Cesarean delivery affecting fetus or newborn • 763.5, Maternal anesthesia and analgesia affecting fetus or newborn • 763.7, Abnormal uterine contractions affecting fetus or newborn • 763.89, Other specified complications of labor and delivery affecting fetus or newborn • 764.00, “Light-for-dates” without mention of fetal malnutrition, unspecified (weight) • 764.90, Fetal growth retardation unspecified (weight) • 765.10, Other preterm infants unspecified (weight) • 765.19, Other preterm infants, 2,500+ grams • 765.20, Unspecified weeks of gestation • 765.29, 37 or more completed weeks of gestation • 767.2, Fracture of clavicle due to birth trauma • 767.3, Other injuries to skeleton due to birth trauma • 767.8, Other specified birth trauma • 767.9, Unspecified birth trauma • 768.2, Fetal distress before onset of labor, in liveborn infant • 768.3, Fetal distress first noted during labor, in liveborn infant • 768.4, Fetal distress, unspecified as to time of onset, in liveborn infant • 768.9, Unspecified severity of birth asphyxia in liveborn infant • 70.9, Unspecified respiratory condition of fetus and newborn • 772.8, Other specified hemorrhage of fetus or newborn • 772.9, Unspecified hemorrhage of newborn • 773.1, Hemolytic disease due to ABO isoimmunization of fetus or newborn • 773.2, Hemolytic disease due to other and unspecified isoimmunization of fetus or newborn • 773.5, Late anemia due to isoimmunization of fetus or newborn • 775.6, Neonatal hypoglycemia • 775.9, Unspecified endocrine and metabolic disturbances specific to the fetus and newborn • 776.4, Polycythemia neonatorum • 776.8, Other specified transient hematological disorders of fetus or newborn • 776.9, Unspecified hematological disorder specific to fetus or newborn • 777.1, Meconium obstruction in fetus or newborn • 777.3, Hematemesis and melena due to swallowed maternal blood of newborn • 777.8, Other specified perinatal disorders of digestive system • 777.9, Unspecified perinatal disorder of digestive system • 778.3, Other hypothermia of newborn • 778.4, Other disturbances of temperature regulation of newborn • 778.6, Congenital hydrocele • 778.7, Breast engorgement in newborn • 778.9, Unspecified condition involving the integument and temperature regulation of fetus and newborn • 779.9, Unspecified condition originating in the perinatal period • 780.6, Fever • 781.0, Abnormal involuntary movements • 781.3, Lack of coordination • 782.1, Rash and other nonspecific skin eruption • 782.2, Localized superficial swelling, mass, or lump • 782.4, Jaundice, unspecified, not of newborn • 782.61, Pallo • 782.62, Flushin • 782.7, Spontaneous ecchymose • 782.8, Changes in skin texture • 782.9, Other symptoms involving skin and integumentary tissues • 783.3, Feeding difficulties and mismanagement • 784.2, Swelling, mass, or lump in head and neck • 784.9, Other symptoms involving head and neck • 785.2, Undiagnosed cardiac murmurs • 785.3, Other abnormal heart sounds • 785.9, Other symptoms involving cardiovascular system • 786.00, Respiratory abnormality, unspecified • 786.7, Abnormal chest sounds • 786.9, Other symptoms involving respiratory system and chest • 787.3, Flatulence, eructation, and gas pain • 790.6, Other abnormal blood chemistry • 790.7, Bacteremia • 790.99, Other nonspecific findings on examination of blood • 795.6, False positive serological test for syphilis • 795.79, Other and unspecified nonspecific immunological findings • 796.1, Abnormal reflex • 910.0, Abrasion or frictions burn of face, neck, and scalp except eye, without mention of infection • 910.2, Blister of face, neck, and scalp except eye, without mention of infection • 910.8, Other and unspecified superficial injury of face, neck, and scalp, without mention of infection • 920, Contusion of face, scalp, and neck except eye(s) • 999.5, Other serum reaction, not elsewhere classified • 999.6, ABO incompatibility reaction, not elsewhere classified • V01.1, Contact with or exposure to tuberculosis • V01.6, Contact with or exposure to venereal diseases • V01.7, Contact with or exposure to other viral diseases • V01.81, Contact with or exposure to communicable diseases, anthrax • V01.89, Contact with or exposure to communicable diseases, other communicable diseases • V01.9, Contact with or exposure to unspecified communicable disease • V02.3, Carrier or suspected carrier of other gastrointestinal pathogens • V05.3, Need for prophylactic vaccination and inoculation against viral hepatitis • V05.4, Need for prophylactic vaccination and inoculation against varicella • V05.8, Need for prophylactic vaccination and inoculation against other specified disease • V05.9, Need for prophylactic vaccination and inoculation against unspecified single disease • V07.8, Need for other specified prophylactic measure • V07.9, Need for unspecified prophylactic measure • V18.0, Family history of diabetes mellitus • V18.1, Family history of other endocrine and metabolic diseases • V18.2, Family history of anemia • V18.3, Family history of other blood disorders • V18.8, Family history of infectious and parasitic diseases • V19.2, Family history of deafness or hearing loss • V19.8, Family history of other condition • V71.9, Observation for unspecified suspected condition • V72.0, Examination of eyes and vision • V72.6, Laboratory examination • V73.89, Special screening examination for other specified viral diseases • V73.99, Special screening examination for unspecified viral disease 7. MDC 23 (Factors Influencing Health Status and Other Contacts With Health Services) In the August 1, 2001 final rule, we included in Table 6A—New Diagnosis Codes (66 FR 40064) code V10.53 (History of malignancy, renal pelvis), which was approved by the ICD-9-CM Coordination and Maintenance Committee as a new code effective October 1, 2001. We assigned the code to DRG 411 (History of Malignancy without Endoscopy) and DRG 412 (History of Malignancy with Endoscopy). We received correspondence which suggested that we should have also assigned code V10.53 to DRG 465 (Aftercare with History of Malignancy as Secondary Diagnosis). The correspondent pointed out that all other codes for a history of malignancy are included in DRG 465. We agree that code V10.53 should be included in the list of the history of malignancy codes within DRG 465. Therefore, we are proposing to add V10.53 to the list of secondary diagnosis in DRG 465. 8. Pre-MDC: Tracheostomy DRG 483 (Tracheostomy Except for Face, Mouth and Neck Diagnoses) is used to classify patients who require long-term mechanical ventilation. Mechanical ventilation can be administered through an endotracheal tube for a limited period of time. When an endotracheal tube is used for an extended period of time (beyond 7 to 10 days), the patient runs a high risk of permanent damage to the trachea. In order to maintain a patient on mechanical ventilation for a longer period of time, the endotracheal tube is removed and a tracheostomy is performed. The mechanical ventilation is then administered through the tracheostomy. A tracheostomy also may be performed on patients for therapeutic purposes unrelated to the administration of mechanical ventilation. Patients with certain face, mouth, and neck disease may have a tracheostomy performed as part of the treatment for the face, mouth, or neck disease. These patients are assigned to DRG 482 (Tracheostomy for Face, Mouth and Neck Diagnoses). Therefore, patients assigned to DRGs 482 and 483 are differentiated based on the principal diagnosis of the patient. At certain times, selecting the appropriate principal diagnosis for the patients receiving tracheostomies for assignment to a DRG can be difficult. The overall number of tracheostomy patients increased by 13 percent between 1994 and 1999. During the same period, the percent of tracheostomy patients in DRG 483 (patients without certain face, mouth, or neck diseases) versus DRG 482 increased from 83.6 percent to 87.6 percent. The payment weight for DRG 483 is more than four times greater than the DRG 482 payment weight, and this has led to concerns about coding compliance. Specifically, the fact that cases are assigned to DRG 483 based on the absence of a code indicating face, mouth, or neck diagnosis creates an incentive to omit codes indicating these diagnoses. To address issues of possible coding noncompliance, we are proposing to modify DRGs 482 and 483 to differentiate the assignment to either DRG based on the presence or absence of continuous mechanical ventilation that lasts more than 96 hours (code 96.72). This modification would ensure that the patients assigned to DRG 483 are patients who had the tracheostomy for long-term mechanical ventilation. Based on an examination of claims data from the FY 2001 MedPAR file, we found that many patients assigned to DRG 483 do not have the code 96.72 for mechanical ventilation greater than 96 hours recorded. In part, this is the result of the limited number of procedure codes
(six)that can be submitted on the current uniform hospital claim form, and the fact that code 96.72 does not currently affect the DRG assignment. We found that many of the patients who are assigned to DRG 483 have multiple procedures, making it impossible for all procedures performed to be submitted on the hospital claim form. Because of the current underreporting of code 96.72 for continuous mechanical ventilation greater than 96 hours, we do not believe we can accurately determine the payment weights for modified DRGs 482 and 483 as described above. In order to encourage the reporting of the code 96.72 for continuous mechanical ventilation for greater than 96 hours, we are proposing to change the definition of DRG 483 so that patients who have a tracheostomy and continuous mechanical ventilation greater than 96 hours (code 96.72) with a principal diagnosis unrelated to disease of the face, mouth, or neck would be assigned to DRG 483. DRG 483 would be retitled “Tracheostomy/Mechanical Ventilation 96+ Hours Except Face, Mouth, and Neck Diagnosis.” We will give future consideration to modifying DRGs 482 and DRG 483 based on the presence of code 96.72, and invite comments on this area. 9. Medicare Code Editor
(MCE)Change As explained under section II.B.1. of this preamble, the MCE is a software program that detects and reports errors in the coding of Medicare claims data. The MCE includes an edit for “nonspecific principal diagnosis” that identifies a group of codes that are valid according to the ICD-9-CM coding scheme, but are not as specific as the coding scheme permits. The fiscal intermediaries use cases identified in this edit for educational purposes for hospitals only. That is, when a hospital reaches a specific threshold of cases (usually 25) in this edit, the fiscal intermediary will contact the hospital and educate it on how to code diagnoses using more specific codes in the ICD-9-CM coding scheme. The claims identified in this nonspecific principal diagnosis edit are neither denied nor returned to the hospital. Code 436 (Acute, but ill-defined, cerebrovascular disease) is one of the codes included in the groups of codes identified in the nonspecific principal diagnosis edit, and is widely used in smaller hospitals where testing mechanisms are not available to more specifically identify the location and condition of cerebral and precerebral vessels. Because of the frequent use of code 436 among smaller hospitals, we are proposing to remove the code from the nonspecific principal diagnosis edit in the MCE. We address the use of code 436 in section II.B.3. of this proposed rule under the discussion of MDC 5 changes with regard to the remodeling of DRGs 14 and 15. 10. 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 DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule within the GROUPER by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource-intensive to least resource-intensive, performs that function. Its application ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class. Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization. A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class “kidney transplant” consists of a single DRG (DRG 302) and the class “kidney, ureter and major bladder procedures” consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class involves weighting the average resources for each DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG in the class by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of “other O.R. procedures” as discussed below. This methodology may occasionally result in assignment of a case involving multiple procedures to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER searches for the procedure in the most resource-intensive surgical class, this result is unavoidable. We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average charge is ordered above a surgical class with a higher average charge. For example, the “other O.R. procedures” surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the average charge for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The “other O.R. procedures” class is a group of procedures that are only infrequently related to the diagnoses in the MDC but are still occasionally performed on patients in the MDC with these diagnoses. Therefore, these procedures should only be considered if no other procedure more closely related to the diagnoses in the MDC has been performed. 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 since, as a result of the hierarchy change, the average charges are likely to shift such that the higher-ordered surgical class has a lower average charge than the class ordered below it. Based on the preliminary recalibration of the DRGs, we are proposing modifications of the surgical hierarchy as set forth below. At this time, we are proposing to revise the surgical hierarchy for the pre-MDC DRGs and for MDC 5 (Diseases and Disorders of the Circulatory System) as follows: • In the pre-MDC DRGs, we are proposing to reorder DRG 495 (Lung Transplant) above DRG 512 (Simultaneous Pancreas/Kidney Transplant). • In MDC 5, we are proposing to reorder DRG 525 (Heart Assist System Implant) above DRGs 104 and 105 (Cardiac Valve and Other Major Cardiothoracic Procedures with and without Cardiac Catheterization, respectively). 11. Refinement of Complications and Comorbidities
(CC)List 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. Thus, we created the CC Exclusions List. We made these changes for the following reasons:
(1)To preclude coding of CCs for closely related conditions;
(2)to preclude duplicative coding 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. We developed this standard 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 standard list of CCs, either by adding new CCs or deleting CCs already on the list. At this time, we are not proposing to delete any of the diagnosis codes on the CC list. In the May 19, 1987 proposed notice (52 FR 18877) concerning changes to the DRG classification system, 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 (as subsequently corrected in the September 1, 1987 final notice (52 FR 33154)). • 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. The FY 1988 revisions were intended only as a first step toward refinement of the CC list in that the criteria used for eliminating certain diagnoses from consideration as CCs were intended to identify only the most obvious diagnoses that should not be considered CCs of another diagnosis. For that reason, and in light of comments and questions on the CC list, 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. (See the September 30, 1988 final rule (53 FR 38485) for the revision made for the discharges occurring in FY 1989; the September 1, 1989 final rule (54 FR 36552) for the FY 1990 revision; the September 4, 1990 final rule (55 FR 36126) for the FY 1991 revision; the August 30, 1991 final rule (56 FR 43209) for the FY 1992 revision; the September 1, 1992 final rule (57 FR 39753) for the FY 1993 revision; the September 1, 1993 final rule (58 FR 46278) for the FY 1994 revisions; the September 1, 1994 final rule (59 FR 45334) for the FY 1995 revisions; the September 1, 1995 final rule (60 FR 45782) for the FY 1996 revisions; the August 30, 1996 final rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997 final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 1998 final rule (63 FR 40954) for the FY 1999 revisions, the August 1, 2000 final rule (65 FR 47064) for the FY 2001 revisions; and the August 1, 2001 final rule (66 FR 39851) for the FY 2002 revisions. In the July 30, 1999 final rule (64 FR 41490), we did not modify the CC Exclusions List for FY 2000 because we did not make any changes to the ICD-9-CM codes for FY 2000. We are proposing a limited revision of the CC Exclusions List to take into account the proposed changes that will be made in the ICD-9-CM diagnosis coding system effective October 1, 2002. (See section II.B.13. of this preamble for a discussion of ICD-9-CM changes.) These proposed changes are being made in accordance with the principles established when we created the CC Exclusions List in 1987. Tables 6G and 6H in the Addendum to this proposed rule contain the revisions to the CC Exclusions List that would be effective for discharges occurring on or after October 1, 2002. Each table shows the principal diagnoses with changes to the excluded CCs. Each of these principal diagnoses is shown with an asterisk, and the additions or deletions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis. CCs that are added to the list are in Table 6G—Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 2002, the indented diagnoses would not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. CCs that are deleted from the list are in Table 6H—Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 2002, the indented diagnoses would be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. Copies of the original CC Exclusions List applicable to FY 1988 can be obtained from the National Technical Information Service
(NTIS)of the Department of Commerce. It is available in hard copy for $133.00 plus shipping and handling. A request for the FY 1988 CC Exclusions List (which should include the identification accession number
(PB)88-133970) should be made to the following address: National Technical Information Service, United States Department of Commerce, 5285 Port Royal Road, Springfield, VA 2216l; or by calling
(800)553-6847. Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2000, and 2002) and those in Tables 6F and 6G of the final rule for FY 2003 must be incorporated into the list purchased from NTIS in order to obtain the CC Exclusions List applicable for discharges occurring on or after October 1, 2002. (Note: There was no CC Exclusions List in FY 2001 because we did not make changes to the ICD-9-CM codes for FY 2001.) 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 19.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 20.0 of this manual, which includes the final FY 2002 DRG changes, is available for $225.00. 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. 12. Review of Procedure Codes in DRGs 468, 476, and 477 Each year, we review cases assigned to DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these DRGs. DRGs 468, 476, and 477 are reserved for those cases in which none of the O.R. procedures performed are related to the principal diagnosis. These DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. DRG 476 is assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis: 60.0 Incision of prostate 60.12 Open biopsy of prostate 60.15 Biopsy of periprostatic tissue 60.18 Other diagnostic procedures on prostate and periprostatic tissue 60.21 Transurethral prostatectomy 60.29 Other transurethral prostatectomy 60.61 Local excision of lesion of prostate 60.69 Prostatectomy NEC 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 60.99 Other operations on prostate All remaining O.R. procedures are assigned to DRGs 468 and 477, with DRG 477 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis. The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the September 30, 1988 final rule (53 FR 38591). As part of the final rules published on September 4, 1990 (55 FR 36135), August 30, 1991 (56 FR 43212), September 1, 1992 (57 FR 23625), September 1, 1993 (58 FR 46279), September 1, 1994 (59 FR 45336), September 1, 1995 (60 FR 45783), August 30, 1996 (61 FR 46173), and August 29, 1997 (62 FR 45981), we moved several other procedures from DRG 468 to 477, and some procedures from DRG 477 to 468. No procedures were moved in FY 1999, as noted in the July 31, 1998 final rule (63 FR 40962); in FY 2000, as noted in the July 30, 1999 final rule (64 FR 41496); in FY 2001, as noted in the August 1, 2000 final rule (65 FR 47064); or in FY 2002, as noted in the August 1, 2001 final rule (66 FR 39852). a. Moving Procedure Codes From DRGs 468 or 477 to MDCs We annually conduct a review of procedures producing assignment to DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC. We identified those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this year's review, we did not identify any necessary changes in procedures under DRG 477. Therefore, we are not proposing to move any procedures from DRG 477 to one of the surgical DRGs. However, we have identified a number of procedure codes that should be removed from DRG 468 and put into more clinically coherent DRGs. The proposed assignments of these codes are specified in the charts below. Movement of Procedure Codes From DRG 468 Procedure Code Description Included in DRG Description MDC 6—Diseases and Disorders of the Digestive System 387 Interruption vena cava 170 Other Digestive System O.R. Procedures with CC. 387 Interruption vena cava 171 Other Digestive System O.R. Procedures without CC. 3950 Angioplasty or atherectomy of noncoronary vessel 170 Other Digestive System O.R. Procedures with CC. 3950 Angioplasty or atherectomy of noncoronary vessel 171 Other Digestive System O.R. Procedures without CC. MDC 7—Diseases and Disorders of the Hepatobiliary System and Pancreas 387 Interruption vena cava 201 Other Hepatobiliary & Pancreas Procedures. 3949 Other revision of vascular procedure 201 Other Hepatobiliary & Pancreas Procedures. 3950 Angioplasty or atherectomy of noncoronary vessel 201 Other Hepatobiliary & Pancreas Procedures. MDC 8—Diseases and Disorders of the Musculoskeletal System and Connective Tissue 387 Interruption vena cava 233 Other Musculoskeletal System & Connective Tissue O.R. Procedures with CC. 387 Interruption vena cava 234 Other Musculoskeletal System & Connective Tissue O.R. Procedures without CC. 3950 Angioplasty or atherectomy of noncoronary vessel 233 Other Musculoskeletal System & Connective Tissue O.R. Procedures with CC. 3950 Angioplasty or atherectomy of noncoronary vessel 234 Other Musculoskeletal System & Connective Tissue O.R. Procedures without CC. MDC 9—Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast 8344 Other fasciectomy 269 Other Skin, Subcutaneous Tissue & Breast Procedures with CC. 8344 Other fasciectomy 270 Other Skin, Subcutaneous Tissue & Breast Procedures without CC. 8345 Other myectomy 269 Other Skin, Subcutaneous Tissue & Breast Procedures with CC. 8345 Other myectomy 270 Other Skin, Subcutaneous Tissue & Breast Procedures without CC. 8382 Muscle or fascia graft 269 Other Skin, Subcutaneous Tissue & Breast Procedures with CC. 8382 Muscle or fascia graft 270 Other Skin, Subcutaneous Tissue & Breast Procedures without CC. MDC 10—Endocrine, Nutritional and Metabolic Diseases and Disorders 387 Interruption vena cava 292 Other Endocrine, Nutritional, & Metabolic O.R. Procedures with CC. 387 Interruption vena cava 293 Other Endocrine, Nutritional, & Metabolic O.R. Procedures without CC. 5459 Other Lysis of Peritoneal adhesions 292 Other Endocrine, Nutritional, & Metabolic O.R. Procedures with CC. 5459 Other Lysis of Peritoneal adhesions 293 Other Endocrine, Nutritional, & Metabolic O.R. Procedures without CC. MC 11—Diseases and Disorders of the Kidney and Urinary Tract 0492 Implantation or replacement of peripheral neurostimulator 315 Other Kidney & Urinary Tract O.R. Procedures. 3821 Blood vessel biopsy 315 Other Kidney & Urinary Tract O.R. Procedures. 387 Interruption vena cava 315 Other Kidney & Urinary Tract O.R. Procedures. 3949 Other revision of vascular procedure 315 Other Kidney & Urinary Tract O.R. Procedures. MDC 12—Diseases and Disorders Male Reproductive System 387 Interruption vena cava 344 Other Male Reproductive System O.R. Procedures for Malignancy. 387 Interruption vena cava 345 Other Male Reproductive System O.R. Procedures Except for Malignancy. 8622 Excisional debridement of wound, infection, or burn 344 Other Male Reproductive System O.R. Procedures for Malignancy. 8622 Excisional debridement of wound, infection, or burn 345 Other Male Reproductive System O.R. Procedures Except for Malignancy. MDC 13—Diseases and Disorders of the Female Reproductive System 387 Interruption vena cava 365 Other Female Reproductive System O.R. Procedures. MDC 16—Diseases and Disorders of the Blood, Blood Forming Organs, Immunological Disorders 387 Interruption vena cava 394 Other O.R. Procedures of the Blood & Blood Forming Organs. b. Reassignment of Procedures Among DRGs 468, 476, and 477 We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to DRGs 468, 476, and 477, to ascertain if any of those procedures should be reassigned from one of these DRGs to another of these DRGs based on average charges and 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 moving 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. Based on our review this year, we are not proposing to move any procedures from DRG 468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476. c. Adding Diagnosis Codes to MDCs Based on our review this year, we are not proposing to add any diagnosis codes to MDCs. 13. Changes to the ICD-9-CM Coding System As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system that is 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)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 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) (formerly American Medical Record Association (AMRA)), the American Hospital Association (AHA), and various physician specialty groups as well as physicians, medical record administrators, 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 2003 at public meetings held on May 17 and 18, 2001, and November 1 and 2, 2001, and finalized the coding changes after consideration of comments received at the meetings and in writing by January 8, 2002. Copies of the Coordination and Maintenance Committee minutes of the 2001 meetings can be obtained from the CMS home page at: *http://www.cms.gov/medicare/icd9cm.htm.* Paper copies of these minutes are no longer available and the mailing list has been discontinued. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, MD 20782. Comments may be sent by E-mail to: *dfp4@cdc.gov.* Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; CMS, Center for Medicare Management, Purchasing Policy Group, Division of Acute Care; C4-08-06; 7500 Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by E-mail to: *pbrooks@cms.hhs.gov.* The ICD-9-CM code changes that have been approved will become effective October 1, 2002. 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 DRG classification of these new codes. Further, the Committee has approved the expansion of certain ICD-9-CM codes to require an additional digit for valid code assignment. 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, 2002. For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A (New Diagnosis Codes). New procedure codes are shown in Table 6B. Table 6C contains invalid diagnosis codes. There are no invalid procedure codes for FY 2002 (Table 6D). Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the DRG assignments for these revised codes. Revisions to procedure code titles are in Table 6F (Revised Procedure Codes Titles). 14. Other Issues In addition to the specific topics discussed in section II.B.1. through 13. of this proposed rule, we examined a number of other DRG-related issues. Below is a summary of the issues that were addressed. However, we are not proposing any changes at this time. a. Intestinal Transplantation We examined our data to determine whether it is appropriate to propose a new intestinal transplant DRG. There were nine intestinal transplantation cases reported by two facilities. Two of the cases involved a liver transplant during the same admission and, therefore, would be assigned to DRG 480 (Liver Transplant). We do not believe that this is a sufficient sample size to warrant the creation of a new DRG. b. Myasthenia Gravis Myasthenia Gravis is an autoimmune disease manifested by a syndrome of fatigue and exhaustion of the muscles that is aggravated by activity and relieved by rest. The weakness of the muscles can range from very mild to life-threatening. This disease is classified to ICD-9-CM diagnosis code 358.0 and is assigned to DRG 12 (Degenerative Nervous System Disorders). Myasthenia Gravis in crisis patients is being treated with extensive plasmapheresis. We received a request to analyze the charges associated with Myasthenia Gravis in crisis patients receiving plasmapheresis to determine whether DRG 12 is an equitable DRG assignment for these cases. We are currently unable to differentiate between the mild and severe forms of this disease because all types are classified to code 358.0. Therefore, we have requested the NCHS to create a new diagnosis code for Myasthenia Gravis in crisis so that we can uniquely identify these cases to ensure the DRG assignment is appropriate. c. Cardiac Mapping and Ablation In the August 1, 2001 final rule (66 FR 39840), in response to a comment received, we agreed to continue to evaluate DRGs 516 (Percutaneous Cardiovascular Procedure with Acute Myocardial Infarction (AMI)), 517 (Percutaneous Cardiovascular Procedure with Coronary Artery Stent without AMI), and 518 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent or AMI) in MDC 5. We reviewed code 37.26 (Cardiac electrophysiologic stimulation and recording studies), code 37.27 (Cardiac mapping), and code 37.34 (Catheter ablation of lesion or tissues of heart). The commenter had recommended that CMS either create a separate DRG for cardiac mapping and ablation procedures, or assign codes 37.27 and 37.34 to DRG 516 after retitling the DRG. We have reviewed FY 2001 MedPAR data on these specific codes. Over 97 percent of cases with these codes were assigned to DRG 518 and had average charges of $1,741 below the average for all cases in the DRG. Therefore, the data do not support making any DRG changes for these procedure codes. d. Aortic Endograft In the August 1, 2001 final rule (66 FR 39841), we responded to a comment concerning the placement of aortic endografts in DRG 110 (Major Cardiovascular Procedures with CC) and DRG 111 (Major Cardiovascular Procedures without CC). The commenter noted that the cost of the device alone is greater than the entire payment for DRG 111 and recommended that these cases be assigned specifically to DRG 110. Our response at that time was that DRGs 110 and 111 are paired DRGs, differing only in the presence or absence of a CC. We reviewed the MedPAR data again for FY 2001 using the following criteria: all cases were either in DRG 110 or 111, had a principal diagnosis of 441.4 (Abdominal aneurysm without mention of rupture), and included procedure code 39.71 (Endovascular implantation of graft in abdominal aorta). Our conclusion is that the majority of aneurysm cases are already grouped to DRG 110, where they are appropriately compensated. Therefore, we are not proposing to assign cases without CCs from DRG 111 to DRG 110. We reiterate that hospitals should code their records completely and record and submit all relevant diagnosis and procedure codes that have a bearing on the current admission (in particular, any complications or comorbidities associated with a case). e. Platelet Inhibitors In the August 1, 2002 final rule (66 FR 39840), we addressed a commenter's concern that modifications to MDC 5 involving percutaneous cardiovascular procedures would fail to account for the use of GP IIB-IIIA platelet inhibiting drugs for cases with acute coronary syndromes. GROUPER does not recognize procedure code 99.20 (Injection or infusion of platelet inhibitor) as a procedure. Therefore, its presence on a claim does not affect DRG assignment. We agreed to continue to evaluate this issue. We reviewed cases in the FY 2001 MedPAR file for DRG 121 (Circulatory Disorders with AMI and Major Complication, Discharged Alive), DRG 122 (Circulatory Disorders with AMI without Major Complication, Discharged Alive) and DRGs 516, 517, and 518. We looked at all cases in these DRGs containing procedure code 99.20 by total number of procedures and by average charges. There were a total of 73,480 cases where platelet inhibitors were administered, with 70,216 of these cases in DRGs 516, 517, and 518. The average charges for platelet inhibitor cases in these three DRGs are actually slightly below the average for all cases in the respective DRGs. Therefore, we believe these cases are appropriately placed in the current DRGs, and are not proposing any changes to the assignment of these procedure codes. f. Drug-Eluting Stents The drug-eluting stents technology has been developed to combat the problem of restenosis of previously treated blood vessels. The drug is placed onto the stent with a special polymer and slowly released into the vessel wall tissue over a period of 30 to 45 days, and is intended to prevent the build-up of scar tissue that can narrow the reopened artery. In Table 6B of the Addendum to this proposed rule, we list a new procedure code 36.07 (Insertion of drug-eluting coronary artery stents(s)) that will be effective for use October 1, 2002. We also are proposing to add code 00.55 (Insertion of drug-eluting noncoronary artery stent). A manufacturer of this technology requested that code 36.07 be assigned to DRG 516 (Percutaneous Cardiovascular Procedure with Acute Myocardial Infarction (AMI)) even without the presence of AMI. The manufacturer asserted that this technology is significantly more costly than other technologies currently assigned to DRG 517 (Percutaneous Cardiovascular Procedure with Coronary Artery Stent without AMI) (average charges of $29,189 compared to average charges of $22,998), and warrants this DRG assignment. In addition, the manufacturer argued that this technology should be given preferential treatment because it will fundamentally change the treatment of multivessel disease. Specifically, the manufacturer stated that due to the absence of restenosis in patients treated with the drug-eluting stents based on the preliminary trial results, bypass surgery may no longer be the preferred treatment for many patients. 1 The manufacturer believes lower payments due to the decline in Medicare bypass surgeries will offset the higher payments associated with assigning all cases receiving the drug-eluting stent to DRG 516. 1 “Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multiveasel Disease,” Serruys, P. W., Unger, F., et. al., *The New England Journal of Medicine,* April 12, 2001, Vol. 344, No. 15, p. 1117. Currently, this technology has not been approved for use by the FDA. If the technology is approved by the FDA and further evidence is presented to us regarding the clinical efficacy and the impact that this technology has on the treatment of multivessel disease, we may reassign this code to another DRG or reassess the construct of all affected DRGs. We also are specifically soliciting comments on our proposal to treat the new codes cited above consistent with the current DRG assignment for stents. g. Cardiac Resynchronization Therapy Cardiac resynchronization therapy for heart failure provides strategic electrical stimulation to the right atrium, right ventricle, and left ventricle, in order to coordinate ventricular contractions and improve cardiac output. This therapy includes cardiac resynchronization therapy pacemakers (CRT-P) and cardiac resynchronization therapy defibrillators (CRT-D). While similar to conventional pacemakers and internal cardioverter-defibrillators, cardiac resynchronization therapy is different because it requires the implantation of a special electrode within the coronary vein, so that it can be attached to the exterior wall of the left ventricle. Currently, defibrillator cases are assigned to either DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) or DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization). DRG 514 has a higher relative weight than DRG 515. We received a recommendation that we assign implantation of CRT-D (code 00.51, effective October 1, 2002) to either DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedure with Cardiac Catheterization) or DRG 514 (Cardiac Defibrillator Implant With Cardiac Catheterization). It is argued that the change should be made because the current DRG structure for cardioverter-defibrillator implants does not recognize the significant amount of additional surgical resources required for cases involving patients with heart failure. The recommendation supported assigning new code 00.50 (Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P]) to DRG 115 (Permanent Cardiac Pacemaker Implantation With AMI, Heart Failure, or Shock, or AICD Lead or Generator Procedure). Currently, pacemaker implantation procedures are assigned to either DRG 115 (Permanent Cardiac Pacemaker Implant with AMI, Heart Failure, or Stroke, or AICD Lead or Generator Procedure) or DRG 116 (Other Permanent Cardiac Pacemaker Implant). DRG 115 has the higher relative weight. Because DRG 115 recognizes patients with heart failure, the manufacturer believed CRT-P cases would be appropriately classified to DRG 115. Our proposed DRG assignment for code 00.51 would be to DRG 514 or 515. Our proposed DRG assignment for code 00.50 would be to DRG 115 and 116. However, we are soliciting comments on these proposed DRG assignments and will carefully consider any relevant evidence about the clinical efficacy and costs of this technology. h. Hip and Knee Revisions We received a request to consider assigning hip and knee revisions (codes 81.53 and 81.55) out of DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) because these revisions are significantly more resource intensive and costly than initial insertions of these joints. We examined claims data and concluded that, while the charges for the hip and knee revision cases were somewhat higher than other cases within DRG 209, they do not support the establishment of a separate DRG. i. Multiple Level Spinal Fusions We received a comment suggesting that we create new spinal fusion DRGs that differentiate by the number of discs that are fused in a spinal fusion. The commenter indicated that the existing ICD-9-CM codes do not identify the number of discs that are fused. Codes were modified for FY 2002 to clearly differentiate between fusions and refusions, and new codes were created for the insertion of interbody spinal fusion device (84.51), 360 degree spinal fusion, single incision approach (81.61), and the insertion of recombinant bone morphogenetic protein (84.52) (66 FR 39841 through 39844). ICD-9-CM codes have not historically been used to differentiate among cases by the number of repairs or manipulations performed in the course of a single procedure. However, we will explore the possibility of creating codes to differentiate cases by the number of discs fused during a spinal fusion procedure at the scheduled April 18 and 19, 2002 meeting of the ICD-9-CM Coordination and Maintenance Committee. We also note that DRGs generally do not segregate cases based on the number of repairs or devices that occur in the course of a single procedure. For instance, DRGs are not split based on the number of vessels bypassed in cardiac surgery, nor are they split based on the number of cardiac valves repaired. Therefore, we are not proposing DRG changes for multiple level spinal fusions in this proposed rule. j. Open Wound of the Hand We received a recommendation that we move code 882.0 (Open Wound of Hand Except Finger(s) Alone Without Mention of Complication) from its current location in MDC 9 (Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast) under DRGs 280 through 282 (Trauma to the Skin, Subcutaneous Tissue and Breast Age >17 with CC, Age >17 without CC, and Age 0-17, respectively) into MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs) under DRGs 444 through 446 (Traumatic Injury Age >17 with CC, Age >17 without CC, and Age 0-17, respectively). In examining our data, we found relatively few cases with code 882.0. These cases had charges that were less than the average charges for DRGs to which they are currently assigned. The data do not support a DRG change. Our medical consultants also believe that the cases are appropriately assigned to DRGs 280 through 282. k. Cavernous Nerve Stimulation As discussed in August 1, 2001 final rule (66 FR 39845), we reviewed data in MDC 12 (Diseases and Disorders of the Male Reproductive System). We looked specifically for code 89.58 (Plethysmogram) in DRG 334 (Major Male Pelvic Procedures with CC), and DRG 335 (Major Male Pelvic Procedures without CC). Our data show that very few
(six)of these procedures were reported on FY 2001 claims. It is not clear whether the small number reflects the fact that the procedure is not being performed, the ICD-9-CM code is not recorded, or the code is recorded but it is not in the top six procedures being performed. However, in all six cases where this procedure was performed, it occurred in conjunction with radical prostatectomy, so we are confident that these cases are consistent with the DRGs to which they have been grouped. Therefore, we are not proposing any DRG assignment changes to code 89.58 or DRGs 334 and 335. C. Recalibration of DRG Weights We are proposing to use the same basic methodology for the FY 2003 recalibration as we did for FY 2002 (August 1, 2001 final rule (66 FR 39828)). That is, we would recalibrate the weights based on charge data for Medicare discharges. However, we are proposing to use the most current charge information available, the FY 2001 MedPAR file. (For the FY 2002 recalibration, we used the FY 2000 MedPAR file.) The MedPAR file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. FY 2001 MedPAR data include discharges occurring between October 1, 2000 and September 30, 2001, based on bills received by CMS through December 31, 2001, from all hospitals subject to the acute care hospital inpatient prospective payment system and short-term acute care hospitals in waiver States. The FY 2001 MedPAR file includes data for approximately 11,420,001 Medicare discharges. The data include hospitals that subsequently became CAHs, although no data are included for hospitals after the point they are certified as CAHs. Section IX. of this preamble contains information about how to obtain the MedPAR data. The proposed methodology used to calculate the DRG relative weights from the FY 2001 MedPAR file is as follows: • To the extent possible, all the claims were regrouped using the DRG classification revisions discussed in section II.B. of this preamble. • Charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment. (See section IX.A.15. of this proposed rule for information on the availability of the prospective payment system standardizing file.) • The average standardized charge per DRG was calculated by summing the standardized charges for all cases in the DRG and dividing that amount by the number of cases classified in the DRG. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, transfer cases paid under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case. • We then eliminated statistical outliers, using the same criteria used in computing the current weights. That is, all cases that are outside of 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG are eliminated. • The average charge for each DRG was then recomputed (excluding the statistical outliers) and divided by the national average standardized charge per case to determine the relative weight. • We established the relative weight for heart and heart-lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner consistent with the methodology for all other DRGs except that the transplant cases that were used to establish the weights were limited to those Medicare-approved heart, heart-lung, liver, and lung transplant centers that have cases in the FY 1999 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.) • Acquisition costs for kidney, heart, heart-lung, liver, lung, and pancreas transplants continue to be paid on a reasonable cost basis. Unlike other excluded costs, the acquisition costs are concentrated in specific DRGs: DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant); DRG 480 (Liver Transplant); DRG 495 (Lung Transplant); and DRGs 512 (Simultaneous Pancreas/Kidney Transplant) and 513 (Pancreas Transplant). Because these acquisition costs are paid separately from the prospective payment rate, it is necessary to make an adjustment to exclude them from the relative weights for these DRGs. Therefore, we subtracted the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers. When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We used that same case threshold in recalibrating the proposed DRG weights for FY 2003. Using the FY 2001 MedPAR data set, there are 41 DRGs that contain fewer than 10 cases. We computed the weights for these 41 low-volume DRGs by adjusting the FY 2002 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs. The proposed new weights are normalized by an adjustment factor (1.43430) so that the average case weight after recalibration is equal to the average case weight before recalibration. This adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the prospective payment system. Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with FY 1991, reclassification and recalibration changes be made in a manner that assures that the aggregate payments are neither greater than nor less than the aggregate payments that would have been made without the changes. Although normalization is intended to achieve this effect, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years and as discussed in section II.A.4.a. of the Addendum to this proposed rule, we are proposing to make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. D. Proposed Add-On Payments for New Services and Technologies 1. Background Section 533(b) of Public Law 106-554 amended section 1886(d)(5) of the Act to add subparagraphs
(K)and
(L)to establish a process of identifying and ensuring adequate payment for new medical services and technologies under Medicare. 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 . . . is inadequate.” Section 1886(d)(5)(K)(vi) of the Act specifies that a medical service or technology will be considered “new” if it meets criteria established by the Secretary (after notice and opportunity for public comment). In the September 7, 200l final rule (66 FR 46902), we established that a new technology would be an appropriate candidate for an additional payment when it represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries (§ 412.87(b)(1)). We also established that new technologies meeting this clinical definition must be demonstrated to be inadequately paid otherwise under the DRG system to receive special payment treatment (§ 412.87(b)(3)). To assess whether technologies would be inadequately paid under the DRGs, we established this threshold at one standard deviation beyond the geometric mean standardized charge for all cases in the DRGs to which the new technology is assigned (or the case-weighted average of all relevant DRGs, if the new technology occurs in many different DRGs) (§ 412.87(b)(3)). Table 10 in the Addendum to this proposed rule lists the proposed qualifying criteria by DRG based on the discharge data used to calculate the proposed FY 2003 DRG weights. The thresholds published in the final rule will be used to evaluate applicants for new technology add-on payments during FY 2004 (beginning October 1, 2003). Similar to the timetable for applying for new technology add-on payments during FY 2003, we are proposing that applicants for FY 2004 must submit a significant sample of the data no later than early October 2002. Subsequently, we are proposing that a complete database must be submitted no later than mid-December 2002. In addition to the clinical and cost criteria, we established that, in order to qualify for the special payment treatment, a specific technology must be “new” under the requirements of § 412.87(b)(2) of our regulations. The statutory provision contemplated the special payment treatment for new technologies until such time as data are available to reflect the cost of the technology in the DRG weights through recalibration (no less than 2 years and no more than 3 years). There is a lag of 2 to 3 years from the point a new technology is first introduced on the market and when data reflecting the use of the technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2001 are used to calculate the proposed FY 2003 DRG weights in this proposed rule. Technology may be considered “new” for purposes of this provision within 2 or 3 years after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the technology. After CMS has recalibrated the DRGs to reflect the costs of an otherwise new technology, the special add-on payment for new technology will cease (§ 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2001 would be eligible to receive add-on payments as a new technology until FY 2004 (discharges occurring before October 1, 2003), when data reflecting the costs of the technology would be used to recalibrate the DRG weights. Because the FY 2004 DRG weights will be calculated using FY 2002 MedPAR data, the costs of such a new technology would be reflected in the FY 2004 DRG weights. For technologies that do not qualify for special payments under § 412.87, we will continue our past practice of evaluating whether existing procedures are appropriately classified to a DRG. To the extent the introduction of a new code for existing technology helps to better identify higher costs associated with a procedure, we would work to expedite the appropriate assignment of that code (for example, using more recent MedPAR data). In the September 7, 2001 final rule, we established that Medicare would provide higher payments for cases with higher costs involving identified new technologies, while preserving some of the incentives under the average-based payment system. The payment mechanism is based on the cost to hospitals for the new technology. Under § 412.88, Medicare would pay a marginal cost factor of 50 percent for the costs of the new technology in excess of the full DRG payment. If the costs of a new technology case exceed the DRG payment by more than the estimated costs of the new technology, Medicare payment would be limited to the DRG payment plus 50 percent of the estimated costs of the new technology. The report language accompanying section 533 of Public Law 106-554 indicated Congressional intent that the Secretary implement the new mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 106th Cong., 2d Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, we account for projected payments under this provision for new technology during the upcoming fiscal year at the same time we estimate the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision would then be included in the budget neutrality factor, which is applied to the standardized amounts. Because any additional payments directed toward new technology under this provision would be offset to ensure budget neutrality, it is important to carefully consider the extent of this provision and ensure that only technologies representing substantial advances are recognized for additional payments. In that regard, we indicated that we will discuss in the annual proposed and final rules those technologies that were considered under this provision; our determination as to whether a particular new technology meets our criteria for a new technology; whether it is determined further that cases involving the new technology would be inadequately paid under the existing DRG payment; and any assumptions that went into the budget neutrality calculations related to additional payments for that new technology, including the expected number, distribution, and costs of these cases. To appropriately balance Congress' intent to increase Medicare's payments for eligible new technologies with concern that the total size of those payments not result in significantly reduced payments for other cases, we set a target limit for estimated special payments for new technology under the provisions of section 533(b) of Public Law 106-554 at 1.0 percent of estimated total operating prospective payments. If invoked, the target limit would reduce the level of payments for approved technologies across the board, to ensure estimated payments do not exceed the limit. Using this approach, all cases involving approved new technologies that would otherwise receive additional payments would still receive special payments, albeit at a reduced amount. Although the marginal payment rate for individual technologies will be reduced, this would be offset by large overall payments to hospitals for new technologies under this provision. 2. Applicants for FY 2003 We received five applications for new technologies to be designated eligible for inpatient add-on payments under the policy we implemented in the September 7, 2001 final rule. One of these applications was subsequently withdrawn. The remaining four applicants are discussed below. a. Drotrecogin Alfa (Activated)—Xigris TM Eli Lilly and Company (Lilly) developed drotrecogin alfa (activated), trade name Xigris TM , as a new technology and submitted an application to us for consideration under the new technology add-on provision. Xigris TM is used to treat patients with severe sepsis. According to the application— “Approximately 750,000 cases of sepsis associated with acute organ dysfunction (severe sepsis) occur annually in the United States. The mortality rates associated with severe sepsis in the United States range from 28 percent to 50 percent and have remained essentially unchanged for several decades. Each year, 215,000 deaths are associated with severe sepsis; deaths after acute myocardial infarction occur at approximately an equal rate.” Xigris TM is a biotechnology product that is a recombinant version of naturally occurring Activated Protein C (APC). APC is needed to ensure the control of inflammation and clotting in the blood vessels. In patients with severe sepsis, Protein C cannot be converted in sufficient quantities to the activated form. It appears that Xigris TM has the ability to bring blood clotting and inflammation back into balance and restore blood flow to the organs. In support of its application, Lilly submitted data from the Phase III Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial. According to Lilly, this was “an international, multicenter, randomized, double-blind, placebo-controlled trial in which 1,690 patients with severe sepsis received either placebo (n = 840) or drotrecogin alfa (activated) (n = 850).” The results of the trial were published in an article in the March 8, 2001 edition of *The New England Journal of Medicine* (Bernard, G. R., Vincent, J. L., et. al., “Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis,” Vol. 344, No, 10, p. 699). A 6.1 percent reduction in mortality was reported. This conclusion was based on a measure of 28-day all-cause mortality. However, at 28 days, over 10 percent of the study participants were still hospitalized. Whether these patients subsequently went on to recover or died was not reported. Because the reduction in mortality was the result of a treatment effect in a relatively small number of patients and mortality was looked at only 28 days after treatment, we plan to review unpublished data on all-cause mortality at the time of hospital discharge for all patients enrolled in the study using an intent-to-treat analysis. We have asked the trial sponsor to provide CMS with these unpublished data and the analyses performed in the original report, including confidence intervals and Kaplan-Meier curve with log-rank statistics, for death from any cause assessed at the time of hospital discharge. A small increase in the number of deaths among treated patients still hospitalized at 28 days could nullify the survival advantage attributed to the use of Xigris TM . The study had a number of other important methodological limitations that also merit further consideration. Therefore, we are unable to conclude, based on the published data, that Xigris TM represents an advance that substantially improves, relative to technology previously available, treatment for Medicare beneficiaries. However, we are continuing our assessment and will announce our final determination in the final rule. If we subsequently determine that Xigris TM represents a substantial improvement, payment would likely be limited to a subpopulation of patients with severe sepsis, consistent with the FDA labeling and possible other restrictions. Detailed bills were available for 604 of 705 patients in the United States in the PROWESS clinical trial (303 placebo patients and 301 treatment patients). In all, 83 hospitals submitted detailed bills. These data included an indicator whether the patient received the treatment or a placebo, total charges and standardized charges for the stay as well as for the biological, and the patients' APACHE II scores (an assessment of the risk of mortality based on *a* cute *p* hysiology *a* nd *c* hronic *h* ealth *e* valuation). The FDA's approval letter (issued November 21, 2001) stated “drotrecogin alfa (activated) is indicated for the reduction of mortality in adult patients with severe sepsis (sepsis associated with acute organ dysfunction) who have a high risk of death (e.g., as determined by APACHE II).” Of the 604 cases with detailed billing data, 274 were patients age 65 or older. The average total charge for these 274 cases, including the average standardized charge for the biological, was $86,184 (adjusted for inflation using the applicable hospital market baskets, as patients were enrolled in the trial from July 1998 through June 2000). The inflated average standardized charge of the biological only for these cases was $15,562. Lilly also submitted detailed ICD-9-CM diagnosis and procedure codes for a subset of 157 of the 604 U.S. patients with billing data from the PROWESS trial. These data were not requested as part of the trial, but were sent in separately. Of these 157 patients, 82 were over 65 years of age. These 82 patients grouped into 23 DRGs. Approximately 75 percent of these 82 cases were in 5 DRGs: 29 percent were in DRG 475 (Respiratory System Diagnosis with Ventilator Support); 17 percent were in DRG 483 (Tracheostomy Except for Face, Mouth, and Neck Diagnoses); 15 percent were in DRG 416 (Septicemia Age >17); 7 percent were in DRG 415 (OR Procedure for Infectious and Parasitic Diseases); and 5 percent were in DRG 148 (Major Small and Large Bowel Procedures With CC). Using the methodology described in the September 7, 2001 final rule (66 FR 46918), we calculated a case-weighted threshold based on the distribution of these 82 cases across 23 DRGs. In order to qualify for new technology payments based on these DRGs, the threshold would be $82,882 (compared to the average standardized charge of $86,184 noted above). In the September 7, 2001 final rule, we stated that the data submitted must be of a sufficient sample size to demonstrate a significant likelihood that the sample mean approximates the true mean across all cases likely to receive the new technology. Using a standard statistical methodology for determining the needed (random) sample size based on the standard deviations of the DRGs identified in the trial as likely to include cases receiving Xigris TM, we have determined that a random sample of 274 cases can be reasonably expected to produce an estimate within $3,500 of the true mean. 1 Of course, the data submitted do not represent a random sample. 1 The formula is n = 4σ 2 /β 2 , where σ is the standard deviation of the population, and β is the bound on the error of the estimate (the range within which the sample means can reliably predict the population mean). See Statistics for Management and Economics, Fifth Edition, by Mendenhall, W., Reinmuth, J., Beaver, R., and Duhan, D. The 274 case sample was for all U.S. patients over age 65 included in the PROWESS trial. In the September 7, 2001 final rule, we indicated our preference for using Medicare cases identifiable in our MedPAR database, although data from a trial without matching MedPAR data could be considered. We also indicated our intention to independently verify the data submitted. According to Lilly, the patient consent agreements for the PROWESS trial did not provide for the collection and submission of data to CMS. Therefore, we have been unable to identify matching cases in our MedPAR database, or independently verify the data. Due to the passage of Public Law 106-554 in December 2000 and the publication of the final rule in September 2001, it is understandable that our data requirements in order to analyze applicants for new technology add-on payments were not accommodated in the design of the PROWESS trial. We will continue to work with Lilly to independently verify the data in the event it is determined that Xigris TM does represent a substantial clinical improvement. In particular, we note that, even without the biological charges, the standardized mean charge for the cases submitted for analysis is well above the standardized case-weighted DRG mean ($70,623 for the PROWESS trial cases compared to $54,058 for all cases in the relevant DRGs). We are analyzing our MedPAR data to develop a cohort group of patients to assess the validity of the charges reported for the patients in the PROWESS trial and will report the result of our analysis in the final rule. We solicit comments on this and other approaches to verifying these data. Cases where Xigris TM is administered will be identified by use of the new ICD-9-CM procedure code 00.11 (Infusion of drotrecogin alfa (activated)). According to Lilly, “(t)he net wholesale price for drotrecogin alfa (activated) is $210 for a 5-milligram vial and $840 for a 20-milligram vial. The average cost for a one-time 96-hour course of therapy for an average adult patient is $6,800 (24 ug/kg/hr for 96 hours for a 70 kg person).” Because code 00.11 does not identify the actual amount of the drug administered per patient, any additional payment would be based on the average cost per patient of $6,800. If this technology were to be approved for add-on payment under § 412.88, cases involving the administration of Xigris TM would be eligible for additional payments of up to $3,400 (50 percent of the average cost of the drug). For purposes of budget neutrality, we need to estimate the additional payments that would be made under this provision during FY 2003. Lilly has estimated that, initially, 25,000 Medicare patients would receive drotrecogin alfa (activated). If the maximum $3,400 add-on payment is made for all 25,000 of these patients, the total amount that would be paid for these cases would be an additional $85 million. However, comparing the total standardized charges for the 274 patients age 65 or older, 56 percent had average standardized charges below the weighted average standardized charges for the 23 DRGs into which these cases were categorized. Therefore, assuming the costs for these cases would be below the payment received, these 56 percent of cases would not receive any additional payment. Therefore, for purposes of budget neutrality, we estimate the total payments likely to be made under this provision during FY 2003 for cases involving the administration of drotrecogin alfa (activated) would be $37.4 million (44 percent of $85 million). b. Bone Morphogenetic Proteins
(BMPs)for Spinal Fusions BMPs have been isolated and shown to have the capacity to induce new bone formation. Using recombinant techniques, some BMPs (referred to as rhBMPs) can be produced in large quantities. This has cleared the way for their potential use in a variety of clinical applications such as in delayed unions and nonunions of fractured bones and spinal fusions. One such product, rhBMP-2, is developed for use instead of a bone graft with spinal fusions. An application was submitted by Medtronic Sofamor Danek for the InFUSE TM Bone Graft/LT-CAGE TM Lumbar Tapered Fusion Device for approval as a new technology eligible for add-on payments. The product is applied through use of an absorbable collagen sponge and an interbody fusion device, which is then implanted at the fusion site. The patient undergoes a spinal fusion, and the product is placed at the fusion site to promote bone growth. This is done in place of the more traditional use of autogenous iliac crest bone graft. In 1997, in a pilot study conducted under a FDA approved device exemption, 14 patients were enrolled at 4 investigational sites. Eleven patients received rhBMP-2, with 3 control patients. Radiographs and computed tomography scans at 6, 12, and 24 months after surgery showed that all 11 patients who received rhBMP-2 had solid fusions, whereas only 2 of the 3 patients who received autogeneous bone graft had solid fusions. Scores from the Oswestry Low Back Pain Disability Questionnaire showed that 6 of 11 patients treated with rhBMP-2 had a successful outcome at 3 months after surgery, compared with 0 of 3 control patients. After 6 months, the results had changed to 7 of 11 rhBMP-2 patients and 2 control patients with successful treatments; and at 12 months, 10 rhBMP-2 patients and 2 control patients were judged successful. The results were unchanged at 24 months. The trial results were presented in an article in the February 1, 2000 edition of SPINE (Bone, S., Zdeblick, T., et. al., “The Use of rhBMP-2 in Interbody Fusion Cages-Definitive Evidence of Osteoinduction in Humans: A Preliminary Report”), Vol. 25, No. 3, p. 376. The above study was then expanded to involve 281 patients at 16 sites, with 143 patients in the rhBMP-2 group and 138 patients in the autogenous iliac crest bone graft group. In the rhBMP-2 group, 76.9 percent of the patients showed an improvement of at least 15 points in their disability scores at 12 months postoperatively. This compared favorably to 75 percent of patients in the control group. At 6 months following surgery, 97 percent of patients in the rhBMP-2 group showed evidence of interbody fusion, as compared to 95.8 percent in the control group. At 12 months, 96.9 percent of patients in the rhBMP-2 group were fused as compared to 92.5 percent in the control group. At this time, the results of this study are unpublished. On January 10, 2002, the FDA issued an approvable letter for this technology. At this point, however, the technology has not been approved by the FDA for general use. Therefore, we are not proposing to approve this technology for add-on payments in this proposed rule. We discuss thoroughly the data submitted with the application below. However, if the FDA approves the product for general use prior to our issuance of the final rule by August 1, 2002, we will issue a determination whether this technology represents a substantial clinical improvement under the criteria outlined in the September 7, 2001 final rule. Cost data were submitted for 88 patients participating in the followup study described above. This trial was a single-level, anterior lumbar interbody fusion clinical study. Of these 88 bills with cost data, the applicant calculated an average standardized charge for these single-level fusion cases of $33,757. According to the applicant, “it is anticipated that a large number, if not the majority, of cases using BMP technology will, in practice, be multi-level fusions”. The applicant reported the estimated hospital charges (based on general charging practices) to be $17,780 for each level. In order to account for the use of this technology in multilevel spinal fusions, the applicant assumed 47 percent of spinal fusions were multilevel (based on analysis of Medicare spinal fusion cases). Increasing the average standardized charge for the cases in the trial by $17,780, the applicant calculated a weighted average standardized charge (53 percent single-level and 47 percent multilevel) of $45,556. Of these 88 cases, 11 were assigned to DRG 497 (Spinal Fusion Except Cervical With CC) and 77 were assigned to DRG 498 (Spinal Fusion Except Cervical Without CC). In order to qualify for new technology payments based on these DRGs, the threshold would be $37,815. The applicant has submitted data that estimate between 2,300 and 4,600 Medicare spinal fusion procedures involving this technology in FY 2003. The cost of the technology is $3,900 per level. For approximately 45 percent of spinal fusion involving multilevel fusions, the weighted cost of the technology is $5,686, resulting in a maximum add-on payment amount of $2,843. In reference to the utilization estimates above, the total amount for these cases if each case qualified for a new technology payment would be between $6.5 million and $13.0 million. c. Zyvox TM Zyvox TM is the first antibiotic in the oxazolidinone class and is widely used by hospitals in the United States and other countries against the medically significant gram-positive bacteria, including those that are resistant to other therapies. Gram-positive bacterial infections have become increasingly prevalent in recent years, most commonly implicated in infections in the lower respiratory tract, skin and soft tissue, bone and bloodstream, and in meningitis. Significant morbidity and mortality trends are associated with such pathogens. Epinomics Research, Inc., submitted the application on behalf of Pharmacia Corporation (Pharmacia), which markets the drug. The FDA approved Zyvox TM on April 18, 2000, for the treatment of serious infections caused by antibiotic-resistant bacteria. The applicant contends that this qualifies Zyvox TM for approval within the 2-year to 3-year period referenced at § 412.87(b)(2). Furthermore, the applicant notes that the approval of the new ICD-9-CM code 00.14 (Injection or infusion of oxazolidinone class of antibiotics) effective October 1, 2002, will permit a more precise identification of these cases. However, as noted previously, technology will no longer be considered new after the costs of the technology are reflected in the DRG weights. Because the costs of Zyvox TM are currently reflected in the DRG weights, Zyvox TM does not meet our criterion that a medical service or technology be “new”. The FY 2001 MedPAR data used to calculate the proposed DRG weights for FY 2003 include cases where Zyvox TM was administered. The application itself noted that the use of Zyvox TM is widespread. Therefore, even though the existing code, 99.21 (Injection of antibiotic) is a general code used for the administration of various antibiotics including Zyvox TM , and does not separately identify the administration of Zyvox TM as will be possible with the new code 00.14, the charges associated with these cases are reflected in the proposed FY 2003 DRG weights. As stated above, we note that the applicant itself points out that Zyvox TM is widely used currently by hospitals. In its 4th quarter 2001 earnings report, Pharmacia reports total sales in the United States of $97 million, which is an increase of 105 percent over the previous year. This would indicate expanding access to the drug. We would point out that, in response to a comment that technologies should qualify as “new” beginning with the assignment of an appropriate tracking code, we clarified in the September 7, 2001 final rule that we would not consider technologies that have been on the market for more than 2 or 3 years to be “new” on the basis that a more precise ICD-9-CM procedure code has been created (66 FR 46914). However, although such technologies would not qualify for add-on payments under this provision, we did indicate that we would evaluate whether the existing DRG assignments of the technology are appropriate. For example, currently the administration of Zyvox TM does not affect the DRG to which a case is assigned. In its application for add-on payments, Epinomics provided CMS data that included clinical trials as well as data from a sample that spanned MedPAR files from FY 2000 through FY 2002. For its sample study, Epinomics obtained patient records from 70 hospitals that used Zyvox TM treatment on 832 Medicare patients. The cases were distributed across 151 DRGs. Epinomics calculated that the mean standardized charge for these 485 cases was $74,174. The case-weighted mean standardized charge for all cases in these DRGs would be $33,740 (based on the distribution of Zyvox TM cases across the 151 DRGs). The unit price for the drug varies from approximately $30 for a 100 milliliter bag (200 milligram linezolid) to approximately $1,350 for 600 milligram tablets (unit doses of 30 tablets). Nevertheless, it appears the high average charges associated with patients receiving the drug are not directly attributable to the administration of Zyvox TM . Therefore, we are not proposing any changes to the DRG assignment of these cases at this time. To the extent these cases are more expensive due to the severity of illness of the patients being treated, the current outlier policy will offset any extraordinarily high costs incurred. d. Renew TM Radio Frequency Spinal Cord Stimulation Therapy An application was submitted by Advanced Neuromodulation Systems
(ANS)for the Renew TM Spinal Cord Stimulation Therapy for approval as a new technology eligible for add-on payments. ANS is a medical device company that deals with management of chronic pain that is severe, persistent, and unresponsive to drugs or surgery. Spinal cord stimulation
(SCS)offers a treatment alternative to expensive ongoing comprehensive care. Renew TM SCS was introduced in July 1999 as a device for the treatment of chronic intractable pain of the trunk and limbs. According to the applicant: “SCS is a reversible method of pain control that works well for certain types of chronic intractable pain. SCS requires a surgical procedure to implant a receiver and leads. These implanted devices generate electrical stimulation that interrupts pain signals to the brain. SCS is considered to be a treatment of last resort, and is usually undertaken only when first and second-line therapies for chronic pain fail to provide adequate relief. SCS uses low-intensity electrical impulses to trigger nerve fibers selectively along the spinal cord. The stimulation of these nerve fibers diminishes or blocks the intensity of the pain message being transmitted to the brain. SCS replaces areas of intense pain with a more pleasant sensation * * *,” masking the pain that is normally present. Prior to Renew TM , SCS systems offered few technical capabilities for treating complex chronic pain patients who suffered with pain that spanned noncontiguous areas (multi-focal) or that varied in intensity over the painful area. The Renew TM system features a multiplex output mode that controls separate stimulation programs to allow outputs of varying frequencies to be used at the same time. According to ANS, “The significance of this technology is that it is now possible to multiplex (link and cycle) up to 8 programs to provide pain relieving paresthesia overlap of anatomical regions that are not contiguous or that cannot be captured by a single program.” The Renew TM technology also allows the concomitant use of separate programs for patients who require different power settings for different areas that have pain. With this technology, separate programs can be programmed from the same unit, with electrical output parameters customized for each painful region. ANS contends that the clinical significance of this technology is that patients who find satisfactory pain relief will require fewer alternative treatments to treat unrelieved pain. The ANS application specifically requests add-on payments for the costs of the Radio Frequency System (RF System). This system only requires one surgical placement and does not require additional surgeries to replace batteries as do other internal SCS systems. ANS estimates that there are 2,900 RF Systems implanted annually; only 10 percent are in the inpatient setting. ANS is the only company that offers a 16-channel/electrode system. ANS provided the 2001 hospital acquisition cost for ANS Renew TM 8 and 16 Channel/Electrode RF SCS Systems as follows: ANS 2001 List Price 8 Channel/Electrode System: One Lead (8 Electrode) $2,750 One Extension (8 Electrode) 695 Receiver (8 Channel) 4,995 Transmitter (8 Channel) 4,995 Total System 13,435 16 Channel/Electrode System: Two Leads (16 Electrodes) 5,500 Two Extensions (16 Electrodes) 1,390 Receiver (16 Channel) 7,295 Transmitter (16 Channel) 7,295 Total System 21,480 Currently, implanting the ANS 8 or 16 Channel/Electrode SCS System falls into DRG 4 (Spinal Procedures) under ICD-9-CM procedure code, 03.93 (Insertion or replacement, spinal neurostimulation). According to the September 7, 2001 **Federal Register** , the threshold to qualify for additional new technology payments for services classified to DRG 4 would be $38,242 (based on adding the geometric mean and the standard deviation of standardized charges) (66 FR 46922). Relative to hospital invoice information, ANS provided the following estimates: “* * * 90% of the U.S. hospital cost-to-charge ratios fall between .24 and .69, and 75% fall between .29 and .58. The median is .41. This median costs-to-charge ratio equates to an average hospital markup of 144%. If you apply the average hospital markup of 144% to the device acquisition cost plus the estimated facility cost, the result is an estimated hospital invoice for the SCS implant procedure of $40,101.00, for the 8 Channel/Electrode System and $59,731.00 for the 16 Channel/Electrode System.” In support of its application, ANS provided detailed bills for 12 patients. Of the 12 cases with detailed billing data, 3 patients were age 65 or older. The average total charge for these 3 cases, including the average standardized charge for operating room costs, was $42,820. As noted previously, technology will no longer be considered new after the costs of the technology are reflected in the DRG weights. Because the Renew TM RF System was introduced in July 1999, the FY 2001 MedPAR data used to calculate the proposed DRG weights for FY 2003 includes any Medicare cases that involved the implantation of the Renew TM RF System. The charges associated with these cases are reflected in the proposed FY 2003 DRG weights. Therefore, the Renew TM RF System is not considered “new” under our criteria. However, we will continue to monitor these cases in DRG 4 to determine whether this is the most appropriate DRG assignment. 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 Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by the Office of Management and Budget (OMB). OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital wage index, we use the PMSAs rather than CMSAs since they allow a more precise breakdown of labor costs. If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA. Rural areas are areas outside a designated MSA, PMSA, or NECMA. For purposes of the wage index, we combine all of the rural counties in a State to calculate a rural wage index for that State. We note that, effective April 1, 1990, the term Metropolitan Area
(MA)replaced the term MSA (which had been used since June 30, 1983) to describe the set of metropolitan areas consisting of MSAs, PMSAs, and CMSAs. The terminology was changed by OMB in the March 30, 1990 **Federal Register** to distinguish between the individual metropolitan areas known as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes of the prospective payment system, we will continue to refer to these areas as MSAs. Under section 1886(d)(8)(B) of the Act, hospitals in certain rural counties adjacent to one or more MSAs are considered to be located in one of the adjacent MSAs if certain standards are met. Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification from a rural area to a MSA, one rural area to another rural area, or from one MSA to another MSA, for purposes of payment under the acute care hospital inpatient prospective payment system. In a December 27, 2000 notice published in the **Federal Register** (65 FR 82228), OMB issued its revised standards for defining MSAs. In that notice, OMB indicated that it plans to announce in calendar year 2003 definitions of MSAs based on the new standards and the Census 2000 data. We will evaluate the new area designations and their possible effects on the Medicare wage index, as well as other provider payment implications. Although the final construct of the redefined MSAs will not be known until 2003, we intend to work closely with OMB to begin to assess the potential ramifications of these changes. Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey should measure, to the extent feasible, the earnings and paid hours of employment by occupational category, and must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. As discussed below in section III.F. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating the wage index. Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E) of the Act to provide 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. The initial collection of these data must be completed by September 30, 2003, for application beginning October 1, 2004 (the FY 2005 wage index). In the May 4, 2001 proposed rule (66 FR 22674), we suggested possible occupational categories from the Occupational Employment Statistics
(OES)survey conducted by the Bureau of Labor Statistics. In response to comments on the proposed rule, we agreed to work with the health care industry to develop a workable data collection tool. After we develop a method that appropriately balances the need to collect accurate and reliable data with the need to collect data that hospitals can be reasonably expected to have available, we will issue instructions as to the type of data to be collected, in advance of actually requiring hospitals to begin providing the data. B. Proposed FY 2003 Wage Index Update The proposed FY 2003 wage index values in section V. of the Addendum to this proposed rule (effective for hospital discharges occurring on or after October 1, 2002 and before October 1, 2003) are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 1999 (the FY 2002 wage index was based on FY 1998 wage data). The proposed FY 2003 wage index includes the following categories of data associated with costs paid under the hospital inpatient prospective payment system (as well as outpatient costs), which were also included in the FY 2002 wage index: • Salaries and hours from short-term, acute care hospitals. • Home office costs and hours. • Certain contract labor costs and hours. • Wage-related costs. Consistent with the wage index methodology for FY 2002, the proposed wage index for FY 2003 also continues to exclude the direct and overhead salaries and hours for services such as skilled nursing facility
(SNF)services, home health services, and other subprovider components that are not paid under the hospital inpatient prospective payment system. We calculate a separate Puerto Rico-specific wage index and apply it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.) This wage index is based solely on Puerto Rico's data. Finally, section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State. C. FY 2003 Wage Index Proposal 1. Removal of Wage Costs and Hours Related to Graduate Medical Education
(GME)and Certified Registered Nurse Anesthetists (CRNAs) Because the hospital wage index is used to adjust payments to hospitals under the acute care hospital inpatient prospective payment system, the wage index should, to the extent possible, reflect the wage costs associated with those cost centers and units paid under the hospital inpatient prospective payment system. Costs related to graduate medical education
(GME)(teaching physicians and residents) and certified registered nurse anesthetists (CRNAs) are paid by Medicare separately from the hospital inpatient prospective payment system. In 1998, the AHA convened a workgroup to develop a consensus recommendation on this issue. The workgroup, which consisted of representatives from national and State hospital associations, recommended that costs related to GME and CRNAs be phased out of the wage index calculation over a 5-year period. Based upon our analysis of hospitals' FY 1996 wage data, and consistent with the AHA workgroup's recommendation, we specified in the July 30, 1999 final rule (64 FR 41505) that we would phase out these costs from the calculation of the wage index over a 5-year period, beginning in FY 2000. FY 2003 would be the fourth year of the phaseout. Therefore, the wage index calculation for FY 2003 would blend 20 percent of a wage index with GME and CRNA costs included and 80 percent of a wage index with GME and CRNA costs removed. FY 2004 would begin the calculation with 100 percent of the GME and CRNA costs removed. However, we are proposing to remove 100 percent of GME and CRNA costs from the FY 2003 wage index, as discussed below. We have analyzed the FY 2003 wage index both with 100 percent of GME and CRNA costs removed and with 80 percent of these costs removed. We found that the majority of labor market areas, both rural and urban, would benefit by the removal of all of these costs (298 out of 373). Only two rural labor market areas would be negatively impacted by this change (Pennsylvania by −0.01 percent, and New Hampshire by −0.12 percent). We note that, as part of its Report to the Congress on Medicare in Rural America (June 2001), the MedPAC recommended fully implementing this phaseout during FY 2002. Similar to our findings, MedPAC found the effect of completely eliminating GME and CRNA costs “might not be negligible for some areas, but it would not be large in any case” (page 76). Of the urban labor market areas that would be negatively affected, the impacts on all but two areas are less than 0.50 percent, and the largest negative impact is 1.12 percent. Because we believe removing GME and CRNA costs from the wage index calculation is appropriate, and the impact is generally positive and relatively small, we are proposing to remove 100 percent of GME and CRNA costs beginning with FY 2003 wage index. 2. Contract Labor for Indirect Patient Care Services Our policy concerning the inclusion of contract labor costs for purposes of calculating the wage index has evolved with the increasing role of contract labor in meeting special personnel needs of many hospitals. In addition, improvements in the wage data have allowed us to more accurately identify contract labor costs and hours. As a result, effective with the FY 1994 wage index, we included the costs for direct patient care contract services in the wage index calculation, and with the FY 1999 wage index, we included the costs for certain management contract services. (The August 30, 1996 final rule (61 FR 46181) provided an in-depth discussion of the issues related to the inclusion of contract labor costs in the wage index calculation.) Further, the FY 1999 wage index included the costs for contract physician Part A services, and the FY 2002 wage index included the costs for contract pharmacy and laboratory services. We continue to consider whether to expand our contract labor definition to include more types of contract services in the wage index. In particular, we have examined whether to include the costs for acquired dietary and housekeeping services, as many hospitals now provide these services through contracts. Costs for these services tend to be below the average wages for all hospital employees. Therefore, excluding the costs and hours for these services if they are provided under contract, while including them if the services are provided directly by the hospital, creates an incentive for hospitals to contract for these services in order to increase their average hourly wage for wage index purposes. It has also been suggested that we expand our definition to include all contract services, including both direct and indirect patient care services, in order to more appropriately calculate relative hospital wage costs. Our goal is to ensure that our wage index policy continues to be responsive to the changing need for contract labor and allow those hospitals that must depend on contract labor to supply needed services to reflect those costs in their wage data. At the same time, we are concerned about hospitals' ability to provide documentation that sufficiently details contract costs and hours. The added overhead, supplies, and miscellaneous costs typically associated with contract labor may result in higher costs for contract labor compared to salaried labor. If these costs are not separately identifiable and removed, they may cause distortions in the wage index. We agree that it may be appropriate to include indirect patient care contract labor costs in the wage index. However, in light of concerns about hospitals' ability to accurately document and report these costs, we believe the best approach is to assess and include these costs incrementally. Through incremental changes, we can better determine the impact that specific costs have on area wage index values. Also, by including these costs incrementally, hospitals and fiscal intermediaries are able to adjust to the additional documentation and review requirements associated with reporting the additional contract costs and hours. In this proposed rule, we are proposing to begin collecting contract labor costs and hours for management services and the following overhead services: administrative and general, housekeeping, and dietary. We selected these three overhead services because they are provided at all hospitals, either directly or through contracts, and together they comprise about 60 percent of a hospital's overhead hours. In addition, consistent with our consideration of administrative and general services, we propose to collect costs and hours associated with contract management services that are not currently included on Worksheet S-3, Part II, Line 9 (that is, management services other than those of the chief executive officer, chief financial officer, chief operating officer, and nurse administrator). We propose to revise the FY 2002 Medicare cost report (or the next available cost report) to provide for the separate reporting of contract management, administrative and general, housekeeping, and dietary costs and hours. After evaluating these data, we will determine the feasibility of adding these categories of contract labor to the wage index calculation. D. Verification of Wage Data From the Medicare Cost Report The data for the proposed FY 2003 wage index were obtained from Worksheet S-3, Parts II and III of the FY 1999 Medicare cost reports. The data file used to construct the wage index includes FY 1999 data submitted to us as of February 15, 2002. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data. We asked our fiscal intermediaries to revise or verify data elements that resulted in specific edit failures. Some unresolved data elements are included in the calculation of the proposed FY 2003 wage index, pending their resolution before calculation of the final FY 2003 wage index. We have instructed the intermediaries to complete their verification of questionable data elements and to transmit any changes to the wage data no later than April 5, 2002. We expect that all unresolved data elements will be resolved by that date. The revised data will be reflected in the final rule. Also, as part of our editing process, we removed data for 96 hospitals that failed edits. For 6 of these hospitals, we were unable to obtain sufficient documentation to verify or revise the data because the hospitals are no longer participating in the Medicare program, are under new ownership and the data cannot be verified, or are in bankruptcy status. We identified 90 hospitals with incomplete or inaccurate data resulting in zero or negative average hourly wages. Therefore, they were removed from the calculation. The data for these hospitals will be included in the final wage index if we receive corrected data that pass our edits. As a result, the proposed FY 2003 wage index is calculated based on FY 1999 wage data for 4,718 hospitals. E. Computation of the Proposed FY 2003 Wage Index The method used to compute the proposed FY 2003 wage index follows. *Step 1* —As noted above, we based the proposed FY 2003 wage index on wage data reported on the FY 1999 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, 1998 and before October 1, 1999. In addition, we included data from some hospitals that had cost reporting periods beginning before October 1998 and reported a cost reporting period covering all of FY 1999. These data were included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 1999 data. We note that, if a hospital had more than one cost reporting period beginning during FY 1999 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 1998 and before October 1, 1999), we included wage data from only one of the cost reporting periods, the longest, 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 latest period in the wage index calculation. *Step 2* —Salaries—Beginning with the FY 2003 wage index, the method used to compute a hospital's average hourly wage excludes all GME and CRNA costs. In calculating a hospital's average salaries plus wage-related costs, we subtracted from Line 1 (total salaries) the GME and CRNA costs reported on lines 2, 4.01, and 6, the Part B salaries reported on Lines 3 and 5, home office salaries reported on Line 7, and excluded salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not subject to the acute care hospital inpatient prospective payment system). We also subtracted from Line 1 the salaries for which no hours were reported on Line 4. To determine total salaries plus wage-related costs, we added to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9, 9.01, 9.02, and 10), home office salaries and wage-related costs reported by the hospital on Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, and 18). We note that contract labor and home office salaries for which no corresponding hours are reported were not included. In addition, wage-related costs for nonteaching physician Part A employees (Line 18) are excluded if no corresponding salaries are reported for those employees on Line 4. *Step 3* —Hours—With the exception of wage-related costs, for which there are no associated hours, we computed total hours using the same methods as described for salaries in Step 2. *Step 4* —For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocated overhead costs to areas of the hospital excluded from the wage index calculation. First, we determined the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 6, 7, and Part III, Line 13 of Worksheet S-3). We then computed the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we computed the amounts of overhead wage-related costs to be allocated to excluded areas using three steps:
(1)we determined the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 2, 3, 4.01, 5, 6, and 7);
(2)we computed overhead wage-related costs by multiplying the overhead hours ratio by wage-related costs reported on Part II, Lines 13, 14, and 18; and
(3)we multiplied the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtracted the computed overhead salaries, wage-related costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3. *Step 5* —For each hospital, we adjusted the total salaries plus wage-related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimated the percentage change in the employment cost index
(ECI)for compensation for each 30-day increment from October 14, 1998 through April 15, 2000 for private industry hospital workers from the Bureau of Labor Statistics' *Compensation and Working Conditions* . We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below. Midpoint of Cost Reporting Period After Before Adjustment factor 10/14/98 11/15/98 1.04550 11/14/98 12/15/98 1.04325 12/14/98 01/15/99 1.04111 01/14/99 02/15/99 1.03880 02/14/99 03/15/99 1.03632 03/14/99 04/15/99 1.03369 04/14/99 05/15/99 1.03092 05/14/99 06/15/99 1.02801 06/14/99 07/15/99 1.02509 07/14/99 08/15/99 1.02230 08/14/99 09/15/99 1.01962 09/14/99 10/15/99 1.01687 10/14/99 11/15/99 1.01385 11/14/99 12/15/99 1.01056 12/14/99 01/15/2000 1.00710 01/14/2000 02/15/2000 1.00358 02/14/2000 03/15/2000 1.00000 03/14/2000 04/15/2000 0.99638 For example, the midpoint of a cost reporting period beginning January 1, 1999 and ending December 31, 1999 is June 30, 1999. An adjustment factor of 1.02509 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 1999 and covered a period of less than 360 days or more than 370 days, we annualized the data to reflect a 1-year cost report. Annualization is accomplished by dividing the data by the number of days in the cost report and then multiplying the results by 365. *Step 6* —Each hospital was assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B) or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area. *Step 7* —We divided the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area. *Step 8* —We added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the nation and then divided the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the national average hourly wage is $22.9949. *Step 9* —For each urban or rural labor market area, we calculated the hospital wage index value by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8. *Step 10* —Following the process set forth above, we developed a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We added the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divided the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall average hourly wage of $10.8935 for Puerto Rico. For each labor market area in Puerto Rico, we calculated the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage. *Step 11* —Section 4410 of Public Law 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. Furthermore, this wage index floor is to be implemented in such a manner as to ensure that aggregate prospective payment system payments are not greater or less than those that would have been made in the year if this section did not apply. For FY 2003, this change affects 163 hospitals in 40 MSAs. The MSAs affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule. F. Revisions to the Wage Index Based on Hospital Redesignation 1. General Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the prospective payment system. Hospitals can elect to reclassify for the wage index or the standardized amount, or both, and as individual hospitals or as rural groups. 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. Hospitals must apply for reclassification to the MGCRB, which issues its decisions by the end of February for reclassification to become effective for the following fiscal year (beginning October 1). The regulations applicable to reclassifications by the MGCRB are in §§ 412.230 through 412.280. Section 1886(d)(10)(D)(v) of the Act provides that, beginning with FY 2001, a MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 fiscal years, unless the hospital elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of the Act provides that the MGCRB must use the 3 most recent years' average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and any succeeding fiscal year. Section 304(b) of Public Law 106-554 provides that, by October 1, 2001, 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. Beginning October 1, 1988, section 1886(d)(8)(B) of the Act permits a hospital located in a rural county adjacent to one or more urban areas to be designated as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the **Federal Register** on January 3, 1980 (45 FR 956) for designating MSAs (and for designating NECMAs), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized area) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage index. Section 402 of Public Law 106-113 provided that, for FYs 2001 and 2002, hospitals could elect whether to apply standards developed by OMB in 1980 or 1990 in order to qualify for redesignation under section 1886(d)(8)(B) of the Act. However, we are proposing that, beginning with FY 2003, redesignation under section 1886(d)(8)(B) of the Act will be based on the standards published in the **Federal Register** by the Director of OMB based on the most recent decennial census. 2. Effects of Reclassification The methodology for determining the wage index values for redesignated hospitals is applied jointly to the hospitals located in those rural counties that were deemed urban under section 1886(d)(8)(B) of the Act and those hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. 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. 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 area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. • The wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. • Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred. • Rural areas whose wage index values increase as a result of excluding the wage data for the hospitals that have been redesignated to another area have their wage index values calculated exclusive of the wage data of the redesignated hospitals. • 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. The proposed wage index values for FY 2003 are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule. Hospitals that are redesignated should use the wage index values shown in Table 4C. Areas in Table 4C may have more than one wage index value because the wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. Tables 3A and 3B in the Addendum of this proposed rule list the 3-year average hourly wage for each labor market area before the redesignation of hospitals, based on FY 1997, 1998, and 1999 wage data. 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 1997 and FY 1998 cost reporting periods, as well as the FY 1999 period used to calculate the FY 2003 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 under computation of the proposed FY 2003 wage index) 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. At the time this proposed wage index was constructed, the MGCRB had completed its review of FY 2003 reclassification requests. We have included in this proposed rule a new Table 9, which shows hospitals that have been reclassified under either section 1886(d)(8)(B) or section 1886(d)(10)(D) of the Act. This table includes hospitals reclassified for FY 2003 by the MGCRB, as well as hospitals that were reclassified for the wage index in either FY 2001 or FY 2002 and are, therefore, in either the third or second year of their 3-year reclassification. There are 60 hospitals reclassified for the wage index beginning during FY 2003. In addition, 369 hospitals are reclassified for FY 2003 based on their 3-year reclassification that became effective during FY 2001, and 170 hospitals are reclassified for FY 2003 based on their 3-year reclassification that became effective during FY 2002. There are 124 hospitals included in the 3-year reclassification from FY 2001 that were reclassified in accordance with section 152(b) of Public Law 106-113. In addition, there are 38 rural hospitals redesignated to an urban area under section 1886(d)(8)(B) of the Act, and 14 urban hospitals that have been designated rural in accordance with section 1886(d)(8)(E) of the Act. Finally, there are 61 hospitals reclassified by the MGCRB for the standardized amount for FY 2003 (including one hospital that is also redesignated under section 1886(d)(8)(B) of the Act to a different MSA). The final number of reclassifications may vary because some MGCRB decisions are still under review by the Administrator and because some hospitals may withdraw their requests for reclassification. Table 9 shows the various reclassifications and redesignations discussed above by individual hospital. The table does not reflect any hospital withdrawals from reclassifications approved by the MGCRB or decisions of the CMS Administrator. In the final rule to be published by August 1, 2002, we will include a similar table that will include all final reclassifications for FY 2003. Under § 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of this proposed rule in the **Federal Register** . In addition, hospitals may terminate an existing 3-year reclassification within 45 days of the publication of this 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 2003 must be received by the MGCRB by June 24, 2002. A hospital that withdraws its application or terminates an existing 3-year reclassification may not later request reinstatement of the MGCRB decision, except by canceling such a withdrawal or termination in a subsequent year (see § 412.273(b)(2)(i), and the proposed changes and clarifications to the cancellation procedures in section V. of this preamble). Any changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process will be incorporated into the wage index values published in the final rule following this proposed rule. The 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 value for the area to which they are redesignated, or a wage index value 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. We are proposing limited changes and clarifications to the policies related to withdrawals, terminations, and cancellations of the 3-year wage index reclassifications. These are discussed in section V. of this preamble. 3. OMB Standards for Hospitals To Qualify for Redesignation In the August 1, 2001 final rule, we implemented section 402 of Public Law 106-113. Section 402 provided that hospitals could elect whether to apply standards developed by OMB in 1980 or 1990 in order to qualify for redesignation under section 1886(d)(8)(B) of the Act. However, section 402 also states that, beginning with FY 2003, hospitals will be required to use the standards published in the **Federal Register** by the Director of OMB based on the most recent decennial census. At this time, the 1990 standards are the most recent available. Although OMB is working to develop updated standards based on the 2000 census, that work is not yet completed. If the 2000 census population data become available prior to the preparation and publication of the final rule by August 1, 2002, CMS will work with the Population Distribution Branch within the Population Division of the U.S. Census Bureau to compile a list of hospitals that meet the established standards using the 2000 census population data. Otherwise, for purposes of redesignation for FY 2003 under section 1886(d)(8)(B) of the Act, qualifying hospitals must be located in counties meeting the 1990 standards. In the August 1, 2001 final rule, we determined that three counties that qualified for redesignation under the 1980 standards qualified for redesignation to a different MSA using the 1990 standards (66 FR 39869). These counties, which will be redesignated to the MSA to which they qualify based on the 1990 standards, are as follows: 12 Rural county 1980 MSA designation 1990 MSA designation Ionia, MI Lansing-East Lansing, MI Grand Rapids-Muskegon-Hollan, MI. Caswell, NC Danville, VA. Greensboro-Winston Salem-High Point, NC. Harnett, NC Fayetteville, NC Raleigh-Durham-Chapel Hill, NC. Section 402 of Public Law 106-113 allowed hospitals to elect to use either the January 3, 1980 standards or March 30, 1990 standards for payments during FY 2001 and FY 2002. Several hospitals in counties that did not qualify under the January 3, 1980 standards elected to use those older standards so they would not receive the urban designation accorded them under section 402 because they would lose their special rural designation (that is, a sole community hospital
(SCH)or Medicare-dependent hospital (MDH)). Under section 402, the option to make such an election was available only for FY 2001 and FY 2002. Effective for FY 2003, we are proposing that hospitals located in counties qualifying for redesignation under section 1886(d)(8)(B) of the Act based on the 1990 standards would be redesignated under this provision. We also noted in the August 1, 2001 final rule that five rural counties no longer meet the qualifying criteria when we apply the 1990 OMB standards (66 FR 39870). These rural counties are as follows: Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and Lincoln, WV. Therefore, beginning FY 2003, hospitals in these counties will not be eligible for redesignation unless the counties again qualify when the standards based on the 2000 census data are available. G. Requests for Wage Data Corrections As stated in section II.D. of this preamble, the data used to construct the proposed wage index includes FY 1999 data submitted to CMS as of February 15, 2002. In a memorandum dated December 19, 2001, we instructed all Medicare intermediaries to inform the prospective payment hospitals they service of the availability of the wage data file and the process and timeframe for requesting revisions. The wage data file was made available on January 12, 2002, through the Internet at CMS's home page ( *http://www.hcfa.gov* ). We also instructed the intermediaries to advise hospitals of the availability of these data either through their representative hospital organizations or directly from CMS. Additional details on ordering this data file are discussed in section IX.A. of this preamble, “Requests for Data from the Public.” In addition, Table 2 in the Addendum to this proposed rule contains each hospital's adjusted average hourly wage used to construct the proposed wage index values for the past 3 years, including the FY 1999 data used to construct the proposed FY 2003 wage index. It should be noted that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital's data and transmitted to CMS prior to February 15, 2002. Changes approved by a hospital's fiscal intermediary and forwarded to CMS by April 5, 2002, will be reflected in the final public use wage data file scheduled to be made available on or about May 10, 2002. We believe hospitals have sufficient time to ensure the accuracy of their FY 1999 wage data. Moreover, the ultimate responsibility for accurately completing the cost report rests with the hospital, which must attest to the accuracy of the data at the time the cost report is filed. Hospitals should know what wage data were submitted on their cost reports. In addition, they are notified of any changes to their data as a result of their fiscal intermediary's review. However, if a hospital believed that its FY 1999 wage data were incorrectly reported, the hospital was to submit corrections along with complete, detailed supporting documentation to its intermediary by February 8, 2002. Hospitals were notified of this deadline, and of all other possible deadlines and requirements, through the December 19, 2001 memorandum referenced above. After reviewing requested changes submitted by hospitals, fiscal intermediaries transmitted any revised cost reports to CMS and forwarded a copy of the revised Worksheet S-3, Parts II and III to the hospitals. In addition, fiscal intermediaries were to notify hospitals of the changes or the reasons that changes were not accepted. This procedure ensures that hospitals have every opportunity to verify the data that will be used to construct their wage index values. We believe that fiscal intermediaries are generally in the best position to make evaluations regarding the appropriateness of a particular cost and whether it should be included in the wage index data. However, if a hospital disagrees with the fiscal intermediary's resolution of a policy issue (whether a general category of cost is allowable in the wage data), the hospital may contact CMS in an effort to resolve policy disputes. We note that the April 5, 2002 deadline also applies to these requested changes. During this review, we will not consider issues such as the adequacy of a hospital's supporting documentation, as these types of issues should have been resolved earlier in the process. These deadlines are necessary to allow sufficient time to review and process the data so that the final wage index calculation can be completed for development of the final FY 2003 prospective payment rates to be published by August 1, 2002. We have created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 2003 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage data corrections or to dispute the intermediary's decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to later challenge, before the Provider Reimbursement Review Board, CMS's failure to make a requested data revision (See *W. A. Foote Memorial Hospital* v. *Shalala,* No. 99-CV-75202-DT (E.D. Mich. 2001)). The final wage data public use file will be released on approximately May 10, 2002. Hospitals should examine both Table 2 of this proposed rule and the May 2002 final public use wage data file (which reflects revisions to the data used to calculate the values in Table 2) to verify the data CMS is using to calculate the wage index. As with the file made available in January 2002, CMS will make the final wage data file released in May 2002 available to hospital associations and the public on the Internet. However, the May 2002 public use file will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary in the entry of the final wage data that result from the correction process described above (with the February 8 deadline). Hospitals are encouraged to review their hospital wage data promptly after the release of the May 2002 file. Data presented at this time cannot be used by hospitals to initiate new wage data correction requests. If, after reviewing the final file, a hospital believes that its wage data are incorrect due to a fiscal intermediary or CMS error in the entry or tabulation of the final wage data, it should send a letter to both its fiscal intermediary and CMS. The letters should outline why the hospital believes an error exists and provide all supporting information, including dates. These requests must be *received* by CMS and the fiscal intermediaries no later than June 7, 2002. Requests mailed to CMS should be sent to: Center for Medicare & Medicaid Services, Center for Health Plans and Providers, Attention: Wage Index Team, Division of Acute Care, C4-07-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. Each request must also be sent to the hospital's fiscal intermediary. The intermediary will review requests upon receipt and contact CMS immediately to discuss its findings. At this point in the process, that is, between release of the May 2002 wage index file and June 7, 2002, changes to the hospital wage data will only be made in those very limited situations involving an error by the intermediary or CMS that the hospital could not have known about before its review of the final wage data file. Specifically, neither the intermediary nor CMS will accept the following types of requests at this stage of the process: • Requests for wage data corrections that were submitted too late to be included in the data transmitted to CMS by fiscal intermediaries on or before April 5, 2002. • Requests for correction of errors that were not, but could have been, identified during the hospital's review of the January 2002 wage data file. • Requests to revisit factual determinations or policy interpretations made by the intermediary or CMS during the wage data correction process. Verified corrections to the wage index received timely (that is, by June 7, 2002) will be incorporated into the final wage index to be published by August 1, 2002 and effective October 1, 2002. Again, we believe the wage data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage data to the fiscal intermediaries' attention. Moreover, because hospitals will have access to the final wage data by May 2002, they will have the opportunity to detect any data entry or tabulation errors made by the fiscal intermediary or CMS before the development and publication of the FY 2003 wage index by August 1, 2002, and the implementation of the FY 2003 wage index on October 1, 2002. If hospitals avail themselves of this opportunity, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified after that date, we retain the right to make midyear changes to the wage index under very limited circumstances. Specifically, in accordance with § 412.63(x)(2) of our existing regulations, we make midyear corrections to the wage index only in those limited circumstances in which a hospital can show
(1)that the intermediary or CMS made an error in tabulating its data; and
(2)that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of FY 2003 (that is, by the June 7, 2002 deadline). As indicated earlier, since a hospital will have the opportunity to verify its data, and the fiscal intermediary will notify the hospital of any changes, we do not expect that midyear corrections would be necessary. However, if the correction of a data error changes the wage index value for an area, the revised wage index value is effective prospectively from the date the correction is approved. This policy for applying prospective corrections to the wage index was originally set forth in the preamble to the January 3, 1984 final rule (49 FR 258) implementing the hospital inpatient prospective payment system. It has been our longstanding policy to make midyear corrections to the hospital wage data and adjust the wage index for the affected areas on a prospective basis. Section 412.63(x)(3) states that revisions to the wage index resulting from midyear corrections to the wage index values are incorporated in the wage index values for other areas at the beginning of the next Federal fiscal year. Prior to October 1, 1993, the wage index was based on a wage data survey submitted by all hospitals (prior to that, the data came from the Bureau of Labor Statistics' hospital wage and employment data file). Beginning October 1, 1993, as required by section 1886(d)(3)(E) of the Act, we began updating the wage index data on an annual basis. Because the wage index has been updated annually since FY 1994, § 412.63(x)(3) is no longer necessary, and we are proposing to delete it. Similarly, § 412.63(x)(4) provides that the effect on program payments of midyear corrections to the wage index values is taken into account in establishing the standardized amounts for the following year. Again, the wage data are now updated annually. Therefore, § 412.63(x)(4) is no longer necessary, and we are proposing to delete it as well. Finally, we are proposing to revise § 412.63(x)(2) to clarify that CMS will make a midyear correction to the wage index for an area only if a hospital can show that the intermediary or CMS made an error in tabulating the hospital's own data. That is, 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. As described above, the requesting hospital must show that it could not have known about the error, or that it did not have the opportunity to correct the error, before the beginning of the Federal fiscal year. IV. Proposed Rebasing and Revision of the Hospital Market Baskets A. Operating Costs 1. Background Effective for cost reporting periods beginning on or after July 1, 1979, we developed and adopted a hospital input price index (that is, the hospital “market basket”) for operating costs. Although “market basket” technically describes the mix of goods and services used to produce hospital care, this term is also commonly used to denote the input price index (that is, cost category weights and price proxies combined) derived from that market basket. Accordingly, the term “market basket” as used in this document refers to the hospital input price index. The percentage change in the market basket reflects the average change in the price of goods and services hospitals purchased in order to furnish inpatient care. We first used the market basket to adjust hospital cost limits by an amount that reflected the average increase in the prices of the goods and services used to furnish hospital inpatient care. This approach linked the increase in the cost limits to the efficient utilization of resources. With the inception of the acute care hospital inpatient prospective payment system, the projected change in the hospital market basket has been the integral component of the update factor by which the prospective payment rates are updated every year. For FY 2003, payment rates will be updated by the projected increase in the hospital market basket minus 0.55 percentage points. A detailed explanation of the hospital market basket used to develop the prospective payment rates was published in the **Federal Register** on September 3, 1986 (51 FR 31461). We also refer the reader to the August 29, 1997 **Federal Register** (62 FR 45966) in which we discussed the previous rebasing of the hospital input price index. The hospital market basket is a fixed-weight, Laspeyres-type price index that is constructed in three steps. First, a base period is selected and total base period expenditures are estimated for a set of mutually exclusive and exhaustive spending categories based upon type of expenditure. Then, the proportion of total operating costs that each category represents is determined. These proportions are called cost or expenditure weights. Second, each expenditure category is matched to an appropriate price or wage variable, referred to as a price proxy. These price proxies are price levels derived from publicly available statistical series and are published on a consistent schedule, preferably at least on a quarterly basis. Finally, the expenditure weight for each category is multiplied by the level of the respective price proxy. The sum of these products (that is, the expenditure weights multiplied by the price levels) for all cost categories yields the composite index level of the market basket in a given year. Repeating this step for other years produces a series of market basket index levels over time. Dividing one index level by an earlier index level produces rates of growth in the input price index over that time. The market basket is described as a fixed-weight index because it answers the question of how much it would cost, at another time, to purchase the same mix of goods and services that was purchased in the base period. The effects on total expenditures resulting from changes in the quantity or mix of goods and services (intensity) purchased subsequent to the base period are not measured. For example, shifting a traditionally inpatient type of care to an outpatient setting might affect the volume of inpatient goods and services purchased by the hospital, but would not be factored into the price change measured by a fixed weight hospital market basket. In this manner, the index measures only the pure price change. Only rebasing (changing the base year) the index would capture these quantity and intensity effects. Therefore, we rebase the market basket periodically so the cost weights reflect changes in the mix of goods and services that hospitals purchase (hospital inputs) in furnishing inpatient care. We last rebased the hospital market basket cost weights in 1997, effective for FY 1998 (62 FR 45993). This market basket, still used through FY 2002, reflects base year data from FY 1992 in the construction of the cost weights. We note that there are separate market baskets for acute care hospital inpatient prospective payment system hospitals and excluded hospitals and hospital units. In addition, we are in the process of conducting the necessary research to determine if separate market baskets for the inpatient rehabilitation, long-term care, and psychiatric hospital prospective payment systems can be developed. However, for the purpose of this preamble, we are only discussing the market basket based on all excluded hospitals together. 2. Rebasing and Revising the Hospital Market Basket The terms rebasing and revising, while often used interchangeably, actually denote different activities. Rebasing means moving the base year for the structure of costs of an input price index (for example, we are proposing to shift the base year cost structure from FY 1992 to FY 1997). Revising means changing data sources, cost categories, or price proxies used in the input price index. We are proposing to use a rebased and revised hospital market basket in developing the FY 2003 update factor for the prospective payment rates. The new market basket would be rebased to reflect FY 1997, rather than FY 1992, cost data. The 1992-based market baskets contained expenditure data for hospitals from Medicare cost reports for cost reporting periods beginning on or after October 1, 1991, and before October 1, 1992. The 1997-based market baskets use data for hospitals from Medicare cost reports for cost reporting periods beginning on or after October 1, 1996, and before October 1, 1997. Fiscal year 1997 was selected as the new base year because 1997 is the most recent year for which relatively complete data are available. These include data from FY 1997 Medicare cost reports as well as 1997 data from two U.S. Department of Commerce publications: the Bureau of the Census' Business Expenditure Survey
(BES)and the Bureau of Economic Analysis' Annual Input-Output Tables. In addition, preliminary analysis of FYs 1998 and 1999 Medicare cost report data showed little difference in cost shares from FY 1997 data. In developing the proposed rebased and revised market baskets, we reviewed hospital operating expenditure data for the market basket cost categories in determining the cost weights. We relied primarily on Medicare hospital cost report data for the proposed rebasing. We prefer to use cost report data wherever possible because these are the cost data supplied directly from hospitals. Other data sources such as the BES and the input-output tables serve as secondary sources used to fill in where cost report data are not available or appear to be incomplete. Below we are providing a detailed discussion of the process for calculating cost share weights. Cost category weights for the proposed FY 1997-based market baskets were developed in several stages. First, base weights for several of the categories (Wages and Salaries, Employee Benefits, Contract Labor, Pharmaceuticals and Blood and Blood Products) were derived from the FY 1997 Medicare cost reports for operating costs. The expenditures for these categories were calculated as a percentage of total operating costs from those hospitals covered under the inpatient hospital prospective payment system. These data were then edited to remove outliers and ensure that the hospital participated in the Medicare program and had Medicare costs. However, we were unable to measure only those operating costs attributable to the inpatient portion of the hospital, because many cost centers are utilized by both inpatients and outpatients in the hospital. Health Economics Research (HER), under contract with CMS, is currently in the process of researching the possibility of constructing a separate outpatient market basket for CMS' outpatient hospital prospective payment system. This research may provide some insight and guidance for separating inpatient and outpatient costs. We excluded hospital-based subprovider cost centers (for example, skilled nursing, nursing, hospice, psychiatric, rehabilitation, intermediate care/mental retardation, and other long-term care) as well as the portion of overhead and ancillary costs incurred by these subproviders. Second, the weight for professional liability insurance was calculated using data from a survey conducted by ANASYS under contract to CMS. This survey, called the National Hospital Malpractice Insurance Survey (NHMIS), was conducted to estimate hospital malpractice insurance costs over time at the national level. A more detailed description of this survey is found later in this preamble. Third, data from the 1997 Business Expenditure Survey
(BES)was used to develop a weight for the utilities and telephone services categories. Like most other data sources, the BES includes data for all hospitals and does not break out data by payer. However, we believe the overall data from the BES does not produce results that are inconsistent with the prospective payment system hospitals, particularly at the detailed cost category level with which we are working. Fourth, the sum of the weights for wages and salaries, employee benefits, contract labor, professional liability insurance, utilities, pharmaceuticals, blood and blood products, and telephone services was subtracted from other operating expenses to obtain a portion for all other expenses. Finally, the remainder of the weight for all other expenses was divided into subcategories using relative cost shares from the 1997 Annual Input-Output Table for the hospital industry, produced by the Bureau of Economic Analysis, U.S. Department of Commerce. The 1997 Benchmark Input-Output data will be available, at the earliest, in late 2002, so we will be unable to incorporate these data in the final rule. Below, we further describe the sources of the six main category weights and their subcategories in the proposed FY 1997-based market basket. We note the differences between the methodologies used to develop the FY 1992-based and the FY 1997-based market baskets. • *Wages and Salaries:* The cost weight for the wages and salaries category was derived using Worksheet S-3 from the FY 1997 Medicare cost reports. Contract labor, which is also derived from the FY 1997 Medicare cost reports, is split between the wages and salaries and employee benefits cost categories, using the relationship for employed workers. An example of contract labor is registered nurses who are employed and paid by firms that contract for their work with the hospital. The wages and salaries category in the FY 1992-based market basket was developed from the FY 1992 Medicare cost reports. In addition, we used the 1992 Current Population Survey to break out more detailed occupational subcategories. These subcategories were not broken out for the proposed FY 1997-based market basket. • *Employee Benefits:* The cost weight for the employee benefits category was derived from Worksheet S-3 of the FY 1997 Medicare cost reports. The employee benefits category in the FY 1992-based market basket was developed from FY 1992 Medicare cost reports and used the 1992 Current Population Survey to break out various occupational subcategories. These subcategories were not broken out for the proposed FY 1997-based market basket. • *Nonmedical Professional Fees:* This category refers to various types of nonmedical professional fees such as legal, accounting, engineering and management and consulting fees. Management and consulting and legal fees make up the majority of professional fees in the hospital sector. The cost weight for the nonmedical professional fees category was derived from the Bureau of Economic Analysis Input-Output data for 1997. The FY 1992-based index used a combination of data from the American Hospital Association
(AHA)and the Medicare cost reports to arrive at a weight. However, because the AHA survey data for professional fees are no longer published, we were unable to duplicate this method. Had we used the proposed methodology to calculate the FY 1992 nonmedical professional fees component, the proportion would have been similar to the FY 1997 share. • *Professional Liability Insurance:* The proposed FY 1997-based market basket uses a weight for professional liability insurance derived from a survey conducted by ANASYS under contract to CMS (Contract Number 500-98-005). This survey attempted to estimate hospital malpractice insurance costs over time at the national level for years 1996 and 1997. The population universe of the survey was defined as all non-Federal short-term, acute care prospective payment system hospitals. A statistical sample of hospitals was drawn from this universe and data collected from those hospitals. This sample of hospitals was then matched to the appropriate cost report data so that a malpractice cost weight could be calculated. The questions used in the survey were based on a 1986 General Accounting Office
(GAO)malpractice survey questionnaire that was modified so data could be collected to calculate a malpractice cost weight and the rate of change for a constant level of malpractice coverage at a national level. The 1997 proportion as calculated by ANASYS was compared to limited data for FYs 1998 and 1999 contained in the Medicare Health Care System Cost Report Information System (HCRIS). The percentages are relatively comparable. However, since this field was virtually incomplete in the FY 1997 cost report file, we were unable to use this cost report data. In contrast, the FY 1992-based market basket professional liability insurance weight was determined using the cost report data for PPS-6 (cost reporting periods beginning in FY 1989), the last year these costs had to be treated separately from all other administrative and general costs, trended forward to FY 1992 based on the relative importance of malpractice costs found in the previous market basket. • *Utilities:* For the proposed FY 1997-based market baskets, the cost weight for utilities was derived from the Bureau of the Census' Business Expenditures Survey. For the FY 1992-based market baskets, the cost weight for utilities was derived from the Bureau of the Census' Asset and Expenditures Survey. The Business Expenditure Survey replaced the Asset and Expenditure Survey and the categories and results are similar. • *All Other Products and Services:* The all other products and services category includes the remainder of products and services that hospitals purchase in providing care. Products found in this category include: direct service food, contract service food, pharmaceuticals, blood and blood products, chemicals, medical instruments, photo supplies, rubber and plastics, paper products, apparel, machinery and equipment, and miscellaneous products. Services found in this category include: telephone, postage, other labor-intensive services, and other nonlabor-intensive services. Labor-intensive services include those services for which local labor markets would likely influence prices. A complete discussion of the labor-related share is presented later in this preamble. The shares for pharmaceuticals and blood and blood products were derived from the FY 1997 Medicare cost reports, while the share for telephone services was derived from the BES. Relative shares for the other subcategories were derived from the 1997 Bureau of Economic Analysis Annual Input-Output Table for the hospital industry. The calculation of these subcategories involved calculating a residual from the Input/Output Table using categories similar to those not yet accounted for in the market basket. Subcategory weights were then calculated as a proportion of this residual and applied to the similar residual in the market basket. • *Blood and blood products:* When the market basket was last revised and rebased to FY 1992, the component for blood services was discontinued because of the lack of appropriate data to determine a weight. The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
(BIPA)required that CMS consider the prices of blood and blood products purchased by hospitals and determine whether those prices are adequately reflected in the market basket. In accordance with this requirement, CMS has done considerable research to determine if a component for blood and blood products should be added to the market basket and, if so, how the weight should be determined. CMS has studied four alternative data sources to possibly determine a weight for blood in the market basket. If none of these data sources was deemed acceptable, we could conclude that a component for blood should not be reintroduced in the hospital market basket. In a December 2001 report by the MedPAC entitled “Blood Safety in Hospitals and Medicare Inpatient Payment,” MedPAC recommended that the market basket should explicitly account for the cost of blood and blood products by reintroducing a separate component for their prices. The first alternative data source studied was using data from the Medicare cost reports. The cost reports have two cost centers where the costs of blood can be recorded:
(1)whole blood and packed red blood cells (nonsalary); and
(2)blood storing, processing, and transfusion (nonsalary). Although all prospective payment system hospitals submit a cost report, less than half of these hospitals reported data in either of the two blood cost centers. However, if we can determine that the hospitals reporting blood are representative of all prospective payment system hospitals, then a cost share can be computed using the cost reports. The second alternative involves constructing weights from the Input-Output Table from the BEA, Department of Commerce. These data were used to construct the weight when the market basket was revised before FY 1992. Unfortunately, BEA stopped reporting blood separately in their Input-Output Table in 1987. One possible use of these data would be to calculate a weight by updating the prior weight by the relative price change for blood between the last data point available and 1997. However, by using this method, only the escalation in prices, not the changes in quantity or intensity of use of blood products, would be captured. The third alternative was using data from the MedPAR files. This option was discussed in MedPAC's December 2001 report, and involves using claims data or data on hospital charges. In order to construct a weight for the market basket, the underlying costs of blood must be calculated from the claims data. An analysis of cost-to-charge ratios of hospitals can determine if this is feasible. The final alternative data source is the Bureau of the Census' quinquennial Business Expenditure Survey and the Economic Census. A weight can be obtained indirectly by taking the ratio of receipts of nonprofit blood collectors to total operating expenses of hospitals. Some adjustments would be needed in order for the weight calculated in this way to be completely valid. In addition, this method assumes that all blood used by hospitals comes from nonprofit sources. However, in 1999, hospitals collected 7 percent of the donated units. After a thorough analysis, CMS has determined that the Medicare cost reports, after minor adjustments, are the best option. The data from the Input-Output Table are not optimal because they are not current and would have to be aged using only price data, which do not reflect quantity and intensity changes over this period. Although the MedPAR data could be adjusted to compute a cost share, using claims data is not the preferred alternative. Census data would be an attractive option if the cost reports were not available. The main weakness of the Medicare cost reports is the inconsistent reporting of hospitals in the two blood cost centers. In 1997, only 48.0 percent of all hospitals reported blood in one or both cost centers. However, these hospitals accounted for 62.2 percent of the operating costs of all hospitals. In order for the calculation of the blood cost share weight to be acceptable, the hospitals that reported blood would need to be adjusted to be representative of all hospitals, including those that did not report blood on the cost reports. Because of the similarity of data in the two blood cost centers, the assumption was made that if a hospital reported blood in only one of the two cost centers, all of its blood costs were reported in that cost center. In the FY 1997 cost reports, of the hospitals that reported blood, 41.3 percent reported only in the blood cells cost center, 58.2 percent reported only in the blood storing cost center, and only 0.5 percent reported in both blood cost centers. To calculate a weight, the numerator was the summation of the data in both blood cost centers. The denominator was the summation of the operating costs of each hospital that reported blood in each cost center minus the operating costs of the few hospitals that reported blood in both cost centers to avoid double counting. The blood cost share calculated from these data was then adjusted so that the hospitals reporting blood had the same characteristics of all other hospitals. Adjustments were necessary because the hospitals that reported blood were more likely to be urban and teaching hospitals than those hospitals that did not report blood. The adjustments made less than a 0.1 percent difference in the cost share. The weight produced using the cost report for FY 1997 was 0.875 percent. We also looked at cost report data from FYs 1996 and 1998. The weights calculated in these years were similar to the FY 1997 weight. The calculation of the blood cost share using the alternative data sources cited above was similar to the results using the cost reports. Given the consistency with these other sources, the representativeness of our estimate, and the stability of the cost share, we are proposing to use the Medicare cost reports to determine a weight for blood and blood products in the proposed hospital market basket. Overall, our work resulted in the identification of 23 separate cost categories that represent the rebased weights in the proposed rebased and revised hospital market basket. There is one more category than was included in the FY 1992-based market basket (FY 1992-based had 22). The differences between the weights of the major categories determined from the Medicare cost reports for the proposed FY 1997-based index and the previous FY 1992-based index are summarized in Table 1. Table 1.—FY 1992-Based and Proposed FY 1997-Based Prospective Payment Hospital Operating Major Cost Categories and Weights as Determined From the Medicare Cost Reports Expense categories Proposed rebased FY 1997 hospital market basket FY 1992-based hospital market basket Wages and Salaries 50.686 50.244 Employee Benefits 10.970 11.146 Pharmaceuticals 5.416 4.162 Blood and Blood Products 0.875 All Other 32.053 34.448 Total 100.000 100.000 Table 2 sets forth all of the proposed market basket cost categories and weights. For comparison purposes, the 1992-based cost categories and weights are included in the table. Table 2.—FY 1992-Based and Proposed FY 1997-Based Prospective Payment Hospital Operating Cost Categories and Weights Expense categories Proposed rebased FY 1997 hospital market basket weights FY 1992-based hospital market basket weights 1. Compensation 61.656 61.390 A. Wages and Salaries* 50.686 50.244 B. Employee Benefits* 10.970 11.146 2. Professional Fees* 5.401 2.127 3. Utilities 1.353 1.542 A. Fuel, Oil, and Gasoline 0.284 0.369 B. Electricity 0.833 0.927 C. Water and Sewerage 0.236 0.246 4. Professional Liability Insurance 0.840 1.189 5. All Other 30.749 33.752 A. All Other Products 19.537 24.825 (1.) Pharmaceuticals 5.416 4.162 (2.) Direct Purchase Food 1.370 2.314 (3.) Contract Service Food 1.274 1.072 (4.) Chemicals 2.604 3.666 (5.) Blood and Blood Products 0.875 (6.) Medical Instruments 2.192 3.080 (7.) Photographic Supplies 0.204 0.391 (8.) Rubber and Plastics 1.668 4.750 (9.) Paper Products 1.355 2.078 (10.) Apparel 0.583 0.869 (11.) Machinery and Equipment 1.040 0.207 (12.) Miscellaneous Products 0.956 2.236 B. All Other Services 11.212 8.927 (1.) Telephone Services 0.398 0.581 (2.) Postage 0.857 0.272 (3.) All Other: Labor Intensive* 5.438 7.277 (4.) All Other: Non-Labor Intensive 4.519 0.796 Total 100.000 100.000 * Labor-related. Note: Due to rounding, weights may not sum to total. 3. Selection of Price Proxies After computing the FY 1997 cost weights for the proposed rebased hospital market basket, it is necessary to select appropriate wage and price proxies to monitor the rate of change for each expenditure category. Most of the indicators are based on Bureau of Labor Statistics
(BLS)data and are grouped into one of the following BLS categories: • Producer Price Indexes—Producer Price Indexes
(PPIs)measure price changes for goods sold in other than retail markets. PPIs are preferable price proxies for goods that hospitals purchase as inputs in producing their outputs because a PPI would better reflect the prices faced by hospitals. For example, we used the PPI for ethical (prescription) drugs, rather than the Consumer Price Index
(CPI)for prescription drugs, because hospitals generally purchase drugs directly from the wholesaler. The PPIs that we use measure price change at the final stage of production. • Consumer Price Indexes—Consumer Price Indexes
(CPIs)measure change in the prices of final goods and services bought by the typical consumer. Because they may not represent the price faced by a producer, the consumer price indexes were used only if an appropriate PPI was not available, or if the expenditure was more similar to that of retail consumers in general rather than a purchase at the wholesale level. For example, the CPI for food purchased away from home was used as a proxy for contracted food services. • Employment Cost Indexes—Employment Cost Indexes
(ECIs)measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. They are appropriately not affected by shifts in employment mix. Table 3 sets forth the complete proposed hospital market basket including cost categories, weights, and price proxies. For comparison purposes, the respective FY 1992-based market basket price proxies are listed as well. A summary outlining the choice of the various proxies follows the table. Table 3.—Proposed FY 1997-Based Prospective Payment Hospital Operating Cost Categories, and Weights, and FY 1992-Based and Proposed FY 1997-Based Price Proxies Expense categories Proposed rebased FY 1997 hospital market basket weights Proposed rebased FY 1997 hospital market basket price proxy FY 1992 hospital market basket price proxy 1. Compensation 61.656 A. Wages and salaries * 50.686 ECI-wages and salaries, civilian hospital workers CMS occupational wage proxy. B. Employee benefits * 10.970 ECI—benefits, civilian hospital workers CMS occupational benefit proxy. 2. Professional fees * 5.401 ECI—compensation for professional specialty & technical ECI—compensation for professional, specialty & technical. 3. Utilities 1.353 A. Fuel, oil, and gasoline 0.284 PPI refined petroleum products PPI refined petroleum products. B. Electricity 0.833 PPI commercial electric power PPI commercial electric power. C. Water and sewerage 0.236 CPI-U water & sewerage maintenance CPI-U water & sewerage maintenance. 4. Professional liability insurance 0.840 CMS professional liability insurance premium index CMS professional liability insurance premium index. 5. All other products 30.749 A. All other products 19.537 (1.) Pharmaceuticals 5.416 PPI ethical (prescription) drugs PPI ethical (prescription) drugs. (2.) Direct purchase food 1.370 PPI processed foods and feeds PPI processed foods and feeds. (3.) Contract service food 1.274 CPI-U food away from home CPI-U food away from home. (4.) Chemicals 2.604 PPI industrial chemicals PPI industrial chemicals. (5.) Blood and blood products 0.875 PPI blood and blood derivatives, human use N/A. (6.) Medical instruments 2.192 PPI medical instruments & equipment PPI medical instruments and equipment. (7.) Photographic supplies 0.204 PPI photographic supplies PPI photographic supplies. (8.) Rubber and plastics 1.668 PPI rubber & plastic products PPI rubber and plastic products. (9.) Paper products 1.355 PPI converted paper and paperboard products PPI converted paper and paperboard products. (10.) Apparel 0.583 PPI apparel PPI apparel. (11.) Machinery and equipment 1.040 PPI machinery and equipment PPI machinery and equipment. (12.) Miscellaneous products 0.956 PPI finished goods less food and energy PPI finished goods. B. All other services 11.212 (1.) Telephone services 0.398 CPI-U telephone services CPI-U telephone services. (2.) Postage 0.857 CPI-U postage CPI-U postage. (3.) All other: labor intensive * 5.438 ECI—Compensation for private service occupations ECI—compensation for private service occupations. (4.) All other: non-labor intensive 4.519 CPI-U all items CPI-U all items. Total 100.000 * Labor related. a. Wages and Salaries For measuring the price growth of wages in the FY 1997-based market basket, we are proposing to use the ECI for civilian hospitals. This differs from the proxy used in the FY 1992-based index in which a blended occupational wage index was used. The blended occupational wage proxy used in the FY 1992-based index and the ECI for wages and salaries for hospitals both reflect a fixed distribution of occupations within the hospital. The major difference between the two proxies is in the treatment of professional and technical wages. In the blended occupational wage proxy, the professional and technical category is blended evenly between the ECI for wages and salaries for hospitals and the ECI for wages and salaries for professional and technical occupations in the overall economy, instead of hospital-specific occupations as reflected in the ECI for hospitals. This blend was done to create a normative price index that did not reflect the market imperfections in the hospital labor markets that existed for much of the 1980s and early 1990s. Between 1987 (the first year the ECI for hospitals was available, although the pattern existed before then using other measures of hospital wages) and 1994, the ECI for wages and salaries for hospital workers grew faster than the blended occupational wage proxy. This trend then reversed for the 1995 through 2000 period when the ECI grew slower than the blended occupational wage proxy each year. This is the apparent result of the shift of private insurance enrollees from fee-for-service plans to managed care plans and the tighter controls these plans exhibited over hospital utilization and incentives to shift care out of the inpatient hospital setting. More recently, the ECI for wages and salaries for hospital workers is again growing faster than the blended occupational wage proxy, raising the question of whether the relationship between hospital wages and the occupational wage blend from 1994 through 2000 was the signaling of a new era in the competitiveness of the hospital labor market, or simply the temporary reversal of the long-term pattern of labor market imperfections in hospitals. In order to answer this question, we researched the historical determinants of this relationship and estimated what the future market conditions are likely to be. Our analysis indicated that the driving force behind the long-term differential between hospital wages and the blended occupational wage proxy was the increased demand for hospital services and the subsequent increase in hospital utilization, particularly in outpatient settings. However, during the 1994-2000 period, the major force behind the reversal of the differential was the shift of enrollees to managed care plans that had tighter restrictions on hospital utilization and encouraged the shift of care out of the hospital setting. To a lesser extent, the robust economic growth and tight economy-wide labor markets that accompanied this period helped to reverse the differential as well. Over the last year or two, there has been a move back towards less restrictive plans, and a subsequent increase in the utilization of medical services. This recent surge appears to reflect the true underlying fundamentals of health care demand. This concept is reinforced by the similar patterns being observed for nursing homes and other health sectors as well. This is an important development, specifically when compared to the ECI for wages and salaries for nursing homes, which reflect less skilled occupations, yet still experienced a similar acceleration in wage growth. Thus, we would expect that this recent surge in hospital wages is reflective of competitive labor market conditions, and would likely persist only as long as the underlying demand for health care was accelerating. While the shift to managed care plans had a noticeable one-time effect, we do feel that the hospital labor market is more competitive than prior to this period and that the expected shift towards more restrictive insurance plans over the coming decade will act to create a wage differential that reflects the underlying increases in demand for hospital services. As shown in Table 5, using the ECI has only a minor overall impact (0.1 percentage point per year) from FY 1995 through FY 2001 on the hospital market basket. For FY 2003, the proposed hospital market basket is forecast to increase 0.2 percentage points faster (3.3 vs. 3.1) than it would have if the occupational blend had been used. Based on this, we are proposing to use the ECI for wages and salaries for hospitals and the ECI for benefits for hospitals as the proxies in the hospital market basket for wages and benefits, respectively. The ECI met our criteria of relevance, reliability, availability, and timeliness. Relevance means that the proxy is applicable and representative of the cost category that it proxies. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Availability means that the proxy is publicly available. Timeliness implies that the proxy is published regularly, at least once a quarter. b. Employee Benefits The proposed FY 1997-based hospital market basket uses the ECI for employee benefits for civilian hospitals. This differs from the FY 1992-based index in which a blended occupational index was used. Our conclusions were based on a similar analysis that was done for the wages and salaries proxy described above. c. Nonmedical Professional Fees The ECI for compensation for professional and technical workers in private industry is applied to this category since it includes occupations such as management and consulting, legal, accounting and engineering services. The same price measure was used in the FY 1992-based market basket. d. Fuel, Oil, and Gasoline The percentage change in the price of gas fuels as measured by the PPI (Commodity Code #0552) was applied to this component. The same price measure was used in the FY 1992-based market basket. e. Electricity The percentage change in the price of commercial electric power as measured by the PPI (Commodity Code #0542) was applied to this component. The same price measure was used in the FY 1992-based market basket. f. Water and Sewerage The percentage change in the price of water and sewerage maintenance as measured by the Consumer Price Index
(CPI)for all urban consumers (CPI Code # CUUR0000SEHG01) was applied to this component. The same price measure was used in the FY 1992-based market basket. g. Professional Liability Insurance The percentage change in the hospital professional liability insurance price as estimated by the CMS Hospital Malpractice Index was applied. In the FY 1992-based market basket, the same proxy was used. We are currently conducting research into improving our proxy for professional liability insurance. This research includes subcontracting with ANASYS through a contract with DRI-WEFA to extend the results of its NHMIS survey to set up a sample of hospitals from which malpractice insurance premium data will be directly collected. This new information, which would include liability estimates for hospitals that self-insure, would be combined with our current proxy data to obtain a more accurate price measure. Depending on the timing of this new information, the proxy for professional liability insurance in the market basket may be modified for the final rule. In addition, we are researching a BLS PPI for malpractice premiums that may be a more appropriate proxy for this cost category. h. Pharmaceuticals The percentage change in the price of prescription drugs as measured by the PPI (Commodity Code # PPI283D#RX) was applied to this variable. This is a special index produced by BLS. The previous price proxy used in the FY 1992-based index (Commodity Code #0635) was discontinued after BLS revised its indexes. i. Food, Direct Purchases The percentage change in the price of processed foods and foods as measured by the PPI (Commodity Code #02) was applied to this component. The same price measure was used in the FY 1992-based market basket. j. Food, Contract Services The percentage change in the price of food purchased away from home as measured by the CPI for all urban consumers (CPI Code # CUUR0000SEFV) was applied to this component. The same price measure was used in the FY 1992-based market basket. k. Chemicals The percentage change in the price of industrial chemical products as measured by the PPI (Commodity Code #061) was applied to this component. While the chemicals in this category include industrial as well as other types of chemicals, the industrial chemicals component constitutes the largest proportion by far. Thus, Commodity Code #061 is the appropriate proxy. The same price measure was used in the FY 1992-based market basket. l. Blood and Blood Products The percentage change in the price of blood and derivatives for human use as measured by the PPI (Commodity Code #063711) was applied to this component. As discussed earlier in this preamble, a comparable cost category was not available in the FY 1992-based market basket. We are proposing that the blood and blood products cost category use the PPI for blood and blood derivatives as its price proxy. This proxy is relevant, reliable, available, and timely. We considered placing the blood weight in the Chemicals or Pharmaceuticals cost category, but found this made only minor changes to the total index. We also considered constructing an index based on blood cost data received from the American Red Cross, America's Blood Centers, and Zeman and Company. However, these data are collected annually and not widely available. The PPI for blood and blood derivatives was the only index we found that met all of our criteria. m. Surgical and Medical Equipment The percentage change in the price of medical and surgical instruments as measured by the PPI (Commodity Code #1562) was applied to this component. The same price measure was used in the FY 1992-based market basket. n. Photographic Supplies The percentage change in the price of photographic supplies as measured by the PPI (Commodity Code #1542) was applied to this component. The same price measure was used in the FY 1992-based market basket. o. Rubber and Plastics The percentage change in the price of rubber and plastic products as measured by the PPI (Commodity Code #07) was applied to this component. The same price measure was used in the FY 1992-based market basket. p. Paper Products The percentage change in the price of converted paper and paperboard products as measured by the PPI (Commodity Code #0915) was used. The same price measure was used in the FY 1992-based market basket. q. Apparel The percentage change in the price of apparel as measured by the PPI (Commodity Code #381) was applied to this component. The same price measure was used in the FY 1992-based market basket. r. Machinery and Equipment The percentage change in the price of machinery and equipment as measured by the PPI (Commodity Code #11) was applied to this component. The same price measure was used in the FY 1992-based market basket. s. Miscellaneous Products The percentage change in the price of all finished goods less food and energy as measured by the PPI (Commodity Code #SOP3500) was applied to this component. The percentage change in the price of all finished goods was used in the FY 1992-based market basket. This change was made to remove the effect of food and energy prices, which are already captured elsewhere in the market basket. t. Telephone The percentage change in the price of telephone services as measured by the CPI for all urban consumers (CPI Code # CUUR0000SEED) was applied to this component. The same price measure was used in the FY 1992-based market basket. u. Postage The percentage change in the price of postage as measured by the CPI for all urban consumers (CPI Code # CUUR0000SEEC01) was applied to this component. The same price measure was used in the FY 1992-based market basket. v. All Other Services, Labor Intensive The percentage change in the ECI for compensation paid to service workers employed in private industry was applied to this component. The same price measure was used in the FY 1992-based market basket. w. All Other Services, Nonlabor Intensive The percentage change in the all-items component of the CPI for all urban consumers (CPI Code # CUUR0000SA0) was applied to this component. The same price measure was used in the FY 1992-based market basket. For further discussion of the rationale for choosing many of the specific price proxies, we reference the August 30, 1996 final rule (61 FR 46326). Table 4 shows the historical and forecasted updates under both the proposed FY 1997-based and the FY 1992-based market baskets. For comparison purposes, the FY 1997-based index incorporating different wage and benefit proxies is included in Table 5. Table 4.—FY 1992-Based and Proposed FY 1997-Based Prospective Payment Hospital Operating Index Percent Change, 1995-2004 Fiscal year
(FY)Prospective rebased 1997 hospital market basket FY 1992-based market basket Historical data: FY 1995 2.8 3.1 FY 1996 2.3 2.4 FY 1997 1.6 2.1 FY 1998 2.7 2.9 FY 1999 2.7 2.5 FY 2000 3.3 3.6 FY 2001 4.2 4.1 Average FYs 1995-2001 2.8 3.0 Forecast: FY 2002 3.7 2.8 FY 2003 3.3 3.0 FY 2004 2.9 3.2 Average FYs 2002-2004 3.3 3.0 Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. Table 5 indicates that switching the proxy for wages and benefits to the ECI for Civilian Hospitals has a minimal effect on the FY 2003 update and a minimal effect over time. However, we believe that it is a more appropriate measure of price change in hospital wages and benefit prices given the current labor market conditions facing hospitals. Table 5.—Proposed 1997-Based Prospective Payment Hospital Operating Index Percent Change, Using Different Wage and Benefit Proxies, 1995-2004 Fiscal year
(FY)Proposed rebased 1997 hospital market basket using ECIs for wages and benefits Proposed rebased 1997 market basket using occupational wage and benefit proxies Historical data: FY 1995 2.8 2.9 FY 1996 2.3 2.5 FY 1997 1.6 2.3 FY 1998 2.7 3.2 FY 1999 2.7 2.9 FY 2000 3.3 3.5 FY 2001 4.2 4.0 Average FYs 1995-2001 2.8 3.0 Forecast: FY 2002 3.7 3.0 FY 2003 3.3 3.1 FY 2004 2.9 3.1 Average FYs 2002-2004 3.3 3. Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. The reintroduction of a cost component for blood and blood products in the market basket also does not make a noticeable impact on the market basket. Table 6 shows the proposed FY 1997-based market basket percentage change with blood broken out separately compared to market baskets with blood included in either chemicals or drugs. Table 6.—Proposed 1997-Based Prospective Payment Hospital Operating Index Percent Change, Using Cost Categories for Blood and Blood Products, 1995-2004 Fiscal year
(FY)Proposed FY 1997-based market basket With blood as a separate category With blood included in chemicals With blood included in drugs Historical data: FY 1995 2.8 2.9 2.8 FY 1996 2.3 2.3 2.4 FY 1997 1.6 1.6 1.6 FY 1998 2.7 2.7 2.8 FY 1999 2.7 2.5 2.7 FY 2000 3.3 3.4 3.3 FY 2001 4.2 4.2 4.2 Average FYs 1995-2001 2.8 2.8 2.8 Forecast: FY 2002 3.7 3.6 3.7 FY 2003 3.3 3.3 3.3 FY 2004 2.9 3.0 3.0 Average FYs 2002-2004 3.3 3.3 3.3 Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. 4. Labor-Related Share Sections 1886(d)(2)(H) and (d)(3)(E) of the Act direct the Secretary to estimate from time to time the proportion of payments 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 * * *”. In its June 2001 Report to Congress, MedPAC recommended that “To ensure accurate input-price adjustments in Medicare's prospective payment systems, the Secretary should reevaluate current assumptions about the proportions of providers' costs that reflect resources purchased in local and national markets.” (Report to the Congress: Medicare in Rural America, p. 80, Recommendation 4D.) MedPAC believes that the labor-related share is an estimate of the national average proportion of providers' costs associated with inputs that are *only* affected by local market wage levels. MedPAC recommended the labor-related share include the weights for wages and salaries, fringe benefits, contract labor, and other labor-related costs for locally purchased inputs only. By changing the definition, and thereby lowering the labor-related share, funds would be transferred from urban to rural hospitals, which generally have wage index values less than 1.0. Given the recommendation by MedPAC and our proposal to rebase and revise the hospital market basket, we have reviewed the definition and methodology of the labor-related share. In addition, we reviewed the differences between urban and rural hospitals, updated regression results, and began reviewing possible alternative methodologies for calculating the labor-related share. The labor-related share is used to determine the proportion of the national prospective payment system base payment rate to which the area wage index is applied. In the past we have defined the labor-related share for prospective payment system acute care hospitals as the national average proportion of operating costs that are related to, influenced by, or vary with the local labor market. The labor-related share for the acute care hospital inpatient prospective payment system market basket has been the sum of the weights for wages and salaries, fringe benefits, professional fees, contract labor, postage, business services, and labor-intensive services. The difference between the CMS definition of the labor-related share and MedPAC's recommendation is that MedPAC includes inputs that can only be purchased in the local labor market, while CMS' includes inputs that are related to, influenced by, or vary with the local labor market, even if those services may be purchased at the national level. We believe our measure of the labor-related share reflects the cost of those inputs that are likely purchased in the local market, and is consistent with the requirements under sections 1886(d)(2)(H) and (d)(3)(E) of the Act described at the beginning of section IV.A.4. of this proposed rule. In connection with the rebasing and revising of the prospective payment system hospital market basket to 1997 data, we are proposing to recalculate the labor-related share of the standardized amounts. Our methodology is consistent with that used in the past to determine the labor-related share, which is the summation of the cost categories from the market basket deemed to vary with the local labor market. Based on the relative weights listed in Table 7, the proposed labor-related portion (wages and salaries, employee benefits, professional fees, and all other labor-intensive services) of the prospective payment system hospital market basket is 72.5 percent, and the nonlabor-related portion is 27.5 percent. By capturing more than just the direct labor costs that are available from the Medicare cost reports, our definition captures the “buy-versus-hire” decisions hospitals make in the purchase of their inputs. Accordingly, effective with discharges occurring on or after October 1, 2002, we are proposing to use these revised labor-related and nonlabor-related shares of the large urban and other areas' standardized amounts used to establish the prospective payment rates. Table 7 compares the FY 1992-based labor-related share with the proposed FY 1997-based labor-related share. As shown in Table 7, we have removed postage costs from the proposed FY 1997-based labor-related share because we do not believe these costs are likely to vary with the local labor market. Also, by changing the data source used to determine professional fees, the weight for that category has increased significantly. Table 7.—Labor-Related Share Cost category FY 1992-based weight Proposed 1997-based weight Difference Wages and salaries 50.244 50.686 0.442 Fringe benefits 11.146 10.970 −0.176 Nonmedical professional fees 2.127 5.401 3.274 Postal services* 0.272 −0.272 Other labor-intensive services** 7.277 5.438 −1.839 Total labor-related 71.066 72.495 1.429 Total nonlabor-related 28.934 27.505 −1.429 * No longer considered to be labor-related. ** Other labor-intensive services includes landscaping services, services to buildings, detective and protective services, repair services, insurance services, laundry services, auto parking and repairs, physical fitness facilities, other medical services, colleges and professional schools, and other government enterprises. We are concerned that the result of this methodology could have negative impacts that would fall predominantly on rural hospitals and are interested in public comments on alternative methodologies. While we are not proposing to change the methodology for calculating the labor-related share in this proposed rule, we have begun the research necessary to reevaluate the current assumptions used in determining this share. This reevaluation is consistent with the MedPAC recommendation in MedPAC's June 2001 report. 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 just a portion of professional fees and nonlabor intensive services should be considered labor-related. Although we have not completed our research into this issue, we are summarizing some of our preliminary findings below. We encourage comments on this research and any information that is available to help determine the most appropriate measure. The compensation share of costs for hospitals in rural areas was higher on average than the compensation share for hospitals in urban areas. Using FY 1997 Medicare cost report data, rural areas had an average compensation share of 62.7 percent, while urban areas had a share of 61.5 percent. This compares to a share of 61.7 percent for all hospitals. These findings were validated consistently through our regression analysis, described in more detail below, as the coefficient on the wage index was higher when the regressions were run only for rural hospitals compared to when the regressions were run only for urban hospitals. Based on these findings, it does not appear that using a national average labor share for all hospitals to adjust the national payment rate by the area wage index disadvantages rural hospitals that tend to have a wage index value below 1.0. Our research attempted to validate our national average labor share by conducting regression analysis to determine the proportion of hospital's costs that varied with the area wage index. We have conducted this type of regression analysis before in helping to determine the labor-related share, most recently for the SNF prospective payment system (66 FR 39585). Our first step was to edit the data, which had significant outliers in some of the variables we used in the regressions. We originally began with an edit that excluded the top and bottom 5 percent of reports based on average Medicare cost per discharge and number of discharges. We also used edits to exclude reports that did not meet basic criteria for use, such as having costs greater than 0 for total, operating, and capital for the overall facility and for only the Medicare proportion. We also required that the hospital occupancy rate, length of stay, number of beds, full-time equivalents (FTEs), and overall and Medicare discharges be greater than 0. Finally, we excluded reports with occupancy rates greater than 1. Our initial regression specification (in log form) was the Medicare operating cost per Medicare discharge as the dependent variable and the independent variables being the area wage index, the case mix index, the ratio of interns and residents per bed (as proxy for IME status), and a dummy for large urban hospitals. This regression produced a coefficient for all hospitals for the area wage index of 0.638 (which is equivalent to the labor share and can be interpreted as an elasticity because of the log specification) with an adjusted R-squared of 64.3. While on the surface this would appear to be a reasonable result, this same specification for urban hospitals had a coefficient of 0.532 (adjusted R-squared = 53.2) and a coefficient of 0.709 (adjusted R-squared = 36.4) for rural hospitals. This highlighted some apparent problems with the specification because the overall regression results appear to be masking underlying problems. It would not seem reasonable that urban hospitals would have a labor share below their actual compensation share or that the discrepancy between urban and rural hospitals would be this large. The other major problem with the regression was that the coefficient on the case-mix index was significantly below 1.0 for each specification. When we standardized the Medicare operating cost per Medicare discharge for case mix, the fit fell dramatically and the urban/rural discrepancy became even larger. Based on this initial result, we tried two modifications to the regressions to correct for the underlying problems. First, we edited the data differently to determine if a few reports were causing the inconsistent results. We found that when we tightened the edits, the wage index coefficient was lower and the fit was worse. When we loosened the edits, we found higher wage index coefficients and still a worse fit. Second, we added variables to the regression equation to attempt to explain some of the variation that was not being captured. We found the best fit occurred when the following variables were added: the occupancy rate, the number of hospital beds, a dummy for control status, the Medicare length of stay, the number of FTEs per bed, and the age of fixed assets. The result of this specification was a wage index coefficient of 0.620 (adjusted R-squared = 68.7), with the regression on rural hospitals having a coefficient of 0.772 (adjusted R-squared = 45.0) and the regression on urban hospitals having a coefficient of 0.474 (adjusted R-squared = 60.9). Neither of these alternatives seemed to help the underlying difficulties with the regression analysis. Because the market basket method determines the proportion of labor-related costs for the entire hospital, not just Medicare costs (due to the unavailability of Medicare specific data for such detailed cost categories) we also ran the regressions on overall hospital operating cost per discharge. The initial specification (only 4 independent variables) produced similar results to those discussed above, that is, what appeared to be a reasonable overall share but with major problems underlying the data. The more detailed specification also did not improve the results over the previous runs. Because of these problems, we did not believe the regression analysis was producing enough sound evidence at this point for us to make the decision to change from the current method for calculating the labor-related share using market basket categories. We plan to continue to analyze these data and work on alternative specifications, including working with MedPAC, which has done a similar analysis in its studies of payment adequacy in the past. We welcome comments on this approach, given the difficulties we have encountered. We also have been examining ways to refine our market basket approach to more accurately account for the proportion of costs influenced by the local labor market. Specifically, we have been looking at the professional fees and labor intensive cost categories to determine if only a proportion of the costs in these categories should be considered labor-related, not the entire cost category. Professional fees include management and consulting fees, legal services, accounting services, and engineering services. Labor-intensive services are mostly building services, but also include other maintenance and repair and insurance services. While we have identified some possible approaches for accomplishing this, we do not believe at this point that we have completely validated them and thus are not proposing to change from our current method. Below we briefly describe the possible approaches and some of the issues surrounding these approaches. One possible option would be to only include in the labor-related share the compensation portion of the cost category for each industry included in professional fees and labor-intensive services. This could be done using data from the 1997 BES, which reports detailed cost categories by industry
(SIC)code. For example, management and consulting fees (SIC 874) is one of the major pieces of professional fees. The BES indicates that compensation accounts for 59.2 percent of operating costs in management and consulting fees. If we only considered for inclusion in the labor-related share the portion that is compensation, this would result in a lower labor share. However, at this point, there does not appear to be enough information available from the BES to do this for every industry code. It is also not clear that at least some proportion of noncompensation costs of these inputs for hospitals would not vary with the local labor market. We are still researching the appropriateness of this option and whether it could be used to assist in determining the labor-related share. Another possible option would be to use data from the Bureau of the Census' 1992 Enterprise Statistics to attempt to determine the proportion of costs for professional fees and labor-intensive services associated with centrally located overhead. That is, could we identify the proportion of costs that are borne in a central location such that they would not be related to the local labor market? The Enterprise Statistics include payroll data for both auxiliary establishments of a multiestablishment company and the entire company. Since auxiliary establishments primarily manage, administer, service, and support the activities of other establishments of the company, we were considering using this information to estimate the proportion of professional fees and labor-intensive services associated with central locations instead of with the location of the hospital. The Enterprise Statistics data are available for specific enterprise industry codes
(EIC)that could seemingly be matched to the industry codes from the I-O used to determine professional fees and labor-intensive services. The methodology would consist of determining the auxiliary establishments payroll share of the total establishment, and subtracting that portion from the compensation portion of expenses for each I-O industry code. The initial research into this method is pointing out some difficulties in matching industry and EIC codes since the Enterprise Statistics do not contain as much detail as the I-O. In addition, it is not clear yet that this method would remove the appropriate amount of central office labor costs. We will continue to research this option, but at this time we are not proposing to use it in the calculation of the labor-related share. We plan to continue researching whether an alternative methodology for determining the labor-related share would be more appropriate than our current methodology, including working with MedPAC. We plan to complete this research prior to August 1 and would make the appropriate changes in the final rule if we found another methodology to be superior to our current methodology. At this time, we are proposing to continue to use our existing methodology in determining the labor-related share. 5. Separate Market Basket for Hospitals and Hospital Units Excluded From the Acute Care Hospital Inpatient Prospective Payment System In its March 1, 1990 report, ProPAC recommended that we establish a separate market basket for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system. Effective with FY 1991, we adopted ProPAC's recommendation to implement separate market baskets. (See the September 4, 1990 final rule (55 FR 36049).) Prospective payment system hospitals and excluded hospitals and units tend to have different case mixes, practice patterns, and composition of inputs. The fact that excluded hospitals are not included under the acute care hospital inpatient prospective payment system in part reflects these differences. Studies completed by CMS, ProPAC, and the hospital industry have documented different weights for excluded hospitals and units and prospective payment system hospitals. The excluded hospital market basket is a composite set of weights for Medicare-participating psychiatric hospitals and units, rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals. We are proposing to use cost report data for excluded freestanding hospitals whose Medicare average length of stay is within 15 percent (that is, 15 percent higher or lower) of the total facility average length of stay for excluded hospitals, except psychiatric hospitals. A tighter measure of Medicare length of stay within 8 percent (that is, 8 percent higher or lower) of the total facility average length of stay is proposed for freestanding psychiatric hospitals. This was done because psychiatric hospitals have a relatively small proportion of costs from Medicare and a relatively small share of Medicare psychiatric cases. While the 15 percent length of stay edit was used for the FY 1992-based index, the tighter, 8 percent edit for psychiatric hospitals was not. We believe that limiting our sample to hospitals with a Medicare average length of stay within a comparable range to the total facility average length of stay provides a more accurate reflection of the structure of costs for treating Medicare patients. Table 8 compares major weights in the proposed rebased FY 1997 market basket for excluded hospitals with weights in the proposed rebased FY 1997 market basket for acute care prospective payment system hospitals. Wages and salaries are 51.998 percent of total operating costs for excluded hospitals compared to 50.686 percent for acute care prospective payment hospitals. Employee benefits are 11.253 percent for excluded hospitals compared to 10.970 percent for acute care prospective payment hospitals. As a result, compensation costs (wages and salaries plus employee benefits) for excluded hospitals are 63.251 percent of costs compared to 61.656 percent for acute care prospective payment hospitals, reflecting the more labor-intensive services conducted in excluded hospitals. A significant difference in the category weights also occurs in pharmaceuticals. Pharmaceuticals represent 5.416 percent of costs for acute care prospective payment hospitals and 6.940 percent for excluded hospitals. The weights for the excluded hospital market basket were derived using the same data sources and methods as for the acute care prospective payment market basket as outlined previously. Differences in weights between the proposed excluded hospital and acute care prospective payment hospital market baskets do not necessarily lead to significant differences in the rate of price growth for the two market baskets. If individual wages and prices move at approximately the same annual rate, both market baskets may have about the same overall price growth, even though the weights may differ substantially, because both market baskets use the same wage and price proxies. Also, offsetting price increases for various cost components can result in similar composite price growth in both market baskets. Table 8.—Proposed FY 1997-Based Excluded Hospital and Prospective Payment Hospital Market Baskets, Comparison of Significant Weights Category Proposed rebased 1997 excluded hospital market basket Proposed rebased 1997 Prospective Payment System hospital market basket Wages and salaries 51.998 50.686 Employee benefits 11.253 10.970 Professional fees 4.859 5.401 Pharmaceuticals 6.940 5.416 All other 24.950 25.527 Total 100.000 100.000 Table 9 lists the cost categories, weights, and proxies for the proposed FY 1997-based excluded hospital market basket. For comparison, the FY 1992-based cost category weights are included. The proxies are the same used in the proposed FY 1997-based acute care hospital inpatient prospective payment system market basket discussed above. Table 9.—FY 1992-Based and Proposed FY 1997-Based Excluded Hospital Operating Cost Categories, Weights, and Price Proxies Expense categories Proposed rebased 1997 excluded hospital market basket weights FY 1992-based excluded hospital market basket weights FY 1997-based price proxy 1. Compensation 63.251 63.721 A. Wages and salaries* 51.998 52.152 ECI-wages and salaries, civilian hospitals. B. Employee benefits* 11.253 11.569 ECI-benefits, civilian hospitals. 2. Professional fees* 4.859 2.098 ECI-compensation for professional, specialty & technical. 3. Utilities 1.296 1.675 — A. Fuel, oil, and gasoline 0.272 0.401 PPI commercial natural gas. B. Electricity 0.798 1.007 PPI commercial electric power. C. Water and sewerage 0.226 0.267 CPI-U water and sewerage maintenance. 4. Professional liability insurance 0.805 1.081 CMS professional liability insurance premiums index. 5. All other 29.790 31.425 — A. All other products 19.680 24.227 —
(1)Pharmaceuticals 6.940 3.070 PPI ethical (prescription) drugs.
(2)Direct purchase food 1.233 2.370 PPI processed foods & feeds.
(3)Contract service food 1.146 1.098 CPI-U food away from home.
(4)Chemicals 2.343 3.754 PPI industrial chemicals.
(5)Blood and blood products 0.821 N/A PPI blood and blood derivatives, human use.
(6)Medical instruments 1.972 3.154 PPI medical instruments & equipment.
(7)Photographic supplies 0.184 0.400 PPI photographic supplies.
(8)Rubber and plastics 1.501 4.865 PPI rubber & plastic products.
(9)Paper products 1.219 2.182 PPI converted paper & paperboard products.
(10)Apparel 0.525 0.890 PPI apparel.
(11)Machinery and equipment 0.936 0.212 PPI machinery & equipment.
(12)Miscellaneous products 0.860 2.232 PPI finished goods less food and energy. B. All other services 10.110 7.198 —
(1)Telephone services 0.382 0.631 CPI-U telephone services.
(2)Postage 0.771 0.295 CPI-U postage.
(3)All other: labor intensive* 4.892 5.439 ECI-compensation for private service occupations.
(4)All other: Non-labor intensive 4.065 0.833 CPI-U all items. Total 100.000 100.000 — *Labor-related. Note: Due to rounding, weights may not sum to total. Table 10 shows the historical and forecasted updates under both the proposed FY 1997-based and the FY 1992-based excluded hospital market baskets. Table 10.—FY 1992-Based and Proposed FY 1997-Based Excluded Hospital Operating Index Percent Change, 1995-2004 Fiscal year
(FY)Proposed rebased 1997 excluded hospital market basket FY 1992-based excluded hospital market basket Historical data: FY 1995 2.7 3.2 FY 1996 2.4 2.5 FY 1997 1.7 2.0 FY 1998 3.0 2.7 FY 1999 2.9 2.4 FY 2000 3.3 3.6 FY 2001 4.3 4.1 Average FYs 1995-2001 2.9 2.9 Forecast: FY 2002 3.7 2.8 FY 2003 3.4 3.0 FY 2004 3.0 3.1 Average FYs 2002-2004 3.4 3.0 Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. A comparison of the proposed FY 1997-based index incorporating the new wage and benefits proxies
(ECIs)and updated occupational wage proxies is included in Table 11. Table 11.—Proposed FY 1997-Based Excluded Hospital Operating Index Percent Change, Using Different Wage and Benefit Proxies, 1995-2004 Fiscal year
(FY)Proposed rebased 1997 excluded hospital market basket Using ECIs for hospital wages and nenefits Using occupational wage and benefit proxies Historical data: FY 1995 2.7 2.9 FY 1996 2.4 2.5 FY 1997 1.7 2.3 FY 1998 3.0 3.4 FY 1999 2.9 3.1 FY 2000 3.3 3.5 FY 2001 4.3 4.0 Average FYs 1995-2001 2.9 3.1 Forecast: FY 2002 3.7 3.1 FY 2003 3.4 3.2 FY 2004 3.0 3.2 Average FYs 2002-2004 3.4 3.2 Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. Like the proposed FY 1997-based prospective payment hospital index showed, there is little difference in the index over time when different compensation proxies are used. Table 12 shows the labor-related share for excluded hospitals. Table 12.—Labor-Related Share, Excluded Hospitals Cost category FY 1992-based weight Proposed FY 1997-based weight Difference Wages and salaries 52.152 51.998 −0.154 Fringe benefits 11.569 11.253 −0.316 Nonmedical professional fees 2.098 4.859 2.761 Postal services* 0.295 −0.295 Other labor intensive services** 5.439 4.892 −0.547 Total labor-related 71.553 73.002 1.449 Total nonlabor-related 28.447 26.998 −1.449 * No longer considered to be labor-related. ** Other labor-intensive services includes landscaping services, services to buildings, detective and protective services, repair services, insurance services, laundry services, auto parking and repairs, physical fitness facilities, other medical services, colleges and professional schools, and other government enterprises. B. Capital Input Price Index The Capital Input Price Index
(CIPI)was originally detailed in the September 1, 1992 **Federal Register** (57 FR 40016). There have been subsequent discussions of the CIPI presented in the May 26, 1993 (58 FR 30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), September 1, 1995 (60 FR 45815), May 31, 1996 (61 FR 27466), and August 30, 1996 (61 FR 46196) rules in the **Federal Register** . The August 30, 1996 rule discussed the most recent revision and rebasing of the CIPI to a FY 1992 base year, which reflects the capital cost structure facing hospitals in that year. We are proposing to revise and rebase the CIPI to a FY 1997 base year to reflect the more recent structure of capital costs. To do this, we reviewed hospital expenditure data for the capital cost categories of depreciation, interest, and other capital expenses. As with the FY 1992-based index, we have developed two sets of proposed weights in order to calculate the proposed FY 1997-based CIPI. The first set of proposed weights identifies the proportion of hospital capital expenditures attributable to each capital expenditure category, while the second set of proposed weights is a set of relative vintage weights for depreciation and interest. The set of vintage weights is used to identify the proportion of capital expenditures within a cost category that is attributable to each year over the useful life of capital assets in that category. A more thorough discussion of vintage weights is provided later in this section. Both sets of weights are developed using the best data sources available. In reviewing source data, we determined that the Medicare cost reports provided accurate data for all capital expenditure cost categories. We are proposing to use the FY 1997 Medicare cost reports for acute care prospective payment system hospitals, excluding expenses from hospital-based subproviders, to determine weights for all three cost categories: Depreciation, interest, and other capital expenses. We compared the weights determined from the Medicare cost reports to other data sources for 1997, specifically the Bureau of the Census' BES and the AHA Annual Survey, and found the weights to be consistent with those data sources. Lease expenses are not a separate cost category in the CIPI, but are distributed among the cost categories of depreciation, interest, and other, reflecting the assumption that the underlying cost structure of leases is similar to capital costs in general. We assumed 10 percent of lease expenses are overhead and assigned them to the other capital expenses cost category as overhead, as was done in previous capital market baskets. The remaining lease expenses were distributed to the three cost categories based on the weights of depreciation, interest, and other capital expenses not including lease expenses. Depreciation contains two subcategories: Building and fixed equipment and movable equipment. The split between building and fixed equipment and movable equipment was determined using the Medicare cost reports. This methodology was also used to compute the FY 1992-based index. Table 13 presents a comparison of the proposed rebased FY 1997 capital cost weights and the FY 1992 capital cost weights. Table 13.—Comparison of FY 1992 and Proposed Rebased FY 1997 Cost Category Weights Expense categories FY 1992 weights Proposed rebased FY 1997 weights Price proxy Total 1.0000 1.0000 Total depreciation 0.6484 0.7135 Building and fixed equipment depreciation 0.3009 0.3422 Boeckh Institutional Construction Index—vintage weighted (23 years). Movable equipment depreciation 0.3475 0.3713 PPI for machinery and equipment—vintage weighted (11 years). Total interest 0.3184 0.2346 Government/nonprofit interest 0.2706 0.1994 Average yield on domestic municipal bonds (Bond Buyer 20 bonds)—vintage weighted (23 years). For-profit interest 0.0478 0.0352 Average yield on Moody's Aaa bonds—vintage weighted (23 years). Other 0.0332 0.0519 CPI—Residential Rent. Because capital is acquired and paid for over time, capital expenses in any given year are determined by past and present purchases of physical and financial capital. The vintage-weighted CIPI is intended to capture the long-term consumption of capital, using vintage weights for depreciation (physical capital) and interest (financial capital). These vintage weights reflect the purchase patterns of building and fixed equipment and movable equipment over time. Because depreciation and interest expenses are determined by the amount of past and current capital purchases, we used the vintage weights to compute vintage-weighted price changes associated with depreciation and interest expense. Vintage weights are an integral part of the CIPI. Capital costs are inherently complicated and are determined by complex capital purchasing decisions over time, based on such factors as interest rates and debt financing. Capital is depreciated over time instead of being consumed in the same period it is purchased. The CIPI accurately reflects the annual price changes associated with capital costs, and is a useful simplification of the actual capital accumulation process. By accounting for the vintage nature of capital, we are able to provide an accurate, stable annual measure of price changes. Annual nonvintage price changes for capital are unstable due to the volatility of interest rate changes. These unstable annual price changes do not reflect the actual annual price changes for Medicare capital-related costs. CMS's CIPI reflects the underlying stability of the capital acquisition process and provides hospitals with the ability to plan for changes in capital payments. To calculate the vintage weights for depreciation and interest expenses, we used a time series of capital purchases for building and fixed equipment and movable equipment. We found no single source that provides the best time series of capital purchases by hospitals for all of the above components of capital purchases. The early Medicare cost reports did not have sufficient capital data to meet this need. While the AHA Panel Survey provided a consistent database back to 1963, it did not provide annual capital purchases. The AHA Panel Survey did provide time series of depreciation and interest expenses that could be used to infer capital purchases over time. Although the AHA Panel Survey was discontinued after September 1997, we were able to use all of the available historical data from this survey since our proposed base year is FY 1997. In order to estimate capital purchases from AHA data on depreciation and interest expenses, the expected life for each cost category (building and fixed equipment, movable equipment, debt instruments) is needed. The expected life is used in the calculation of vintage weights. We used FY 1997 Medicare cost reports to determine the expected life of building and fixed equipment and movable equipment. The expected life of any piece of equipment can be determined by dividing the value of the fixed asset (excluding fully depreciated assets) by its current year depreciation amount. This calculation yields the estimated useful life of an asset if depreciation were to continue at current year levels, assuming straight-line depreciation. From the FY 1997 cost reports, we determined the expected life of building and fixed equipment to be 23 years, and the expected life of movable equipment to be 11 years. By comparison, the FY 1992-based index showed that the expected life for building and fixed equipment was 22 years, while that for movable equipment was 10 years. Our analysis of data for FYs 1996, 1998, and 1999 indicates very little change in these measures over time. We used the fixed and movable weights derived from the FY 1997 Medicare cost reports to separate the AHA Panel Survey depreciation expenses into annual amounts of building and fixed equipment depreciation and movable equipment depreciation. By multiplying the annual depreciation amounts by the expected life calculations from the FY 1997 Medicare cost reports, we determined year-end asset costs for building and fixed equipment and movable equipment. We subtracted the previous year asset costs from the current year asset costs and estimated annual purchases of building and fixed equipment and movable equipment back to 1963. From this capital purchase time series, we were able to calculate the vintage weights for building and fixed equipment, movable equipment, and debt instruments. Each of these sets of vintage weights is explained in detail below. For building and fixed equipment vintage weights, we used the real annual capital purchase amounts for building and fixed equipment derived from the AHA Panel Survey. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of the effect of price inflation. This real annual purchase amount for building and fixed equipment was produced by deflating the nominal annual purchase amount by the building and fixed equipment price proxy, the Boeckh institutional construction index. Because building and fixed equipment has an expected life of 23 years, the vintage weights for building and fixed equipment are deemed to represent the average purchase pattern of building and fixed equipment over 23-year periods. Vintage weights for each 23-year period are calculated by dividing the real building and fixed capital purchase amount in any given year by the total amount of purchases in the 23-year period. This calculation is done for each year in the 23-year period, and for each of the twelve 23-year periods from 1963 to 1997. The average of the twelve 23-year periods is used to determine the 1997 average building and fixed equipment vintage weights. For movable equipment vintage weights, we used the real annual capital purchase amounts for movable equipment derived from the AHA Panel Survey. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of price inflation. This real annual purchase amount for movable equipment was calculated by deflating the nominal annual purchase amount by the movable equipment price proxy, the PPI for machinery and equipment. Because movable equipment has an expected life of 11 years, the vintage weights for movable equipment are deemed to represent the average purchase pattern of movable equipment over 11-year periods. Vintage weights for each 11-year period are calculated by dividing the real movable capital purchase amount for any given year by the total amount of purchases in the 11-year period. This calculation is done for each year in the 11-year period, and for each of the twenty-four 11-year periods from 1963 to 1997. The average of the twenty-four 11-year periods is used to determine the FY 1997 average movable equipment vintage weights. For interest vintage weights, we used the nominal annual capital purchase amounts for total equipment (building and fixed, and movable) derived from the AHA Panel Survey. Nominal annual purchase amounts were used to capture the value of the debt instrument. Because debt instruments have an expected life of 23 years, the vintage weights for interest are deemed to represent the average purchase pattern of total equipment over 23-year periods. Vintage weights for each 23-year period are calculated by dividing the nominal total capital purchase amount for any given year by the total amount of purchases in the 23-year period. This calculation is done for each year in the 23-year period and for each of the twelve 23-year periods from 1963 to 1997. The average of the twelve 23-year periods is used to determine the FY 1997 average interest vintage weights. The vintage weights for the FY 1992 CIPI and the proposed FY 1997 CIPI are presented in Table 14. Table 14.—Current and Proposed Vintage Weights for Capital-Related Price Proxies Year (from farthest to most recent) Building and fixed equipment FY 1992 22 years Proposed FY 1997 23 years Movable equipment FY 1992 10 years Proposed FY 1997 11 years Interest FY 1992 22 years Proposed FY 1992 23 years 1 0.019 0.018 0.069 0.063 0.007 0.007 2 0.020 0.021 0.075 0.068 0.008 0.009 3 0.023 0.023 0.083 0.074 0.010 0.011 4 0.026 0.025 0.091 0.080 0.012 0.012 5 0.028 0.026 0.097 0.085 0.014 0.014 6 0.030 0.028 0.103 0.091 0.016 0.016 7 0.031 0.030 0.109 0.096 0.018 0.019 8 0.032 0.032 0.115 0.101 0.021 0.022 9 0.036 0.035 0.124 0.108 0.024 0.026 10 0.039 0.039 0.133 0.114 0.029 0.030 11 0.043 0.042 0.119 0.035 0.035 12 0.047 0.044 0.041 0.039 13 0.050 0.047 0.047 0.045 14 0.052 0.049 0.052 0.049 15 0.055 0.051 0.059 0.053 16 0.059 0.053 0.067 0.059 17 0.062 0.057 0.074 0.065 18 0.065 0.060 0.081 0.072 19 0.067 0.062 0.088 0.077 20 0.069 0.063 0.093 0.081 21 0.072 0.065 0.099 0.085 22 0.073 0.064 0.103 0.087 23 0.065 0.090 Total 1.000 1.000 1.000 1.000 1.000 1.000 After the capital cost category weights were computed, it was necessary to select appropriate price proxies to reflect the rate of increase for each expenditure category. Our proposed price proxies for the FY 1997-based CIPI are the same as those for the FY 1992-based CIPI. We still believe these are the most appropriate proxies for hospital capital costs that meet our selection criteria of relevance, timeliness, availability, and reliability. We ran the proposed FY 1997-based index using the Moody's Aaa bonds average yield and using the Moody's Baa bonds average yield as proxy for the for-profit interest cost category. There was no difference in the two sets of index percent changes either historically or forecasted. The rationale for selecting the price proxies is explained more fully in the August 30, 1996 final rule (61 FR 46196). The proposed proxies are presented in Table 13. Global Insights, Inc., DRI-WEFA forecasts a 0.7 percent increase in the proposed rebased FY 1997 CIPI for FY 2003, as shown in Table 15. Table 15.—FY 1992 and Proposed FY 1997-Based Capital Input Price Index, Percent Change, 1995-2004 Federal fiscal year CIPI, FY 1992-based Proposed CIPI, FY 1997-based 1995 1.2 1.5 1996 1.0 1.3 1997 0.9 1.2 1998 0.7 0.9 1999 0.7 0.9 2000 0.9 1.1 2001 0.7 0.9 Average: FYs 1995-2001 0.9 1.1 Forecast: 2002 0.6 0.8 2003 0.5 0.7 2004 0.6 0.7 Average: FYs 2002-2004 0.6 0.7 Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND @CISSIM/TRENDLONG0202. This 0.7 percent increase is the result of a 1.3 percent increase in projected vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 2.7 percent increase in other capital expense prices, partially offset by a 2.2 percent decrease in vintage-weighted interest rates in FY 2003, as indicated in Table 16. Table 16.—CMS Proposed Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1985-2005 Fiscal year Total Total depreciation Depreciation, building and fixed equipment Depreciation, movable equipment Interest Other Wgts FY 1997 1.000 0.7135 0.3422 0.3713 0.2346 0.0519 Vintage-Weighted Price Changes 1995 1.5 2.7 4.0 1.6 −1.8 2.5 1996 1.3 2.5 3.8 1.4 −2.3 2.6 1997 1.2 2.3 3.6 1.2 −2.4 2.8 1998 0.9 2.1 3.3 0.9 −3.0 3.2 1999 0.9 1.9 3.2 0.7 −2.8 3.2 2000 1.1 1.7 3.1 0.4 −1.6 3.4 2001 0.9 1.5 2.9 0.1 −2.2 4.3 Forecast: 2002 0.8 1.4 2.8 0.0 −2.2 4.0 2003 0.7 1.3 2.7 −0.1 −2.2 2.7 2004 0.7 1.3 2.5 −0.1 −2.1 2.8 2005 0.7 1.3 2.5 −0.1 −2.0 2.8 Rebasing the CIPI from FY 1992 to FY 1997 increased the percent change in the FY 2003 forecast by 0.2 percentage points, from 0.5 to 0.7 as shown in Table 15. The difference is caused mostly by changes in cost category weights, particularly the smaller weight for interest and larger weight for depreciation. Because the interest component has a negative price change associated with it for FY 2003, the smaller share it accounts for in the FY 1997-based index means it has less of an impact than in the FY 1992-based index. The changes in the expected life and vintage weights have only a minor impact on the overall percent change in the index. V. Other Decisions and Proposed Changes to the Prospective Payment System for Inpatient Operating Costs and Graduate Medical Education Costs A. Transfer Payment Policy 1. Expanding the Postacute Care Transfer Policy to Additional DRGs (§ 412.4) Existing regulations at § 412.4(a) define discharges under the acute care hospital inpatient prospective payment system 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, and § 412.4(c) defines transfers to certain postacute care providers. Our policy provides that, in transfer situations, full payment is made to the final discharging hospital and each transferring hospital is paid a per diem rate for each day of the stay, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred. Under section 1886(d)(5)(J) of the Act, which was added by section 4407 of Public Law 105-33, a “qualified discharge” from one of 10 DRGs selected by the Secretary to a postacute care provider is treated as a transfer case beginning with discharges on or after October 1, 1998. This section requires the Secretary to define and pay as transfers all cases assigned to one of 10 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 skilled nursing facility (as defined at section 1819(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 July 31, 1998 final rule (63 FR 40975 through 40976), we specified the appropriate time period during which we would consider postacute home health services to constitute a transfer situation as within 3 days after the date of discharge. Also, in the July 31, 1998 final rule, we did not include in the definition of postacute transfer cases patients transferred to a swing-bed for skilled nursing care (63 FR 40977). The Conference Agreement that accompanied Public Law 105-33 noted that “(t)he Conferees are concerned that Medicare may in some cases be overpaying hospitals for patients who are transferred to a postacute care setting after a very short acute care hospital stay. The conferees believe that Medicare's payment system should continue to provide hospitals with strong incentives to treat patients in the most effective and efficient manner, while at the same time, adjust PPS [prospective payment system] payments in a manner that accounts for reduced hospital lengths of stay because of a discharge to another setting.” (H.R. Report No. 105-217, 105th Cong., 1st Sess., 740 (1997).) In the July 31, 1998 final rule (63 FR 40975), we implemented section 1886(d)(5)(J) of the Act, which directed the Secretary to select 10 DRGs based upon a high volume of discharges to postacute care and a disproportionate use of postacute care services. As discussed in the July 31, 1998 final rule, these 10 DRGs were selected in 1998 based on the MedPAR data from FY 1996. Using that information, we identified and selected the first 20 DRGs that had the largest proportion of discharges to postacute care (and at least 14,000 such transfer cases). In order to select 10 DRGs from the 20 DRGs on our list, we considered the volume and percentage of discharges to postacute care that occurred before the mean length of stay and whether the discharges occurring early in the stay were more likely to receive postacute care. We identified the following DRGs to be subject to the special 10 DRG transfer rule: • DRG 14 (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 Age >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 Except for Face, Mouth and Neck Diagnoses). Similar to our existing policy for transfers between two acute care hospitals, the transferring hospital in a postacute transfer for 7 of the 10 DRGs receives twice the per diem rate the first day and the per diem rate for each following day of the stay prior to the transfer, up to the full DRG payment. However, 3 of the 10 DRGs exhibit a disproportionate share of costs very early in the hospital stay in postacute transfer situations. For these 3 DRGs, hospitals receive 50 percent of the full DRG payment for the first day of the stay and 50 percent of the per diem for the remaining days of the stay, up to the full DRG payment. This is consistent with section 1886(d)(5)(J)(i) of the Act, which recognizes that in some cases “a substantial portion of the costs of care are incurred in the early days of the inpatient stay.” The statute provides that, after FY 2000, the Secretary is authorized to expand this policy to additional DRGs. In July 1999, the previous Administration committed to not expanding the number of DRGs included in the policy until FY 2003. Therefore, CMS did not propose any change to the postacute care settings or the 10 DRGs in FY 2001 or FY 2002. Under contract with CMS (Contract No. 500-95-0006), Health Economics Research, Inc.
(HER)conducted an analysis of the impact on hospitals and hospital payments of the postacute care transfer provision. We included in the August 1, 2000 final rule (65 FR 47079) a summary of that analysis. Among other issues, the analysis sought to evaluate the reasonableness of expanding the transfer payment policy beyond the current 10 selected DRGs. The analysis supported the initial 10 DRGs selected as being consistent with the nature of the Congressional mandate. According to HER, “[t]he top 10 DRGs chosen initially by HCFA exhibit very large PAC [postacute care] levels and PAC discharge rates (except for DRG 264, Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC, which was paired with DRG 263). All 10 appear to be excellent choices based on the other criteria as well. Most have fairly high short-stay PAC rates (except possibly for Strokes, DRG 14, and Mental Retardation, DRG 429).” The HER report discussed the issues related to potentially expanding the postacute care transfer policy to all DRGs. In favor of this expansion, HER pointed to the following benefits: • A simple, uniform, formula-driven policy; • The same policy rationale exists for all DRGs; • DRGs with little utilization of short-stay postacute care would not be harmed by the policy; • Less confusion in discharge destination coding; and • Hospitals that happen to be disproportionately treating the current 10 DRGs may be harmed more than hospitals with an aggressive, short-stay, postacute care transfer policy for other DRGs. The complete HER report may be obtained at: *http://www.cms.gov/medicare/ippsmain.htm.* Consistent with HER's findings, we believe expanding the postacute care transfer policy to all DRGs may be the most equitable approach at this time, since a policy that is limited to certain DRGs may result in disparate payment treatment across hospitals, depending on the types of cases treated. We are considering implementing this expansion of the postacute transfer policy in the final rule. For example, a hospital specializing in some of the types of cases included in the current 10 DRG transfer policy would receive reduced payments for those cases transferred for postacute care after a brief acute inpatient stay, while a hospital specializing in cases not included in the current 10 DRGs may be just as aggressive in transferring its patients for postacute care, but it would receive full payment for those cases. Another aspect of the issue is that some hospitals have fewer postacute care options available for their patients. In its June 2001 Report to Congress: Medicare in Rural America, MedPAC wrote: “[a] shortage of ambulatory and post-acute care resources may prevent rural hospitals from discharging patients as early in the episode of care as urban hospitals would” (page 68). MedPAC went on to note that the decline in length of stay for urban hospitals since 1989 was greater for urban hospitals than for rural hospitals (34 percent compared with 25 percent through 1999), presumably due to earlier discharges to postacute care settings. Although MedPAC contemplated returning money saved by expanding the policy to the base payment rate, thereby increasing payments for nontransfer cases, currently section 1886(d)(5)(I)(ii) of the Act provides that any expansion to the postacute transfer policy would not be budget neutral. (Budget neutrality refers to adjusting the base payment rates to ensure total aggregate payments are the same after implementing a policy change as they were prior to the change.) Nevertheless, over the long run, reducing the Medicare Trust Fund expenditures for patients who are transferred to a postacute care setting after a very short acute care hospital stay will improve the program's overall financial stability. Our analysis indicates that expanding the postacute care transfer policy to all DRGs would reduce program payments for these cases by approximately $1.9 billion for FY 2002. If we were to expand the transfer policy to all DRGs, we would expand the list of those DRGs where a disproportionate share of the costs of the entire stay occurs early in the stay. We conducted analysis to identify those DRGs that would be eligible for the special transfer payment methodology specified in § 412.4(f)(2). As stated above, currently, three DRGs (DRGs 209, 210, and 211) are paid under a special transfer payment calculation whereby they receive 50 percent of the full DRG payment amount on the first day of the stay for cases transferred to a postacute care provider. We identified cases that were transferred to home health care, SNFs, or long-term care, matching records by beneficiary identification numbers and discharge and admission dates. We standardized charges to account for differences in area wage levels, indirect medical education costs, and disproportionate share payments, and we reduced charges to costs using the available cost-to-charge ratios. We then grouped the costs by DRG and length of stay. The average costs for transfer cases with a length of stay of 1 day were compared to the costs of transfer cases whose length of stay approximated the geometric mean length of stay for that particular DRG. The average costs for the transfer cases with a length of stay of 1 day were also compared to costs for all cases with a length of stay approximating the geometric mean length of stay across the DRG. Based on this analysis, we identified the following DRGs that, if the postacute care transfer policy were to be expanded, would qualify for the special postacute care transfer payment policy of 50 percent of the full DRG payment for the first day of the stay: • DRG 7 (Peripheral and Cranial Nerve and Other Nervous System Procedures with CC); • DRG 159 (Hernia Procedures Except Inguinal and Femoral Age >17 with CC); • DRG 218 (Lower Extremity and Humerus Procedure Except Hip, Foot, Femur Age >17 with CC); • DRG 226 (Soft Tissue Procedures with CC); • 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 306 (Prostatectomy with CC); • DRG 308 (Minor Bladder Procedures with CC); • DRG 315 (Other Kidney and Urinary Tract O.R. Procedures); • DRG 493 (Laparoscopic Cholecystectomy without C.D.E. with CC); and • DRG 497 (Spinal Fusion Except Cervical with CC). This list contains DRGs not currently paid under the special formula (DRGs 209, 210, and 211 will continue to receive the special payment). All of the DRGs in the list meet the following criteria: The average costs of transfer cases on the first day equals the average costs of cases staying the geometric mean length of stay; the geometric mean length of stay is 4 days or greater; and there were at least 50 transfer cases occurring on the first day of the stay. We also note that DRGs 263 and 264 (which are included in the current list of 10 DRGs subject to the postacute care transfer policy) would qualify for special payment, even though both DRGs have not previously received payment under the special payment provision. However, DRG 264 does qualify under the criteria described above for identifying cases for the potential expanded postacute care transfer policy. Because DRGs 263 and 264 are paired DRGs (that is, the only difference in the cases assigned to DRG 263 as opposed to DRG 264 is that the patient has a complicating or comorbid condition), we would include both DRGs under this expanded policy. If we were to include only DRG 264, there would be an incentive not to include a code identifying a complicating or comorbid condition, so that a transfer case would be assigned to DRG 264 instead of DRG 263 due to the higher per diem payment for DRG 264. Rather than expand the postacute care transfer policy to all DRGs, another option that we are considering for the final rule is expanding the postacute care transfer policy only to additional DRGs that have high rates of transfers, similar to the initial implementation of only 10 DRGs. For example, an incremental expansion would be to add another 10 DRGs to the policy. Using the same criteria to identify DRGs with high postacute care transfer rates, we identified additional DRGs to include in the postacute care transfer policy. We note that three of the DRGs we identified are paired DRGs (that is, they contain a CC/no-CC split). For the same reason given above for treating paired DRGS consistently, we would include the pairs for the 10 DRGs identified. We estimate the impact of this approach would be to reduce payments to hospitals by approximately $916 million for FY 2002. Under this approach, discharges from the following 13 DRGs (in addition to the 10 DRGs already subject to the postacute care transfer policy) could be considered to be subject to an alternative postacute care transfer policy: • DRG 12 (Degenerative Nervous System Disorders); • DRG 79 (Respiratory Infections and Inflammations Age >17 with CC); • DRG 80 (Respiratory Infections and Inflammations Age >17 without CC); • DRG 107 (Coronary Bypass with Cardiac Catheterization); • DRG 109 (Coronary Bypass with PTCA or Cardiac Catheterization); • DRG 148 (Major Small and Large Bowel Procedures with CC); • DRG 149 (Major Small and Large Bowel Procedures without CC); • DRG 239 (Pathological Fractures and Musculoskeletal System and Connective Tissue Malignancy); • DRG 243 (Medical Back Problems); • DRG 320 (Kidney and Urinary Tract Diagnoses Age >17 with CC); • DRG 321 (Kidney and Urinary Tract Diagnoses Age >17 without CC); • DRG 415 (O.R. Procedure for Infections and Parasitic Diseases); and • DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis). Expanding the postacute care transfer policy in this limited manner, however, would retain many of the potential inequities of the current system. Although we are concerned about the potential for a large impact of implementing any expansion of the postacute care transfer payment policy, we believe that the current policy may create payment inequities across patients and across hospitals. By expanding the postacute transfer policy, we would expect to reduce or eliminate these possible inequities. Therefore, we are soliciting comments on the two options we have identified and discussed in this proposed rule. In the final rule, we could adopt one of the approaches discussed above, or some other approach based on comments received on this proposal for addressing this issue. If commenters submit comments on alternate approaches, we are asking them to also provide useful data relating to alternative DRGs to which the expansion should or should not apply and detailed supporting explanations. If we adopt either of the proposals discussed above or a variation based on comments submitted, we would follow procedures similar to those that are currently followed for treating cases identified as transfers in the DRG recalibration process. That is, as described in the discussion of DRG recalibration in section II.C. of this proposed rule, additional transfer cases would be counted as a fraction of a case based on the ratio of a hospital's transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. 2. Technical Correction When we revised our regulations on payments for discharges and transfers under § 412.4 in the July 31, 1998 final rule (63 FR 41003), we inadvertently did not exclude discharges from one hospital area or unit to another inpatient area or unit of the hospital that is paid under the acute care hospital inpatient prospective payment system (§ 412.4(b)(2)) from the types of cases paid under the general rule for transfer cases. We are proposing to correct the regulation text to reflect our policy (as reflected in prior preamble language) that transfers from one area or unit within a hospital to another are not paid as transfers (except as described under the special 10 DRG rule at § 412.4(c)). We are proposing to correct this error by revising § 412.4(f)(1) to provide that only the circumstances described in paragraph (b)(1) and
(c)of § 412.4 are paid as transfers under the general transfer rule. This proposed correction would reflect the fact that transfers under § 412.4(b)(2) are to be paid as discharges and not transfers. B. Sole Community Hospitals
(SCHs)(§§ 412.77 and 412.92) 1. Phase-In of FY 1996 Hospital-Specific Rates Under the acute care hospital inpatient prospective payment system, 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 § 412.92. To be classified as an SCH, a hospital either must have been designated as an SCH prior to the beginning of the hospital inpatient prospective payment system on October 1, 1983, or must be located more than 35 miles from other like hospitals, or the hospital must be located in a rural area and meet one of the following requirements: • It is located between 25 and 35 miles from other like hospitals, and it— —Serves at least 75 percent of all inpatients, or at least 75 percent of Medicare beneficiary inpatients, within a 35-mile radius or, if larger, within its service area; or —Has fewer than 50 beds and would qualify on the basis of serving at least 75 percent of its area's inpatients except that some patients seek specialized care unavailable at the hospital. • It is located between 15 and 35 miles from other like hospitals, and because of local topography or extreme weather conditions, the other like hospitals are inaccessible for at least 30 days in each of 2 out of 3 years. • The travel time between the hospital and the nearest like hospital is at least 45 minutes because of distance, posted speed limits, and predictable weather conditions. Effective with hospital cost reporting periods beginning on or after April 1, 1990, section 1886(d)(5)(D)(i) of the Act, as amended by section 6003(e) of Public Law 101-239, provides 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; or • The updated hospital-specific rate based on FY 1987 costs per discharge. Section 405 of Public Law 106-113 added section 1886(b)(3)(I) to the Act, and section 213 of Public Law 106-554 made further amendments to that section of the Act extending to all SCHs the ability to rebase their hospital-specific rates using their FY 1996 operating costs, effective for cost reporting periods beginning on or after October 1, 2000. The provisions of section 1886(b)(3)(I) of the Act were addressed in the June 13, 2001 interim final rule with comment period (66 FR 32177) and were finalized in the August 1, 2001 final rule (66 FR 39872). In the June 13, 2001 interim final rule, we correctly described the provisions of section 1886(b)(3)(I) of the Act, as amended, and their implementation. However, in the August 1, 2001 final rule, in summarizing the numerous legislative provisions that had affected payments to SCHs, we incorrectly described the application of the statutory provisions in the background section of the preamble on SCHs (66 FR 39872). (We wish to point out that the Addendum to the August 1, 2001 final rule accurately describes the calculation of the hospital-specific rate (66 FR 39944).) Specifically, the payment options that we described in the August 1, 2001 preamble language on SCHs were incorrect in that we did not include the Federal rate in the blends. Therefore, we are providing below a correct description of the provisions of section 1886(b)(3)(I) of the Act and clarifying their application in determining which of the payment options will yield the highest rate of payment for SCHs. For purposes of payment to SCHs for which the FY 1996 hospital-specific rate yields the greatest aggregate payment, the Federal rate is included in the blend, as set forth below: • For discharges during FY 2001, 75 percent of the greater of the Federal amount or the updated FY 1982 or FY 1987 hospital-specific rates (identified in the statute as the subsection (d)(5)(D)(i) amount), plus 25 percent of the updated FY 1996 hospital-specific rate (identified in the statute as the “rebased target amount”). • For discharges during FY 2002, 50 percent of the greater of the Federal amount or the updated FY 1982 or FY 1987 hospital-specific rates, plus 50 percent of the updated FY 1996 hospital-specific rate. • For discharges during FY 2003, 25 percent of the greater of the Federal amount or the updated FY 1982 or FY 1987 hospital-specific rates, plus 75 percent of the updated FY 1996 hospital-specific rate. • For discharges during FY 2004 and subsequent fiscal years, the hospital-specific rate would be determined based on 100 percent of the updated FY 1996 hospital-specific rate. For each cost reporting period, the fiscal intermediary determines which of the payment options will yield the highest rate of payment. Payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary makes the determination. However, it may not be possible for the fiscal intermediary to determine in advance precisely which of the rates will yield the highest payment by year's end. In many instances, it is not possible to forecast the outlier payments, the amount of the disproportionate share hospital
(DSH)adjustment, or the indirect medical education
(IME)adjustment, all of which are applicable only to payments based on the Federal rate. The fiscal intermediary makes a final adjustment at the close of the cost reporting period to determine precisely which of the payment rates would yield the highest payment to the hospital. If a hospital disagrees with the fiscal intermediary's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's decision in accordance with the procedures set forth in Subpart R of Part 405, which concern provider payment determinations and appeals. The regulation text of § 412.77 and § 412.92(d) that was revised to incorporate the provisions of section 1886(b)(3)(I) of the Act, as amended, and published in the June 13, 2001 interim final rule with comment period (66 FR 32192 through 32193) and finalized in the August 1, 2001 final rule (66 FR 39932), is accurate. 2. SCH Like Hospitals Section 1886(d)(5)(D)(iii) of the Act provides that, to qualify as a SCH, a hospital must be not more than 35 road miles from another hospital. There are several other conditions under which a hospital may qualify as a SCH, including if it is the “* * * sole source of inpatient hospital services reasonably available to individuals in a geographic area * * *” because of factors such as the “* * * absence of other like hospitals * * *” We have defined a “like hospital” in regulations as a hospital furnishing short-term, acute care (§ 412.92(c)(2)). Like hospitals refers to hospitals paid under the acute care hospital inpatient prospective payment system. We have become aware that, in some cases, new specialty hospitals that offer a very limited range of services have opened within the service area of a SCH and may be threatening the special status of the SCH. For example, a hospital that offers only a select type of surgery on an inpatient basis would qualify under our existing rules as an SCH “like hospital” if it met the hospital conditions of participation and was otherwise eligible for payment under the acute care hospital inpatient prospective payment system. Under our existing regulations, a SCH could lose its special status due to the opening of such a specialty hospital, even though there is little, if any, overlap in the types of services offered by the SCH and the specialty hospital. We believe that limiting eligibility for SCH status to hospitals without SCH like hospitals in their service area is a way to identify those hospitals that truly are the sole source of short-term acute-care inpatient services in the community. A limited-service, specialty hospital, by definition, would not offer an alternate source of care in the community for most inpatient services and therefore, we believe, should not be considered a “like” hospital with the effect of negating SCH status of a hospital that is the sole source of short-term acute care inpatient services in the community. Therefore, we are proposing to amend the definition of SCH like hospitals under § 412.92(c)(2), effective with cost reporting periods beginning on or after October 1, 2002, to exclude any hospital that provides no more than a very small percent of the services furnished by the limited-service facility that overlap with the services provided by the SCH. We believe the percentage of overlapping services should be sufficiently small so that we can ensure that only hospitals that truly are the sole source of short-term acute-care in their community qualify for SCH status. Therefore, we are proposing that this percentage be set at 3 percent. However, we are soliciting public comments on alternate appropriate levels of service overlap, as well as on the overall proposed change to the definition of like hospitals. C. Outlier Payments: Technical Change (§ 412.80) Sections 1886(d)(5)(A) and (d)(5)(K) of the Act provide for payments, in addition to the basic prospective payments, for “outlier” cases; that is, cases involving extraordinarily high costs. Cases qualify for outlier payments by demonstrating costs that exceed a fixed loss cost outlier threshold equal to the prospective payment rate for the DRG plus any IME (§ 412.105) and DSH (§ 412.106) payments for the case and, for discharges on or after October 1, 2001, additional payments for new technologies or services. Implementing regulations for outlier payments are located in subpart F of part 412. Paragraph
(a)of § 412.80 specifies the basic rules for making the additional outlier payments, broken down into three applicable effective periods. We have become aware that in paragraph (a)(2), which relates to outlier payments for discharges occurring on or after October 1, 1997, and before October 1, 2001, we did not include language to specify that the additional costs of outlier cases must exceed the standard DRG payment and any additional payment the hospital would receive for IME and for DSH, plus a fixed loss dollar threshold. Therefore, we are proposing to make a technical change by revising § 412.80(a)(2), applicable for discharges occurring during the period between October 1, 1997 and October 1, 2001, to include the appropriate language regarding additional payments for IME and payments for DSH. (We note that when we amended § 412.80 to incorporate the provisions on the additional payments for new technology under paragraph (a)(3) (66 FR 46924, September 7, 2001), effective October 1, 2001, we did include this language.) D. Rural Referral Centers (§ 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 prospective payment system as a rural referral center. For discharges occurring before October 1, 1994, rural referral centers received the benefit of payment based on the other urban amount rather than the rural standardized amount. Although the other urban and rural standardized amounts were the same for discharges beginning with that date, rural referral centers continue to receive special treatment under both the DSH payment adjustment and the criteria for geographic reclassification. Section 1886(d)(8)(E) of the Act, as amended, creates a mechanism, separate and apart from the MGCRB, permitting an urban hospital to apply to the Secretary to be treated as being located in the rural area of the State in which the hospital is located. The statute directs the Secretary to treat a qualifying hospital as being located in the rural area for purposes of provisions under section 1886(d) of the Act. One of the criteria under section 1886(d)(8)(E) of the Act is that the hospital would qualify as an SCH or a rural referral center if it were located in a rural area. An SCH would be eligible to be paid on the basis of the higher of its hospital-specific rate or the Federal rate. On the other hand, a primary benefit under section 1886(d) of the Act for an urban hospital to become a rural referral center would be waiver of the proximity requirements that are otherwise applicable under the MGCRB process, as set forth in § 412.230(a)(3)(i). Although hospitals that are reclassified as rural under section 1886(d)(8)(E) of the Act are not permitted to reclassify through the MGCRB, effective October 1, 2000, hospitals located in what is now an urban area if they were ever a rural referral center, were reinstated to rural referral center status. These hospitals may then take advantage of the waiver from the proximity requirements for reclassification. In addition, as discussed in 62 FR 45999 and 63 FR 26317, under section 4202 of Public Law 105-33, a hospital that was classified as a rural referral center for FY 1991 is to be classified as a rural referral center for FY 1998 and later years so long as that hospital continued to be located in a rural area and did not voluntarily terminate its rural referral center status. Otherwise, a hospital seeking rural referral center status must satisfy applicable criteria. One of the criteria under which a hospital may qualify as a rural referral center is to have 275 or more beds available for use. A rural hospital that does not meet the bed size requirement can qualify as a rural referral center if the hospital meets two mandatory prerequisites (specifying a minimum case-mix index 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). With respect to the two mandatory prerequisites, a hospital may be classified as a rural referral center if— • The hospital's case-mix index is at least equal to the lower of the median case-mix index for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median case-mix index 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.) 1. Case-Mix Index Section 412.96(c)(1) provides that CMS will establish updated national and regional case-mix index values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. The methodology we use to determine the proposed national and regional case-mix index values is set forth in regulations at § 412.96(c)(1)(ii). The proposed national mean case-mix index value includes all urban hospitals nationwide, and the proposed regional values are the median values of urban hospitals within each census region, excluding those with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in § 412.105). These values are based on discharges occurring during FY 2001 (October 1, 2000 through September 30, 2001) and include bills posted to CMS's records through December 2001. We are proposing that, in addition to meeting other criteria, hospitals with fewer than 275 beds, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2002, must have a case-mix index value for FY 2001 that is at least— • 1.3229; or • The median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105) calculated by CMS for the census region in which the hospital is located. The median case-mix index values by region are set forth in the following table: Region Case-Mix index value 1. New England (CT, ME, MA, NH, RI, VT) 1.2089 2. Middle Atlantic (PA, NJ, NY) 1.2235 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.2985 4. East North Central (IL, IN, MI, OH, WI) 1.2377 5. East South Central (AL, KY, MS, TN) 1.2459 6. West North Central (IA, KS, MN, MO, NE, ND, SD) 1.1616 7. West South Central (AR, LA, OK, TX) 1.2641 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.3255 9. Pacific (AK, CA, HI, OR, WA) 1.2779 The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2001 MedPAR file, which will contain data from additional bills received through March 31, 2002. Hospitals seeking to qualify as rural referral centers or those wishing to know how their case-mix index value compares to the criteria should obtain hospital-specific case-mix index values from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these case-mix index values are computed based on all Medicare patient discharges subject to DRG-based payment. 2. Discharges Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. We are proposing to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2001 (that is, October 1, 2000 through September 30, 2001). That is the latest year for which we have complete discharge data available. Therefore, we are proposing that, in addition to meeting other criteria, a hospital, if it is to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2002, must have as the number of discharges for its cost reporting period that began during FY 2001 a figure that is at least— • 5,000; 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) 6,905 2. Middle Atlantic (PA, NJ, NY) 8,648 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 8,914 4. East North Central (IL, IN, MI, OH, WI) 8,040 5. East South Central (AL, KY, MS, TN) 6,748 6. West North Central (IA, KS, MN, MO, NE, ND, SD) 5,696 7. West South Central (AR, LA, OK, TX) 6,220 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 9,167 9. Pacific (AK, CA, HI, OR, WA) 7,053 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. These numbers will be revised in the final rule based on the latest FY 2001 cost report data. We reiterate that an osteopathic hospital, if it is to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 2002, must have at least 3,000 discharges for its cost reporting period that began during FY 2001. E. Indirect Medical Education
(IME)Adjustment (§ 412.105) 1. Background Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education
(GME)program receive an additional payment for a Medicare discharge to reflect the higher indirect operating costs of teaching hospitals relative to nonteaching hospitals. The existing regulations regarding the calculation of this additional payment, known as the indirect medical education
(IME)adjustment, are located at § 412.105. The additional payment is based on the IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a multiplier, which is represented as c, in the following equation: c × [(1 + r) .405 − 1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to-bed ratio. Section 1886(d)(5)(B)(ii)(VII) of the Act provides that, for discharges occurring during FY 2003 and thereafter, the “c” variable, or formula multiplier, is 1.35. The formula multiplier of 1.35 represents a 5.5-percent increase in IME payment for every 10-percent increase in the resident-to-bed ratio. 2. Temporary Adjustments to the FTE Cap To Reflect Residents Affected by Residency Program Closure: Resident-to-Bed Ratio for Displaced Residents (§§ 412.105(a) and (f)(1)(ix)) In the August 1, 2001 hospital inpatient prospective payment system final rule (66 FR 39899), we expanded the policy at existing § 413.86(g)(8) (proposed to be redesignated as § 413.86(g)(9) in this proposed rule), which allows a temporary adjustment to a hospital's FTE cap when a hospital trains additional residents because of another hospital's closure, to also allow a temporary adjustment when a hospital trains residents displaced by the closure of another hospital's residency program (but the hospital itself remains open). We revised regulations at existing § 413.86(g)(8) to state that, if a hospital that closes its residency training program agrees to temporarily reduce its FTE cap, another hospital(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of the former hospital's residency training program. We defined “closure of a hospital residency training program” as when the hospital ceases to offer training for residents in a particular approved medical residency training program. The methodology for adjusting the caps for the “receiving” hospital and the “hospital that closed its program” as they apply to the IME adjustment and direct GME payments is set forth in the regulations at existing §§ 412.105(f)(1)(ix) and 413.86(g)(8)(iii), respectively. In the August 1, 2001 rule, we noted a commenter who requested that CMS further revise the regulations to grant temporary relief to hospitals in calculating the IME adjustment with regard to application of the resident-to-bed ratio cap (66 FR 39900). The commenter believed that while the cap on the number of residents has been temporarily adjusted, if the receiving hospital is not allowed to also adjust its resident-to-bed ratio in the prior year, the lower resident-to-bed ratio from the prior year would act to reduce the IME payments to the receiving hospital. The commenter suggested that, similar to the exception for residents in hospitals that begin new programs under § 412.105(a)(1), an adjustment should be made to the prior year's FTE residents equal to the increase in the current year's FTEs that is attributable to the transferred residents. In response to the commenter, we stated that we had decided not to allow the exclusion of these displaced residents in applying the resident-to-bed ratio cap. We explained that, while we believed that the receiving hospital may be held to a lower cap in the first year of training the displaced residents, the receiving hospital would benefit from the higher cap in the subsequent years as the displaced residents complete their training and leave that hospital. However, we indicated that we would consider suggestions for possible future changes to this policy. We have revisited this policy and now realize that our rationale for not allowing the adjustment for displaced residents to the resident-to-bed ratio cap may have been faulty. We initially believed that, in the year following the last year in which displaced residents trained at the receiving hospital, the receiving hospital would benefit from the higher resident-to-bed ratio cap. However, we have determined that, while it is correct that the hospital will have a higher resident-to-bed ratio cap because of the higher number of displaced residents in the prior year, the receiving hospital's FTE count decreases as the displaced residents finish their training. Therefore, the receiving hospital would not need a higher resident-to-bed ratio cap to accommodate the remaining FTEs. Consequently, the higher resident-to-bed ratio cap in fact would not benefit the receiving hospital. Thus, we are now proposing to allow the exclusion of residents displaced by either the closure of another hospital's program or another hospital's closure in applying the resident-to-bed ratio cap. Specifically, assuming a hospital is eligible to receive a temporary adjustment to its FTE cap as described in existing § 413.86(g)(8), we are proposing that, solely for purposes of applying the resident-to-bed ratio cap in the *first* year in which the receiving hospital is training the displaced residents, the receiving hospital may adjust the numerator of the prior year's resident-to-bed ratio by the number of FTE residents that has caused the receiving hospital to exceed its FTE cap. (We note that this adjustment to the resident-to-bed ratio cap does not apply to changes in bed size). In the years subsequent to the first year in which the receiving hospital takes in the displaced residents, we believe an adjustment to the numerator of the prior year's resident-to-bed ratio is unnecessary because the receiving hospital's actual FTE count in those years would either stay the same or, as the displaced residents complete their training or leave that hospital, decrease each year. If all other variables remain constant, an increase in the current year's resident-to-bed ratio will establish a higher cap for the following year. In the second and subsequent years of training the displaced residents, the receiving hospital's resident-to-bed ratio for the current year would not be higher than the prior year's ratio and thus would not be limited by the resident-to-bed ratio cap. In the cost reporting period following the departure of the last displaced residents, when the temporary FTE cap adjustment is no longer applicable, we are proposing that, solely for purposes of applying the resident-to-bed ratio cap, the resident-to-bed ratio be calculated *as if* the displaced residents had not trained at the receiving hospital in the prior year. In other words, in the year that the hospital is no longer training displaced residents, the attendant FTEs should be removed from the numerator of the resident-to-bed ratio from the prior year (that is, the resident-to-bed ratio cap). We believe that because we are proposing to allow the adjustment to the resident-to-bed ratio cap in the first year in which the receiving hospital trains displaced residents, it is equitable to remove those FTEs when calculating the resident-to-bed ratio cap after all the displaced residents have completed their training at the receiving hospital. The following is an example of how the receiving hospital's IME resident-to-bed ratio cap would be adjusted for displaced residents coming from either a closed hospital or a closed program: *Example:* Hospital A has a family practice program with 3 residents. On June 30, 2002, Hospital A closes. Hospital B, which also has a family practice program, agrees to continue the training of Hospital A's residents beginning July 1, 2002. Its fiscal year end is June 30. As of July 1, 2002, the 3 residents displaced by the closure of Hospital A include 1 PGY1 resident, 1 PGY2 resident, and 1 PGY3 resident. In addition, Hospital B has 5 of its own residents, an IME FTE resident cap of 5, and 100 beds. Subject to the criteria under existing § 413.86(g)(8), Hospital B's FTE cap is temporarily increased to 8 FTEs. According to the proposed policy stated above, Hospital B's resident-to-bed ratio and resident-to-bed ratio cap would be determined as follows: *July 1, 2002 through June 30, 2003* • Resident-to-bed ratio: 5 FTEs + 3 displaced FTEs / 100 beds = .08 (line 3.18 of Worksheet E, Part A of the Medicare cost report, Form CMS 2552-96). ( **Note:** For purposes of applying the rolling average calculation at § 412.105(f)(1)(v) to this example, it is assumed that Hospital B had 5 FTE residents in both the prior and the penultimate cost reporting periods. Therefore, 5 FTEs are used in the numerator of the resident-to-bed ratio. Under § 412.105(f)(1)(v), displaced residents are added to the receiving hospital's rolling average FTE count in each year that the displaced residents are training at the receiving hospital.) • Resident-to-bed ratio cap: 5 FTEs (from fiscal year end June 30, 2002) + *3 displaced FTEs (from fiscal year end June 30, 2003)* / 100 beds = .08 (line 3.19 of Worksheet E, Part A of Form CMS 2552-96). • The lower of the resident-to-bed ratio from the current year (.08) or the resident-to-bed ratio cap from the prior year (.08) is used to calculate the IME adjustment. Therefore, Hospital B would use a resident-to-bed ratio of .08 (line 3.20 of Worksheet E, Part A of Form CMS 2552-96). *July 1, 2003 through June 30, 2004* The PGY3 displaced resident has completed his or her family practice training on June 30, 2003 and has left Hospital B. Hospital B continues to train a displaced
(now)PGY2 resident, and a displaced
(now)PGY3 resident. • Resident-to-bed ratio: 5 FTEs + 2 displaced FTEs / 100 beds = .07 (line 3.18 of Worksheet E, Part A of Form CMS 2552-96). • Resident-to-bed ratio cap: 5 FTEs (from fiscal year end June 30, 2003) + 3 displaced FTEs (from fiscal year end June 30, 2003) / 100 beds = .08 (line 3.19 of Worksheet E, Part A of Form CMS 2552-96). • The lower of the resident-to-bed ratio from the current year (.07) or the resident-to-bed ratio cap from the prior year (.08) is used to calculate the IME adjustment. Hospital B would use a resident-to-bed ratio of .07 (line 3.20 of Worksheet E, Part A of Form CMS 2552-96). *July 1, 2004 through June 30, 2005* Another of the remaining displaced residents has completed his or her family practice training on June 30, 2004 and has left Hospital B. Hospital B continues to train one displaced
(now)PGY3 resident. • Resident-to-bed ratio: 5 FTEs + 1 displaced FTE / 100 beds = .06 (line 3.18 of Worksheet E, Part A of Form CMS 2552-96). • Resident-to-bed ratio cap: 5 FTEs (from fiscal year end June 30, 2004) + 2 displaced FTEs (from fiscal year end June 30, 2004) / 100 beds = .07 (line 3.19 of Worksheet E, Part A of Form CMS 2552-96). • The lower of the resident-to-bed ratio from the current year (.06) or the resident-to-bed ratio cap from the prior year (.07) is used to calculate the IME adjustment. Hospital B would use a resident-to-bed ratio of .06 (line 3.20 of Worksheet E, Part A of Form CMS 2552-96). *July 1, 2005 through June 30, 2006* The last displaced resident has completed his or her family practice training on June 30, 2005 and has left Hospital B. Hospital B no longer trains any displaced residents, and, therefore, the last displaced resident is *removed* from the numerator of the resident-to-bed ratio cap. • Resident-to-bed ratio: 5 FTEs + 0 displaced FTEs / 100 beds = .05 • Resident-to-bed ratio cap: 5 FTEs (from fiscal year end June 30, 2005) + *0 displaced FTEs (subtract 1 displaced FTE from FYE June 30, 2005)* / 100 beds = .05 • The lower of the resident-to-bed ratio from the current year (.05) or the resident-to-bed ratio cap from the prior year (.05) is used to calculate the IME adjustment. Hospital B would use a resident-to-bed ratio of .05. We are proposing that this exception to the resident-to-bed ratio cap for residents coming from a closed hospital or a closed program would be effective for cost reporting periods beginning on or after October 1, 2002. We are proposing to revise § 412.105(a)(1) accordingly. 3. Counting Beds for the IME and DSH Adjustments (§ 412.105(b) and § 412.106(a)(l)(i)) As discussed under section V.E.2. of this proposed rule, the regulations for determining the number of beds to be used in calculating the resident-to-bed ratio for the IME adjustment are located at § 412.105(b). These regulations also are used to determine the number of beds for other purposes, including calculating the DSH adjustment at § 412.106(a)(l)(i). Section 412.105(b) specifies that the number of beds in a hospital is determined by counting the number of available bed days during the cost reporting period and dividing that number by the number of days in the cost reporting period. The number of available bed days does not include beds or bassinets in the healthy newborn nursery, custodial care beds, or beds in excluded distinct part hospital units. Section 2405.3G of Part I of the Medicare Provider Reimbursement Manual
(PRM)further defines “available” beds. Specifically, section 2405.3G states that an available bed is a bed that is permanently maintained and is available for use to lodge inpatients. However, there has been some uncertainty concerning the application of this definition of “available.” For example, a question arises as to whether beds in rooms or entire units that are unoccupied for extended periods of time should continue to be counted on the basis that, if there would ever be a need, they could be put into use. Counting the number of beds in a hospital is intended to measure the size of a hospital's routine acute care inpatient operations. While hospitals necessarily maintain some excess capacity, we believe there is a point where excess capacity may distort the bed count. Therefore, we are proposing to revise our policy concerning the determination of a hospital's bed size to exclude beds that represent an excessive level of unused capacity. We believe this proposed refinement of our bed counting policy would better capture the size of a hospital's inpatient operations as described above. We analyzed Medicare hospital data and found that, among hospitals that have between 100 and 130 beds, hospitals receiving DSH payments have lower occupancy rates than similar hospitals not receiving DSH payments. Because DSH payments are higher for urban hospitals with more than 100 beds, there may be an incentive for these hospitals to maintain excess capacity in order to qualify for those higher payments. Among 189 urban hospitals in this bed-size range that did not receive DSH payments during FY 1999, the average occupancy rate was 55 percent. However, among 294 urban hospitals in this bed-size range that did receive DSH payments during FY 1999, the average occupancy rate was 47 percent. Twenty-five percent of this group of hospitals (those receiving DSH payments) had occupancy rates below 35 percent. Among the hospitals not receiving DSH payments, 25 percent had occupancy rates below 43 percent. We believe this is indicative of a tendency among some small urban hospitals to maintain excess capacity in order to qualify for higher DSH payments. Therefore, we are proposing that if a hospital's reported bed count results in an occupancy rate (average daily census of patients divided by number of beds) below 35 percent, the applicable bed count, for purposes of establishing the number of available beds for that hospital, would exclude beds that would result in an average annual occupancy rate below 35 percent (proposed § 412.105(b)(3)). For example, if a hospital reports 105 beds for a cost reporting period, but has an average daily census of 26 patients for that same cost reporting period, its occupancy rate equals 24.8 percent (that is, 26/105). Because its occupancy rate is below the proposed minimum threshold of 35 percent, its maximum available bed count would be 74, which is the number of beds that would result in an occupancy rate of 35 percent, given an average daily census of 26 patients (that is, 26/.35). We would otherwise continue to determine a hospital's bed size using existing regulations and program manual instructions, including the application of the available bed policy. Following are the steps a hospital would undertake in determining its number of beds in a cost reporting period under our proposed policy: *Step 1:* Determine the number of available beds using the existing regulations at § 412.105(b) and PRM instructions. *Step 2:* Determine the average daily census by dividing the total number of inpatient acute care days in the hospital by the number of days in the cost reporting period. *Step 3:* Divide the average daily census determined in step 2 by 35 percent. *Step 4:* Use the *lower* of the number of beds as determined under step 1, or the result of step 3 for purposes of the IME and DSH calculations. We believe that this proposed policy more accurately indicates the size of a hospital's operations. We are proposing to specify under proposed § 412.105(b)(3) that if a hospital's reported bed count results in an occupancy rate below 35 percent, the applicable bed count for that hospital would be the number of beds that would result in an occupancy rate of 35 percent. We are proposing to make this proposed policy effective for discharges occurring on or after October 1, 2002. F. Medicare-Dependent, Small Rural Hospitals: Ongoing Review of Eligibility Criteria (§ 412.108(b)) Section 6003(f) of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) added section 1886(d)(5)(G) to the Act and created the category of Medicare-dependent, small rural hospitals (MDHs). MDHs are eligible for a special payment adjustment under the acute care hospital inpatient prospective payment system. Initially, in order to be classified as an MDH, a hospital must have met all of the following criteria: • The hospital is located in a rural area (as defined in § 412.63(b); • The hospital has 100 or fewer beds (as defined at § 412.105(b)) during the cost reporting period; • The hospital is not classified as an SCH (as defined at § 412.92); and • The hospital has no less than 60 percent of its inpatient days or discharges attributable to inpatients receiving Medicare Part A benefits during its cost reporting period beginning in FY 1987. MDHs were eligible for a special payment adjustment under the acute care hospital inpatient prospective payment system, effective for cost reporting periods beginning on or after April 1, 1990, and ending on or before March 31, 1993. Hospitals classified as MDHs were paid using the same methodology applicable to SCHs, that is, based on whichever of the following rates yielded the greatest aggregate payment for the cost reporting period: • The national 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. Section 13501(e)(1) of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) extended the MDH provision through FY 1994 and provided that, after the hospital's first three 12-month cost reporting periods beginning on or after April 1, 1990, the additional payment to an MDH whose applicable hospital-specific rate exceeded the Federal rate was limited to 50 percent of the amount by which the hospital-specific rate exceeded the Federal rate. The MDH provision expired effective with cost reporting periods beginning on or after October 1, 1994. Section 4204(a)(3) of Public Law 105-33 reinstated the MDH special payment for discharges occurring on or after October 1, 1997 and before October 1, 2001, but did not revise the qualifying criteria for these hospitals or the payment methodology. Section 404(a) of Public Law 106-113 extended the MDH provision to discharges occurring before October 1, 2006. As specified in the June 13, 2001 interim final rule with comment period (66 FR 32172) and finalized in the August 1, 2001 final rule (66 FR 39883), section 212 of Public Law 106-554 provided that, effective with cost reporting periods beginning on or after April 1, 2001, a hospital has the option to base MDH eligibility on two of the three most recently audited cost reporting periods for which the Secretary has a settled cost report, rather than on the cost reporting period that began during FY 1987 (section 1886(d)(5)(G)(iv)(IV) of the Act). According to section 1886(d)(5)(G)(iv)(IV) of the Act, the criteria for at least 60 percent Medicare utilization will be met if, in at least “2 of the 3 most recently audited cost reporting periods for which the Secretary has a settled cost report”, at least 60 percent of the hospital's inpatient days or discharges were attributable to individuals receiving Medicare Part A benefits. We would like to point out that cost reports undergo different levels of review. For example, some cost reports are settled with a desk review; others, through a full field audit. We believe the intention of the law is to provide hospitals the ability to qualify for MDH status based on their most recent settled cost reporting periods, each of which undergoes a level of audit in its settlement. Hospitals that qualify under section 1886(d)(5)(G)(iv)(IV) of the Act are subject to the other provisions already in place for MDHs. That is, all MDHs are paid using the payment methodology as defined in § 412.108(c) and may be eligible for the volume decrease provision as defined in § 412.108(d). Under existing classification procedures at § 412.108(b), a hospital must submit a written request to its fiscal intermediary to be considered for MDH status based on at least two of its three most recently audited cost reporting periods for which the Secretary has a settled cost report (as specified in § 412.108(a)(1)(iii)(c)). The fiscal intermediary will make its determination and notify the hospital within 90 days from the date it receives the hospital's request and all of the required documentation. The intermediary's determination is subject to review under 42 CFR Part 405, Subpart R. MDH status is effective 30 days after the date of written notification of approval. We are proposing to clarify and to codify in the regulations (proposed § 412.108(b)(4)) that an approved classification as an MDH remains in effect unless there is a change in the circumstances under which the classification was approved. That is, in order to maintain its eligibility for MDH status, a hospital must continue to be a small (100 or fewer beds), rural hospital, with no less than 60 percent Medicare inpatient days or discharges during either its cost reporting period beginning in FY 1987 or during at least two of its three most recently settled cost reporting periods. We also are proposing to clarify and to codify in the regulations (proposed § 412.108(b)(5)) that the fiscal intermediary will evaluate on an ongoing basis whether or not a hospital continues to qualify for MDH status. This proposed clarification would include evaluating whether or not a hospital that qualified for MDH status under section 1886(d)(5)(G)(iv)(IV) of the Act continues to qualify for MDH status based on at least two of its three most recently settled cost reporting periods. In addition, we are proposing, (proposed § 412.108(b)(6)) that if a hospital loses its MDH status, that change in status would become effective 30 days after the fiscal intermediary provides written notification to the hospital that it no longer meets the MDH criteria. If the hospital would like to be considered for MDH status after another cost reporting period has been audited and settled, we are proposing to require that the hospital must reapply by submitting a written request to its fiscal intermediary (proposed § 412.108(b)(7)). An MDH that continues to meet the criteria would not have to reapply. G. Eligibility Criteria for Reasonable Cost Payments to Rural Hospitals for Nonphysician Anesthetists (§ 412.113(c)) Currently, a rural hospital can qualify and be paid on a reasonable cost basis for qualified nonphysician anesthetists (certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants) services for a calendar year beyond 1990 and subsequent years as long as it can establish before January 1 of that year that it did not provide more than 500 surgical procedures requiring anesthesia services, both inpatient and outpatient. In the September 1, 1983 interim final rule with comment period that implemented the acute care hospital inpatient prospective payment system, we established the general policy to include, under that prospective payment system, inpatient hospital services furnished incident to a physician's service, with a time-limited exception for the inpatient hospital services of anesthetists (48 FR 39794). The purpose of this exception, which originally was for cost reporting periods beginning before October 1, 1986, was that the practice of physician-employer and anesthetist-employee was so widespread that we believed “it would be disruptive of medical practice and adverse to the quality of patient care to require all such contracts to be renegotiated in the limited time available before the implementation of the prospective payment system.” Section 2312 of Public Law 98-369 provided for reimbursement to hospitals on a reasonable cost basis as a pass-through for the costs that hospitals incur in connection with 27 the services of CRNAs. 3 Section 2312(c) provided that the amendment was effective for cost reporting periods beginning on or after October 1, 1984, and before October 1, 1987. 3 We noted in the August 31, 1984 final rule that section 2312 and the Conference Report used the term “CRNA” throughout. However, we believed it was Congressional intent to apply this pass-through payment amount to the services of all qualified hospital-employed nonphysician anesthetists (49 FR 34748). Section 9320 of Public Law 99-509 (which established a fee schedule for the services of nurse anesthetists) amended section 2312(c) of Public Law 98-369 by extending the pass-through provision for cost reporting periods beginning before January 1, 1989. Section 608 of Public Law 100-485 limited the pass-through provision effective during 1989, 1990, and 1991, to hospitals meeting the following criteria: • As of January 1, 1988, the hospital employed or contracted with a certified nonphysician anesthetist; • In 1987, the hospital had a volume of surgical procedures (including inpatient and outpatient procedures) requiring anesthesia services that did not exceed 250 (or such higher number as the Secretary determines to be appropriate); and • Each certified nonphysician anesthetist employed by, or under contract with, the hospital has agreed not to bill under Part B of Medicare for professional services furnished by the anesthetist at the hospital. Subsequently, section 6132 of Public Law 101-239 amended section 608 of Public Law 100-458 by raising the established 250-procedure threshold to 500 procedures (effective for anesthesia services furnished on or after January 1, 1990), and extended the cost pass-through indefinitely. However, section 6132 of Public Law 101-239 left intact the requirement that the hospital must have not exceeded a maximum number of surgical procedures (effectively raised to 500), both inpatient and outpatient, requiring anesthesia services during 1987. Also, the statutory authority for the Secretary to adopt such other appropriate maximum threshold volume of procedures as determined appropriate was not affected by section 6132. In light of the age of this provision, we undertook to reexamine the appropriateness of the current 500-procedure threshold. Nonphysician anesthetists who are not employed by or have a contractual relationship with a hospital paid under this provision may receive payments under a fee schedule. Payments under the fee schedule are generally somewhat lower than those made on a reasonable cost basis. Therefore, hospitals that exceed 500 procedures may have difficulty retaining access to nonphysician anesthetists' services because cost reimbursement is unavailable. According to data from the American Association of Nurse Anesthetists (AANA), the average total annual compensation for a CRNA in 2001 was approximately $155,000. The AANA estimates that, based on payments under the Medicare fee schedule, a CRNA would have to provide at least 800 anesthesia procedures to reach this average level of compensation. The statute provides the Secretary with the authority to determine the appropriateness of the volume threshold, in part, so that changes necessary to meet the needs of rural hospitals can be made. As we have found that hospitals that exceed the 500 surgical procedures may have difficulty in retaining access to nonphysician anesthetists' services, we believe that the appropriate maximum threshold for surgical procedures should be raised in order for the payment exception to apply to those hospitals most in need of this payment treatment. Based upon the data available to us concerning the best estimates of average total compensation to a CRNA, we believe that the maximum volume threshold for surgical procedures requiring anesthesia services should be raised to 800. Therefore, to ensure continued access to nonphysician anesthetists' services in rural hospitals, we are proposing to revise §§ 412.113(c)(2)(ii) and (c)(2)(iii) to raise the 500-procedure threshold to 800 procedures. H. Medicare Geographic Classification Review Board (MGCRB) Reclassification Process (§§ 412.230, 412.232, and 412.273) With the creation of the MGCRB, beginning in FY 1991, under section 1886(d)(10) of the Act, hospitals could request reclassification from one geographic location to another for the purpose of using the other area's standardized amount for inpatient operating costs or the wage index value, or both (September 6, 1990 interim final rule with comment period (55 FR 36754), June 4, 1991 final rule with comment period (56 FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). Implementing regulations in Subpart L of Part 412 (§§ 412.230 *et seq.* ) set forth criteria and conditions for redesignations from rural to urban, rural to rural, or from an urban area to another urban area, with special rules for SCHs and rural referral centers. 1. Withdrawals, Teminations, and Cancellations Under § 412.273(a) of our regulations, a hospital, or group of hospitals, may withdraw its application for reclassification at any time before the MGCRB issues its decision or, if after the MGCRB issues its decision, within 45 days of publication of our annual notice of proposed rulemaking concerning changes to the acute care hospital inpatient prospective payment system for the upcoming fiscal year (for example, this proposed rule for FY 2003). In the August 1, 2001 final rule, we specified that, for purposes of implementing section 304 of Public Law 106-554, the withdrawal procedures and the applicable timeframes in the existing regulations would apply to hospitals that receive 3-year reclassification for wage index purposes (66 FR 39886). Once effective, a withdrawal means that the hospital would not be reclassified for purposes of the wage index for FY 2003 (and would not receive continued reclassification for FYs 2004 and 2005), unless the hospital subsequently cancels its withdrawal. Consistent with section 1886(d)(10)(D)(v) of the Act, a hospital may terminate its approved 3-year reclassification during the second or third years (§ 412.273(b)). This is a separate action from a reclassification withdrawal that occurs in accordance with the timeframes described above. Currently, in order to terminate an approved 3-year reclassification, we require the hospital to notify the MGCRB in writing within 45 days of the publication date of the annual proposed rule for changes to the hospital inpatient prospective payment system (§ 412.273(b)(1)(i)). A termination, unless subsequently cancelled, is effective for the full fiscal years remaining in the 3-year period. We also provided that a hospital may apply for reclassification to a different area for the year corresponding to the second or third year of the reclassification (that is, an area different from the one to which it was originally reclassified) and, if successful, the reclassification would be for 3 years. Since the publication of the final rule, we received an inquiry regarding a situation where a hospital with an existing 3-year wage index reclassification successfully reclassifies to a different area, then withdraws from that second reclassification within the allowable timeframe for withdrawals. This scenario raises several issues not specifically addressed in the August 1, 2001 final rule, which we are proposing to clarify in this proposed rule. For example, the question arises, at what point does a hospital's termination of a 3-year reclassification become effective when a hospital applies for reclassification to another area? As noted above, the August 1, 2001 final rule specified that a hospital must file a written request with the MGCRB within 45 days of publication of the annual proposed rule to terminate the reclassification. However, the rules do not specify at what point a previous 3-year reclassification is terminated when a hospital applies for reclassification to another area in subsequent years. One might conclude that an application for a wage index reclassification to another area constitutes a written notification of a hospital's intent to terminate an existing 3-year reclassification. Under this scenario, however, if the application to the second area were denied, it would then be necessary for the hospital to formally cancel the termination of its reclassification to the first area within 45 days of publication of the proposed rule to avoid a lapse in reclassification status the following year. Therefore, we are proposing to clarify, in § 412.273(b)(2)(iii), that, in a situation where a hospital with an existing 3-year wage index reclassification applies to be reclassified to another area, its existing 3-year reclassification will be terminated when a second 3-year wage index reclassification goes into effect for payments for discharges on or after the following October 1. In such a case, it will not be necessary for the hospital to submit a separate written notice of its intent to terminate its existing 3-year reclassification. Of course, a hospital also may still terminate an existing 3-year reclassification through written notice to the MGCRB, regardless of whether it successfully reclassifies to a different area. The scenario of a hospital with an existing 3-year reclassification seeking reclassification to a second area raises another issue. If the hospital's request is approved by the MGCRB, but the hospital withdraws from that successful reclassification and “falls back” to its original 3-year reclassification, does the hospital retain the right to cancel that withdrawal the next year? In this way, a hospital could accumulate multiple reclassifications from which it could choose in any given year through canceling prior withdrawals or terminations to one area and withdrawing or terminating reclassifications to other areas. We do not believe section 304 of Public Law 106-554 was intended to be used in such a manner. Therefore, we are proposing to clarify existing policy that a previous 3-year reclassification may not be reinstated after a subsequent 3-year reclassification to another area takes effect. This would mean that a hospital that is reclassified to an area for purposes of the wage index may have only one active 3-year reclassification at a time. Once a 3-year reclassification to a second area becomes effective, a previously terminated 3-year reclassification may not be reinstated by terminating or withdrawing the reclassification to the second area and then canceling the termination or withdrawal of the reclassification to the first area. As we stated in the August 1, 2001 final rule, we believe the 3-year wage index reclassification policy was intended to provide consistency and predictability in hospital reclassifications and the wage index data. Allowing hospitals multiple reclassification options to choose from would create a situation where many hospitals move in unpredictable ways between the proposed and final rules based on their calculation of which of several areas would yield the highest wage index. This would reduce the predictability of the system, hampering the ability of the majority of hospitals to adequately project their future revenues. Therefore, we are proposing to amend § 412.273(b)(2)(ii) to provide that, once a 3-year reclassification becomes effective, a hospital may no longer cancel a withdrawal or termination of another 3-year reclassification, even within 3 years from the date of such withdrawal or termination. We are also proposing a technical correction to § 412.273(b)(2)(i) to correct the terminology regarding canceling (rather than terminating) a withdrawal. Finally, the August 1, 2001 final rule did not specifically describe the process to cancel a withdrawal or termination. Therefore, we are proposing to add a new § 412.273(d) (existing paragraph
(d)would be redesignated as paragraph (e)) to describe the process whereby a hospital may cancel a previous withdrawal or termination of a 3-year wage index reclassification. Specifically, a hospital may cancel a previous withdrawal or termination by submitting written notice of its intent to the MGCRB no later than the deadline for submitting reclassification applications for reclassifications effective at the start of the following fiscal year (§ 412.256(a)(2)). 2. Effect of Change of Ownership on Hospital Reclassifications Sections 412.230(e)(2)(ii) and 412.232(d)(2)(ii) provide that, for reclassifications effective beginning FY 2003, a hospital must provide a 3-year average of its average hourly wages using wage survey data from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes. As discussed in the August 1, 2001 final rule, we received a comment suggesting that, for purposes of calculating the 3-year average hourly wages, we permit a hospital that has changed ownership the option of excluding prior years' wage data submitted by a previous owner in order for the new hospital to qualify for reclassification. Although we responded to the comment (66 FR 39890), we have now determined that there is a need to further clarify our policy regarding change of ownership and hospitals that do not accept assignment of the previous owner's provider agreement. In our response to the comment, we stated that, where a hospital has simply changed ownership and the new owners have acquired the financial assets and liabilities of the previous owners, all of the applicable wage data associated with that hospital are included in the calculation of its 3-year average hourly wage. Where this is not the case and there is no obligation on the part of the new hospital to claim the financial assets or assume the liabilities of a predecessor hospital, the wage data associated with the previous hospital's provider number would not be used in calculating the new hospital's 3-year average hourly wage. Section 489.18(c) provides that, when there is a change of ownership, the existing provider agreement will automatically be assigned to the new owner. Our regulations at § 412.230(e)(2) do not specifically address the situation of new hospitals seeking to reclassify for wage index purposes, in light of the requirement that reclassification is based on a 3-year average hourly wage. Therefore, we are proposing to revise § 412.230(e)(2), by adding a new paragraph (e)(2)(iii), to clarify our existing policy to specify that, in situations where a hospital does not accept assignment of the existing hospital's provider agreement under § 489.18, the hospital would be treated as a new hospital with a new provider number. In that case, the wage data associated with the previous hospital's provider number would not be used in calculating the new hospital's 3-year average hourly wage. As we stated in the August 1, 2001 final rule, we believe this policy clarification is consistent with how we treat hospitals whose ownership has changed for other Medicare payment purposes. We are proposing to revise § 412.230 to clarify, under proposed new paragraph (e)(2)(iii), that once a new hospital has accumulated at least 1 year of wage data using survey data from the CMS hospital wage survey used to determine the wage index, it is eligible to apply for reclassification on the basis of those data. I. Payment for Direct Costs of Graduate Medical Education (§ 413.86) 1. Background Under section 1886(h) of the Act, Medicare pays hospitals for the direct costs of graduate medical education (GME). The payments are based in part on the number of residents trained by the hospital. Section 1886(h) of the Act caps the number of residents that hospitals may count for direct GME. Section 1886(h)(2) of the Act, as amended by section 9202 of the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (Public Law 99-272), and implemented in regulations at § 413.86(e), establishes a methodology for determining payments to hospitals for the costs of approved GME programs. Section 1886(h)(2) of the Act, as amended by COBRA, sets forth a payment methodology for the determination of a hospital-specific, base-period per resident amount
(PRA)that is calculated by dividing a hospital's allowable costs of GME for a base period by its number of residents in the base period. The base period is, for most hospitals, the hospital's cost reporting period beginning in FY 1984 (that is, the period of October 1, 1983 through September 30, 1984). The PRA is multiplied by the weighted number of full-time equivalent
(FTE)residents working in all areas of the hospital complex (or nonhospital sites, when applicable), and the hospital's Medicare share of total inpatient days to determine Medicare's direct GME payments. In addition, as specified in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods beginning on or after October 1, 1993, through September 30, 1995, each hospital's PRA for the previous cost reporting period is not updated for inflation for any FTE residents who are not either a primary care or an obstetrics and gynecology resident. As a result, hospitals with both primary care and obstetrics and gynecology residents and nonprimary care residents in FY 1994 or FY 1995 have two separate PRAs: one for primary care and obstetrics and gynecology and one for nonprimary care. Section 1886(h)(2) of the Act was further amended by section 311 of Public Law 106-113 to establish a methodology for the use of a national average PRA in computing direct GME payments for cost reporting periods beginning on or after October 1, 2000, and on or before September 30, 2005. Generally, section 1886(h)(2)(D) of the Act establishes a “floor” and a “ceiling” based on a locality-adjusted, updated, weighted average PRA. Each hospital's PRA is compared to the floor and ceiling to determine whether its PRA should be revised. For cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001, the floor PRA is 70 percent of the locality-adjusted, updated, weighted average PRA. For cost reporting periods beginning on or after October 1, 2001, and before October 1, 2002, section 511 of Public Law 106-554 amended the floor PRA to equal 85 percent of the locality-adjusted, updated, weighted average PRA. PRAs that are below the applicable floor PRA for a particular cost reporting period would be adjusted to equal the floor PRA. PRAs that exceed the ceiling, that is, 140 percent of the locality-adjusted, updated, weighted average PRA, would, depending on the fiscal year, either be frozen and not increased for inflation, or increased by a reduced inflation factor. Existing regulations at § 413.86(e)(4) specify the methodology for calculating each hospital's weighted average PRA and the steps for determining whether a hospital's PRA will be revised. 2. Determining the Weighted Average PRAs for Newly Participating Hospitals (§ 413.86(e)(5)) As stated earlier, under section 1886(h) of the Act and implementing regulations, in most cases Medicare pays hospitals for the direct costs of GME on the basis of per resident costs in a 1984 base year. However, under existing § 413.86(e)(5), if a hospital did not have residents in an approved residency training program, or did not participate in Medicare during the base period, the hospital's base period for its PRA is its first cost reporting period during which the hospital participates in Medicare and the residents are on duty during the first month of that period. If there are at least three existing teaching hospitals with PRAs in the same geographic wage area (MSA), as that term is used in 42 CFR Part 412, the fiscal intermediary will calculate a PRA based on the lower of the new teaching hospital's actual cost per resident in its base period or a weighted average of all the PRAs of existing teaching hospitals in the same MSA. There must be at least three existing teaching hospitals with PRAs in the MSA for this calculation. If there are less than three existing teaching hospitals with PRAs within the new teaching hospital's MSA, effective for cost reporting periods beginning on or after October 1, 1997, the fiscal intermediary uses the updated regional weighted average PRA (determined for each of the nine census regions established by the Bureau of Census for statistical and reporting purposes) for the new teaching hospital's MSA (see 62 FR 46004, August 29, 1997). A new teaching hospital is assigned a PRA equal to the lower of its actual allowable direct GME costs per resident or the weighted average PRA as calculated by the fiscal intermediary. Using a methodology based on a weighted average ensures that a new teaching hospital receives a PRA that is representative of the costs of training residents within its specific geographic wage area. Under existing policy, to calculate the weighted average PRA of teaching hospitals within a particular MSA, the fiscal intermediary begins by determining the base year PRA and the base year FTE count of each respective teaching hospital within that MSA. The weighted average PRA is
(a)the sum of the products of each existing teaching hospital's base year PRA in the MSA and its base year FTEs,
(b)divided by the sum of the base year FTEs from each of those hospitals. While a methodology using base year PRAs and FTEs was appropriate and workable in the years closely following the implementation of hospital-specific PRAs, it has become administratively burdensome for both CMS and the fiscal intermediaries to recreate base year information in calculating a weighted average. The methodology is particularly problematic in instances where there are large numbers of teaching hospitals in an MSA. In addition, as discussed in section V.I.1. of this proposed rule, hospitals that were training nonprimary care residents during FYs 1994 and 1995 have a distinct nonprimary care PRA, because there was no update in the inflation factor for these years (§ 413.86(e)(3)(ii)). Thus, most teaching hospitals currently have two PRAs: one for primary care and obstetrics and gynecology; and one for all other residents. (Hospitals that first train residents after FY 1995 only have a single PRA, regardless of whether they train primary care or other residents.) However, since the current methodology for calculating weighted average PRAs is based on data from FY 1984, which was prior to the years during which the PRAs were not adjusted for inflation to reflect nonprimary care residents, the methodology does not account for *all* PRAs (both primary care and obstetrics and gynecology and nonprimary care) within an MSA. Accordingly, we are proposing to simplify and revise the weighted average PRA methodology under § 413.86(e)(5)(i)(B) to reflect the average of all PRAs in an MSA, both primary care and obstetrics and gynecology, and nonprimary care. We would continue to calculate a weighted average PRA. However, rather than using 1984 base year data, we are proposing to use PRAs (both primary care and obstetrics and gynecology and nonprimary care) and FTE data from the most recently settled cost reports of teaching hospitals in an MSA. We are proposing that the intermediary would calculate the weighted average PRA using the following steps: *Step 1:* Identify *all* teaching hospitals (including those serviced by another intermediary(ies)) in the same MSA as the new teaching hospital. *Step 2:* Identify the respective primary care and obstetrics and gynecology FTE counts, the nonprimary care FTE counts, or the total FTE count (for hospitals with a single PRA) of each teaching hospital in step 1 from the most recently settled cost reports. (Use the FTE counts from line 3.07 and line 3.08 of the Medicare cost report, CMS-2552-96, Worksheet E-3, Part IV.) *Step 3:* Identify the PRAs (either a hospital's primary care and obstetrics and gynecology PRA and nonprimary care PRA, or a hospital's single PRA) from the most recently settled cost reports of the hospitals in step 1, and update the PRAs using the CPI-U inflation factor to coincide with the fiscal year end of the new teaching hospital's base year cost reporting period. For example, if the base year fiscal year end of a new teaching hospital is December 31, 2003, and the most recently settled cost reports of the teaching hospitals within the MSA are from the fiscal year ending June 30, 2000, September 30, 2000, or December 31, 2000, the PRAs from these cost reports would be updated for inflation to December 31, 2003. *Step 4:* Calculate the weighted average PRA using the PRAs and FTE counts from steps 2 and 3. For each hospital in the calculation:
(a)Multiply the primary care PRA by the primary care and obstetrics and gynecology FTEs.
(b)Multiply the nonprimary care PRA by the nonprimary care FTEs.
(c)For hospitals with a single PRA, multiply the single PRA by the hospital's total number of FTEs.
(d)Add the products from steps (a), (b), and
(c)for all hospitals.
(e)Add the FTEs from step 3 for all hospitals.
(f)Divide the sum from step
(d)by the sum from step (e). The result is the weighted average PRA for hospitals within an MSA. The following is an example of how to calculate a weighted average PRA under the proposed methodology: Example Assume that new Hospital A has a June 30 fiscal year end and begins training residents for the first time on July 1, 2003. Thus, new Hospital A's base year for purposes of establishing a PRA is the fiscal year ending June 30, 2004. New Hospital A is located in MSA 1234, in which three other teaching hospitals exist, Hospital B, Hospital C, and Hospital D. These three hospitals also have a fiscal year end of June 30 and their most recently settled cost reports are for the fiscal year ending June 30, 2000. For fiscal year ending June 30, 2000, Hospital B has 200 primary care and obstetrics and gynecology FTEs, 150 nonprimary care FTEs, and 150 nonprimary care FTEs. Hospital C has 50 primary care and obstetrics and gynecology FTEs and 60 nonprimary care FTEs. Hospital D has 25 FTEs. After updating the PRAs for inflation by the CPI-U to June 30, 2004, Hospital B has a primary care and obstetrics and gynecology PRA of $120,000 and a nonprimary care PRA of $115,000, Hospital C has a primary care and obstetrics and gynecology PRA of $100,000 and a nonprimary care PRA of $97,000, and Hospital D has a single PRA of $90,000.
(a)Primary care: Hospital B: $120,000 × 200 FTEs = $24,000,000 Hospital C: $100,000 × 50 FTEs = $5,000,000
(b)Nonprimary care: Hospital B: $115,000 × 150 FTEs = $17,250,000 Hospital C: $97,000 × 60 FTEs = $5,820,000
(c)Single PRA: Hospital D: $90,000 × 25 FTEs = $2,250,000
(d)$24,000,000 + 5,000,000 + $17,250,000 + $5,820,000 + $2,250,000 = $54,320,000.
(e)200 + 50 + 150 + 60 + 25 = 485 total FTEs.
(f)$54,320,000/485 FTEs = $112,000, the weighted average PRA for MSA1234 for fiscal year ending June 30, 2004. New Hospital A's PRA would be the lower of $112,000 or its actual base year GME costs per resident. We are proposing that this new weighted average calculation would be effective for hospitals with direct GME base years that begin on or after October 1, 2002. In addition, we are taking the opportunity to clarify the language under existing § 413.86(e)(5)(i)(B), which relates to calculating the weighted average under existing policy. Specifically, existing § 413.86(e)(5)(i)(B) states: “The weighted mean value of per resident amounts of all hospitals located in the same geographic wage area, as that term is used in the prospective payment system under part 412 of this chapter, *for cost reporting periods beginning in the same fiscal years* [emphasis added].” We believe this language could be misinterpreted to imply that only those PRAs of hospitals in the same geographic wage area
(MSA)* that have the same fiscal year end as the new teaching hospital* should be used in the weighted average calculation. However, the PRAs of *all* hospitals within the MSA of the new teaching hospital should be used, not just the PRAs of hospitals with the same fiscal year end as the new teaching hospital. The proposed revision appears under a proposed new § 413.86(e)(5)(i)(c). 3. Aggregate FTE Limit for Affiliated Groups (§§ 413.86
(b)and (g)(7)) Section 1886(h)(4)(H)(ii) of the Act permits, but does not require, the Secretary to prescribe rules that allow institutions that are member of the same affiliated group (as defined by the Secretary) to elect to apply the FTE resident limit on an aggregate basis. This provision allows the Secretary to permit hospitals flexibility in structuring rotations within a combined cap when they share residents' time. In accordance with the broad authority conferred by the statute, we created criteria for defining “affiliated group” and “affiliation agreements” in both the August 29, 1997 final rule (62 FR 45965) and the May 12, 1998 final rule (63 FR 26317). Because we have received many inquiries from the hospital industry on this policy, we are proposing to clarify in regulations the requirements for participating in an affiliated group. These requirements are explicitly derived from the policy explained in the August 29, 1997 and May 12, 1998 final rules. Specifically, we are proposing to add under § 413.86(b) a new definition of “Affiliation agreement.” This new proposed definition would state that an affiliation agreement is a written, signed, and dated agreement by responsible representatives of each respective hospital in an affiliated group (as defined in § 413.86(b)), that specifies— • The term of the agreement, which, at a minimum must be one year, beginning on July 1 of a year. • Each participating hospital's direct and indirect FTE cap. • The annual adjustment to each hospital's FTE caps, for both direct GME and IME. This adjustment must reflect the fact that any positive adjustment to one hospital's direct and indirect FTE caps must be offset by a negative adjustment to the other hospital's (or hospitals') direct and indirect FTE caps of at least the same amount. • The names of the participating hospitals and their Medicare provider numbers. In addition, we are proposing to add a new § 413.86(g)(5)(iv) and a new § 413.86(g)(7) to clarify the requirements for a hospital to receive a temporary adjustment to its FTE cap through an affiliation agreement. (Existing § 413.86(g)(5)(iv) through
(vi)are proposed to be redesignated as § 413.86(g)(5)(v) through (vii), respectively; and existing §§ 413.86(g)(7) through (g)(12) are proposed to be redesignated as §§ 413.86(g)(8) through (g)(13), respectively, to accommodate these additions.) Specifically, we are proposing that a hospital may receive a temporary adjustment to its FTE cap, which is subject to the averaging rules, to reflect residents added or subtracted because the hospital is participating in an affiliated group (as that term is defined under § 413.86(b)). Under this proposed provision— • Each hospital in the affiliated group must submit the affiliation agreement (as that term is proposed to be defined under § 413.86(b)), to the CMS fiscal intermediary servicing the hospital and send a copy to CMS's Central Office no later than July 1 of the residency program year during which the affiliation agreement will be in effect. • There must be a rotation of a resident(s) among the hospitals participating in the affiliated group during the term of the affiliation agreement, such that more than one of the hospitals counts the proportionate amount of the time spent by the resident(s) in their FTE resident counts. (However, no resident may be counted in the aggregate as more than one FTE.) This requirement is intended to ensure that the participating hospitals maintain a “cross-training” relationship during the term of the affiliation agreement. • The net effect of the adjustments (positive or negative) on the affiliated hospitals' aggregate FTE cap for each affiliation agreement must not exceed zero. • If the affiliation agreement terminates for any reason, the FTE cap for each hospital in the affiliated group will revert to the individual hospital's pre-affiliation FTE cap. Except for the proposed new § 413.86(g)(7)(iv) regarding the treatment of FTE caps after termination of the affiliation agreement, each provision of proposed new § 413.86(g)(7) is explicitly derived from policy stated in the May 12, 1998 final rule (63 FR 26336). We are proposing to incorporate in regulations policy that was previously established under the formal rulemaking process. We are proposing a change in policy concerning what happens to each participating affiliated hospital's FTE cap when an affiliation agreement terminates (proposed new § 413.86(g)(7)(iv)). In the preamble of the May 12, 1998 final rule (63 FR 26339), we stated: “Each agreement must also specify the adjustment to each respective hospital cap in the event the agreement terminates, dissolves, or, if the agreement is for a specified time period, for residency training years and cost reporting periods subsequent to the period of the agreement for purposes of applying the FTE cap on an aggregate basis. In the absence of an agreement on the FTE caps for each respective institution following the end of the agreement, each hospital's FTE cap will be the indirect and direct medical education FTE count from each hospital's cost reporting period ending in 1996 and the cap will not be applied on an aggregate basis.” Our purpose for allowing hospitals to redistribute their FTE caps (within the limits of the aggregate FTE caps) upon the termination of an affiliation was to enable hospitals by agreement to more closely reflect the realities of the residency rotational arrangement. However, in practice, very few hospitals have altered their FTE caps following termination of affiliation agreements. Rather, the vast majority of hospitals opted to revert to their respective 1996 FTE caps upon the termination of an affiliation. In addition, we have found that our existing policy is susceptible to the following abusive practice that does not comport with our original purpose for allowing redistribution of FTE caps among hospitals following termination of an affiliation agreement. We have learned of a number of instances in which one hospital (Hospital A) affiliated with another hospital (Hospital B) in anticipation of Hospital B's closure at some point during the residency program year. In these instances, the affiliation agreement was made solely for the purpose of obtaining a permanent adjustment to Hospital A's FTE cap through the terms of the termination clause. We do not believe these permanent FTE cap adjustments that result from hospital closures (or any other circumstances) were intended when Congress passed the provision on affiliation agreements. As stated above, we believe affiliations were meant to provide flexibility for hospitals in the rotations of residents where, in the normal course of an affiliation between two or more hospitals, the actual number of residents training at each hospital may vary somewhat from year to year. Affiliations were *not* intended to be used as a vehicle for circumventing the statutory FTE cap on the number of residents. In addition, we have separately addressed issues that arise when residents are displaced because of a pending hospital closure. We have in place a policy at existing § 413.86(g)(8) (proposed to be redesignated as § 413.86(g)(9) in this proposed rule) that permits *temporary* FTE cap adjustments for hospitals that take on the training of residents displaced by the closure of another hospital. Therefore, we are proposing that, effective October 1, 2002, for hospitals with affiliation agreements that terminate (for any reason) on or after that date, the direct and indirect FTE caps for each hospital in the affiliated group will revert back to each individual hospital's original FTE cap prior to the affiliation (proposed new § 413.86(g)(7)(iv)). This policy would not preclude the participating hospitals from entering into additional affiliation agreements for later residency years. Since this proposed policy would be effective for agreements that terminate on or after October 1, 2002, hospitals that have already received a permanent FTE cap adjustment from their fiscal intermediaries through the existing termination clause policy would retain those cap adjustments. We also are proposing to make a conforming clarification at § 412.105(f)(1)(vi) for purposes of IME payments. 4. Rotating Residents to Other Hospitals At existing § 413.86(f), we state, in part, that a hospital may count residents training in all areas of the hospital complex; no individual may be counted as more than one FTE; and, if a resident spends time in more than one hospital or in a nonprovider setting, the resident counts as a partial FTE based on the proportion of *time worked at the hospital* to the total time worked (emphasis added). A similar policy exists at §§ 412.105(f)(1)(ii) and
(iii)for purposes of counting resident FTEs for IME payment. Although these policies concerning the counting of the number of FTE residents for IME and direct GME payment purposes have been in effect since October 1985, we continue to receive questions about whether residents can be counted by a hospital for the time during which the resident is rotated to other hospitals. We would like to clarify that it is longstanding Medicare policy, based on language in both the regulations and the statute, to prohibit one hospital from claiming the FTEs training at another hospital for IME and direct GME payment. This policy applies even when the hospital that proposes to count the FTE resident(s) actually incurs the costs of training the residents(s) (such as salary and other training costs) at another hospital. First, section 1886(h)(4)(B) of the Act states that the rules governing the direct GME count of the number of FTE residents “shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital.” In the September 4, 1990 **Federal Register** (55 FR 36064), we stated that ” * * * regardless of which teaching hospital employs a resident who rotates among hospitals, each hospital would count the resident in proportion to the amount of time spent at its facility.” Therefore, another hospital *cannot* count the time spent by residents training at another hospital. Only the hospital where the residents are actually training can count those FTEs for that portion of time. For example, if, during a cost reporting year, a resident spends 3 months training at Hospital A and 9 months training at Hospital B, Hospital A can only claim .25 FTE and Hospital B can only claim .75 FTE. Over the course of the entire cost reporting year, the resident would add up to 1.0 FTE. We have been made aware of some instances where an urban hospital may incur all the training costs of residents while those residents train at a rural hospital, because the rural hospital may not have the resources or infrastructure to claim those costs and FTEs on a Medicare cost report. However, even in this scenario, the urban hospital is precluded from claiming any FTEs for the proportion of time spent in training at that rural hospital, or at any other hospital. We note, however, that, consistent with the statutory provisions of section 1886(d)(5)(B)(iv) of the Act for IME payment and section 1886(h)(4)(E) of the Act for direct GME payment, a hospital may count the time residents spend training in a *nonhospital* setting if the hospital complies with the regulatory criteria at § 413.86(f)(4). J. Responsibilities of Medicare-Participating Hospitals in Emergency Cases (EMTALA) 1. Background Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose specific obligations on Medicare-participating hospitals that offer emergency services. These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these patients, regardless of whether or not they are beneficiaries of any program under the Act. Section 1867 of the Act sets forth requirements for medical screening examinations for medical conditions, as well as necessary stabilizing treatment or appropriate transfer. In addition, section 1867 of the Act specifically prohibits a delay in providing required screening or stabilization services in order to inquire about the individual's payment method or insurance status. Section 1867 of the Act also provides for the imposition of civil monetary penalties on hospitals and physicians responsible for the following:
(a)Negligently failing to appropriately screen a patient seeking emergency medical care;
(b)negligently failing to provide stabilizing treatment to an individual with an emergency medical condition; or
(c)negligently transferring a patient in an inappropriate manner. (Section 1867(e)(4) of the Act defines “transfer” to include both transfers to other health care facilities and cases in which the patient is released from the care of the hospital without being moved to another health care facility.) These provisions, taken together, 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 1986 (COBRA). As a result, many people initially referred to EMTALA as “COBRA” or the “COBRA antidumping” statute. Congress enacted these antidumping provisions in the Social Security Act because of its concern with an “increasing number of reports” that hospital emergency rooms were refusing to accept or treat patients with emergency conditions if the patients did not have insurance: “* * * The Committee is most concerned that medically unstable patients are not being treated appropriately. There have been reports of situations where treatment was simply not provided. In numerous other situations, patients in an unstable condition have been transferred improperly, sometimes without the consent of the receiving hospital. “There is some belief that this situation has worsened since the prospective payment system for hospitals became effective. The Committee wants to provide a strong assurance that pressures for greater hospital efficiency are not to be construed as license to ignore traditional community responsibilities and loosen historic standards. “[Under the statute] [a]ll participating hospitals with emergency departments would be required to provide an appropriate medical screening examination for any individual who requests it (or has a request made on his behalf) to determine whether an emergency medical condition exists or if the patient is in active labor.” (H.R. Rept. No. 99-241, Part 1, 99th Cong., 1st Sess. (1985), p. 27.) The regulations implementing section 1867 of the Act are found at 42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. Section 489.24 provides for the following: • Paragraph
(a)requires that when an individual presents to a hospital's emergency department and a request is made on the individual's behalf for examination or treatment of a medical condition, the hospital must provide for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. • Paragraph
(b)provides the definitions of terms, including “comes to the emergency department,” “emergency medical condition,” “stabilized,” and “to stabilize.” • Paragraph
(c)addresses procedures a hospital must follow when it determines that an emergency medical condition exists. If the hospital determines that an emergency medical condition exists, the hospital must provide for further medical examination and treatment as required to stabilize the patient. If the hospital does not have the capabilities to stabilize the patient, an appropriate transfer to another facility is permitted. A transfer is appropriate when the medical benefits of the transfer outweigh the medical risks of the transfer and other requirements, specified in the regulation at paragraph (d), are met. Also, the hospital may transfer an unstable patient who makes an informed written request. Paragraph
(c)further states that a hospital may not delay an appropriate medical screening examination, or further examination or treatment, to inquire about the individual's payment method or insurance status. In addition, § 489.24 addresses:
(a)Restriction of a transfer until the individual is stabilized;
(b)the responsibilities of the receiving hospital;
(c)termination of the provider agreement for failure to comply with EMTALA requirements; and
(d)matters concerning consultation with Peer Review Organizations (paragraphs
(d)through (h), respectively). Some EMTALA-related requirements are implemented under regulations at §§ 489.20(l), (m), (q), and (r)(1), (r)(2), and (r)(3). Those regulations deal with a hospital's obligations to report the receipt of patients that it has reason to believe may have been transferred inappropriately; to post signs in the emergency department describing a patient's rights to emergency treatment under section 1867 of the Act; and to maintain patient records, physician on-call lists, and emergency room logs. We are including this brief description for informational purposes but, because we are not proposing to change the regulations in § 489.20, they will not be discussed further in this document. In promulgating these cited regulatory sections and in enforcing the provisions of EMTALA, we are aware of the necessary balance between the hospital's and a physician's legal duty to provide examination and treatment under the statute and the practical realities of the manner in which hospitals and medical staffs are organized and operated on a day-to-day basis, as well as proper mobilization of resources within hospitals in order to comply with these legal duties. Reports of overcrowding in hospital emergency departments are common in many parts of the country. Within the requirements of EMTALA, individuals should be treated at the appropriate site of care. Hospitals and physicians have now had over 15 years of experience in organizing themselves to comply with the provisions of EMTALA. Throughout this section of this proposed rule relating to EMTALA, we solicit comments from hospitals, physicians, patients, and beneficiary groups on the proposed changes to the EMTALA policies. 2. Special Advisory Bulletin on EMTALA Obligations On November 10, 1999, CMS (previously, HCFA) and the Office of the Inspector General
(OIG)published jointly in the **Federal Register** a Special Advisory Bulletin addressing the requirements of the patient antidumping statute and the obligations of hospitals to medically screen all patients seeking emergency services and provide stabilizing medical treatment as necessary to all patients, including enrollees of managed care plans, whose conditions warrant it (64 FR 61353). The Special Advisory Bulletin addressed issues of dual staffing of hospital emergency rooms by managed care and nonmanaged care physicians, prior authorization requirements of some managed care plans, use of advance beneficiary notices
(ABNs)or other financial responsibility forms, handling of individuals' inquiries about financial liability for emergency services, and voluntary withdrawal of a treatment request. Although it does not amend the Code of Federal Regulations, the Special Advisory Bulletin informs individuals of HHS policy regarding application of the patient antidumping statute and offers advice on the best practices to follow to avoid violation of the requirements imposed under that statute. As discussed further in section V.J.4. of this preamble, we are now proposing to codify certain policies on prior authorization that are currently stated only in the Special Advisory Bulletin. We believe these changes in the regulations are needed to ensure uniform and consistent application of policy and to avoid any misunderstanding of EMTALA requirements by patients, physicians, or hospital employees. 3. EMTALA Provisions in This Proposed Rule Recently, a number of questions have been raised about the applicability of § 489.24 to specific situations. These questions arise in the context of managed care plans' requirements for prior authorization, case experiences involving elective procedures, and situations when patients have been admitted as inpatients but are not stabilized, or later experience a deterioration in their medical condition. Some hospitals are uncertain whether various conditions of participation found in 42 CFR part 482 apply to these situations or whether the EMTALA requirements included in the provider agreement regulations at § 489.24 apply, or both. Some representatives of the provider community have asked us to reexamine CMS policy on the applicability of EMTALA to provider-based departments. Finally, there have also been questions concerning the applicability of EMTALA to physicians who are “on call” and to hospitals that own ambulances when those ambulances operate under communitywide emergency medical services
(EMS)protocols. To help promote consistent application of the regulations concerning the special responsibilities of Medicare hospitals in emergency cases, we are proposing changes to § 489.24 to clarify its application to these situations and at the same time address concerns about EMTALA raised by the Secretary's Advisory Committee on Regulatory Reform. These changes are discussed more fully below and include the following: • We are proposing to change the requirements relating to emergency patients presenting at those off-campus outpatient clinics that do not routinely provide emergency services. We believe these changes would enhance the quality and promptness of emergency care by permitting individuals to be referred to appropriately equipped emergency facilities close to such clinics. • We are proposing to clarify when EMTALA applies to both inpatients and outpatients. We believe these clarifications would enhance overall patient access to emergency services by helping to relieve administrative burdens on frequently overcrowded emergency departments. • We are proposing to clarify the circumstances in which physicians, particularly specialty physicians, must serve on hospital medical staff “on-call” lists. We expect these clarifications would help improve access to physician services for all hospital patients by permitting hospitals local flexibility to determine how best to maximize their available physician resources. We are currently aware of reports of physicians, particularly specialty physicians, severing their relationships with hospitals, especially when those physicians belong to more than one hospital medical staff. Physician attrition from these medical staffs could result in hospitals having no specialty physician service coverage for their patients. Our proposed clarification of the on-call list requirement would permit hospitals to continue to attract physicians to serve on their medical staffs and thereby continue to provide services to emergency room patients. • We are proposing to clarify the responsibilities of hospital-owned ambulances so that these ambulances can be more fully integrated with citywide and local community EMS procedures for responding to medical emergencies and thus use these resources more efficiently for the benefit of these communities. We solicit comments on all of these proposed changes. 4. Prior Authorization Some managed care plans may seek to pay hospitals for services only if the hospitals obtain approval from the plan for the services before providing the services. Requirements for this approval are frequently referred to as “prior authorization” requirements. However, EMTALA (specifically, section 1867(h) of the Act and our regulation at § 489.24(c)(3)) explicitly prohibit hospitals from delaying screening or stabilization services in order to inquire about the individual's method of payment or insurance status. Thus, prior authorization requirements are a matter of concern because hospitals could, in seeking prior authorization from an insurer, present a barrier to or delay in the provision of services required by EMTALA. After review of these considerations, we believe that our existing policy will best implement the intent of the statute by prohibiting a participating hospital from seeking authorization from the individual's insurance company for screening services or services required to stabilize an emergency medical condition until after the hospital has provided the appropriate medical screening examination required by EMTALA to the patient and has initiated any further medical examination and treatment that may be required to stabilize the patient's emergency medical condition. We are soliciting comments as to whether the regulations should be further revised to state that the hospital may seek other information (apart from information about payment) from the insurer about the individual, and may seek authorization for all services concurrently with providing any stabilizing treatment, as long as doing so does not delay required screening and stabilization services. In addition, we are proposing to specify that an emergency physician is not precluded from contacting the patient's physician at any time to seek advice regarding the patient's medical history and needs that may be relevant to the medical screening and treatment of the patient, as long as this consultation does not inappropriately delay required screening or stabilization services. As explained earlier, this policy was stated in a Special Advisory Bulletin published jointly by CMS (then HCFA) and the OIG. However, we are now proposing to clarify existing language at § 489.24(c)(3) (proposed to be redesignated as paragraph (d)(4)) in this proposed rule to include this policy in the regulations. 5. Hospital Responsibility for Communication With Medicare+Choice Organizations Concerning Post-Stabilization Care Services Section 422.113 of our existing regulations establishes rules concerning the responsibility of Medicare+Choice organizations for emergency and post-stabilization care services provided to Medicare+Choice enrollees (65 FR 40170, June 29, 2000). Under § 422.113(c)(2), a Medicare+Choice organization is financially responsible for post-stabilization care under certain circumstances, including situations in which the organization cannot be contacted or does not respond timely to a hospital's request for preapproval of this care. It has come to our attention that, in some instances, hospitals may have failed to contact Medicare+Choice organizations on a timely basis to seek authorization for post-stabilization services. In such a case, the Medicare+Choice organization does not have the opportunity provided for under the regulations to decide whether to approve the provision of post-stabilization services at the hospital where the emergency services were provided, or to require that the enrollee instead be transferred to another hospital for such services. Therefore, we are proposing to add a new paragraph (d)(6) under § 489.24 to specify that a hospital must promptly contact the Medicare+Choice organization after a Medicare+Choice enrollee who is treated for an emergency medical condition is stabilized. 6. Clarification of “Comes to the Emergency Department” Section 1867(a) of the Act and our regulations at § 489.24(a) provide, in part, that if any individual comes to the emergency department of a hospital and a request is made on that individual's behalf for examination or treatment of a medical condition, the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department. If the hospital determines that such an individual has an emergency medical condition, the hospital is further obligated to provide either necessary stabilizing treatment or an appropriate transfer. Occasionally, questions have arisen as to whether these EMTALA requirements apply to situations in which a patient comes to a hospital, but does not present to the hospital's emergency department. We are proposing to clarify under what circumstances a hospital is obligated under EMTALA to screen, stabilize, or transfer an individual who comes to a hospital, presenting either at its dedicated emergency department, as proposed to be defined below, or elsewhere on hospital property, seeking examination or treatment. Sometimes individuals come to hospitals seeking examination or treatment for medical conditions that could be emergency medical conditions, but present for examination or treatment at areas of the hospital other than the emergency department. For example, a woman in labor may go directly to the labor and delivery department of a hospital or a psychiatric outpatient experiencing a psychiatric crisis may present at the psychiatry department. In the June 22, 1994 final rule (59 FR 32098), we defined “comes to the emergency department” at § 489.24(b) to clarify that a hospital's EMTALA obligations are triggered whenever an individual presents on hospital property in this manner in an attempt to gain access to the hospital for emergency care and requests examination or treatment for an emergency medical condition. At the time we adopted this interpretation of “comes to the emergency department,” we explained: “We believe that section 1867 of the Act also applies to all individuals who attempt to gain access to the hospital for emergency care. An individual may not be denied services simply because the person failed to actually enter the facility's designated emergency department.” (59 FR 32098) We repeated this standard for situations in which a hospital becomes bound to meet EMTALA's screening and stabilization or transfer requirements with respect to individuals who present on hospital property in an attempt to gain access to the hospital for emergency care, but outside of a hospital's emergency department, in interpretative guidelines published in the State Operations Manual: “If an individual arrives at a hospital and is not technically in the emergency department, but is on the premises (including the parking lot, sidewalk and driveway) of the hospital and requests emergency care, he or she is entitled to a medical screening examination.” (State Operations Manual Appendix V—Responsibilities of Medicare Participating Hospitals in Emergency Cases, V-16) Thus, an individual can “come to the emergency department,” creating an EMTALA obligation on the part of the hospital, in one of two ways: The individual can present at a hospital's dedicated emergency department (as proposed to be defined below) and request examination or treatment for a medical condition; or the individual can present elsewhere on hospital property in an attempt to gain access to the hospital for emergency care (that is, at a location that is on hospital property but is not part of a dedicated emergency department), and request examination or treatment for what may be an emergency medical condition. Because of the need to clarify the applicability of EMTALA to a particular individual depending on where he or she presents on hospital property in order to obtain emergency care, we are proposing to define “dedicated emergency department.” “Dedicated emergency department” would mean a specially equipped and staffed area of the hospital that is used a significant portion of the time for the initial evaluation and treatment of outpatients for emergency medical conditions, as defined in § 489.24(b), and is either located:
(1)On the main hospital campus; or
(2)off the main hospital campus and is treated by Medicare under § 413.65(b) as a department of the hospital. The EMTALA statute was intended to apply to individuals presenting to a hospital for emergency care services. Accordingly, we believe it is irrelevant whether the dedicated emergency department is located on or off the hospital main campus, as long as the individual is presenting to “a hospital” for those services. Therefore, we are proposing in our definition of “dedicated emergency department” that such a department may be located on the main hospital campus, or it may be a department of the hospital located off the main campus. (We note that this proposed definition would encompass not only what is generally thought of as a hospital's “emergency room,” but would also include other departments of hospitals, such as labor and delivery departments and psychiatric units of hospitals, that provide emergency or labor and delivery services, or both, or other departments that are held out to the public as an appropriate place to come for medical services on an urgent, nonappointment basis.) We are soliciting public comment on whether this proposed definition should more explicitly define what is a “dedicated emergency department.” Specifically, we are seeking comment on whether a “significant portion of the time” should be defined more objectively; for example, in terms of some minimum number or minimum percentage of patients (20, 30, 40 percent or more of all patients seen) presenting for emergency care at a particular area of the hospital in order for it to qualify as a “dedicated emergency department.” As an alternative, we could also consider a qualifying criteria that is based on determining whether the facility is used “regularly” for the evaluation or treatment of emergency medical conditions. Similarly, we are seeking comments on how we could define “regularly” more objectively in our consideration of this alternative. We further seek comments from hospitals, physicians, and others on how hospitals currently organize themselves to react to situations in which individuals come to a hospital requesting a screening examination or medical treatment, or both. This proposed rule would clarify for hospitals that they must provide at least a medical screening examination to all individuals who present to an area of a hospital meeting the definition of dedicated emergency department and request examination or treatment for a medical condition, or have such a request made on their behalf. As we explain in section V.J.7. of this preamble, individuals who present to an area of a hospital other than a dedicated emergency department on hospital property must receive a medical screening examination under EMTALA, only when the individual requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf, as provided in the proposed changes to § 489.24(b) in this proposed rule. 7. Applicability of EMTALA: Individual Comes to the Dedicated Emergency Department for Nonemergency Services We sometimes receive questions as to whether EMTALA's requirements apply to situations in which an individual comes to a hospital's dedicated emergency department, but no request is made on the individual's behalf for emergency medical evaluation or treatment. In view of the specific language of section 1867 of the Act and the discussion in section V.J.6. of this proposed rule, which proposes to define a hospital's dedicated emergency department as a specially equipped and staffed area of the hospital that is used a significant portion of the time for the initial evaluation and treatment of outpatients for emergency medical conditions located on the main hospital campus or at an off-campus department of the hospital, we believe that a hospital must be seen as having an EMTALA obligation with respect to any individual who comes to the dedicated emergency department, if a request is made on the individual's behalf for examination or treatment for a medical condition, whether or not the treatment requested is explicitly for an emergency condition. A request on behalf of the individual would be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition. This does not mean, of course, that all EMTALA screenings must be equally extensive. The statute plainly states that the objective of the appropriate medical screening examination is to determine whether or not an emergency medical condition exists. Therefore, hospitals are not obligated to provide screening services beyond those needed to determine that there is no emergency. In general, a medical screening examination is the process required to reach, with reasonable clinical confidence, a determination about whether a medical emergency does or does not exist. We expect that in most cases in which a request is made for medical care that clearly is unlikely to involve an emergency condition, an individual's statement that he or she is not seeking emergency care, together with brief questioning by qualified medical personnel, would be sufficient to establish that there is no emergency condition and that the hospital's EMTALA obligation would thereby be satisfied. To clarify our policy in this area, we are proposing to redesignate paragraphs
(c)through
(h)of § 489.24 as paragraphs
(d)through
(i)(we are proposing to remove existing paragraph (i), as explained in section V.J.10. of this preamble) and to add a new paragraph
(c)to state that if an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an “emergency medical condition” as defined in paragraph (b). (See example 1 below.) Example 1: A woman walks up to the front desk of a hospital's emergency room, a dedicated emergency department, and tells the hospital employee attending the front desk that she had a wound sutured several days earlier and was directed by her doctor to have the sutures removed that day. The front desk attendant registers the woman according to the hospital's normal registration procedure and directs the woman to the waiting area. An emergency nurse, who has been designated by the hospital as a “qualified medical person” (as provided for in existing § 489.24(a)), calls the woman into the examination area of the emergency room. The nurse asks the woman if she has experienced any discomfort or noticed any problems in the area sutured. The woman explains that she is feeling fine, and the wound is not causing her any discomfort, but that her doctor had directed her a week ago to have the sutures removed that day. The nurse physically inspects the sutures and determines that the wound is healing appropriately. The nurse explains to the woman that she does not have an emergency medical condition and may direct the woman to an outpatient clinic where nonemergency personnel will provide the services the woman has requested. *Application:* In this case, the woman presented at the hospital's dedicated emergency department and requested examination or treatment for a medical condition—specifically, she asked that her sutures be removed. Therefore, the hospital is bound under section 1867(a) of the Act to provide her a medical screening examination in order to determine whether or not she has an emergency medical condition. The actions of the nurse, “a qualified medical person,” constitute an appropriate medical screening examination under EMTALA because the nurse has determined, with reasonable clinical confidence, that the woman has no emergency medical condition. This appropriate medical screening examination fully satisfies the hospital's EMTALA obligations as to that woman; because the screening examination revealed no emergency medical condition, the hospital properly referred the woman to an outpatient clinic for nonemergency care. 8. Applicability of EMTALA: Individual Presents at an Area of the Hospital on the Hospital's Main Campus Other Than the Dedicated Emergency Department Routinely, individuals come to hospitals as outpatients for many nonemergency medical purposes, and if such an individual initially presents at an on-campus area of the hospital other than a dedicated emergency department, we would expect that the individual typically would not be seeking emergency care. Under most of these circumstances, EMTALA would therefore not apply (this concept is further discussed in section V.J.8. of this preamble). A hospital would, however, incur an EMTALA obligation with respect to an individual presenting at that area who requests examination or treatment for what may be an emergency medical condition, or had such a request made on his or her behalf. This policy would not require that an emergency medical condition be found, upon subsequent medical examination, to exist. Rather, EMTALA is triggered in on-campus areas of the hospital other than a dedicated emergency department where, in an attempt to gain access to the hospital for emergency care, an individual comes to a hospital and requests an examination or treatment for a medical condition that may be an emergency. We are proposing to specify in the regulations that such a request would be considered to exist if the individual requests examination or treatment for what the individual believes to be an emergency medical condition. Where there is no actual request because, for example, the individual is unaccompanied and is physically incapable of making a request, the request from the individual would be considered to exist if a prudent layperson observer would believe, based upon the individual's appearance or behavior, that the individual needs emergency examination or treatment. We believe this proposed policy is appropriate because it would not be consistent with the intent of section 1867 of the Act to deny its protections to those individuals whose need for emergency services arises upon arrival on hospital on-campus property at the hospital's main campus but have not been presented to the dedicated emergency department. Under the proposed policies discussed above, a request for examination or treatment by an individual presenting for what may be an emergency medical condition at an on-campus area of the hospital other than the dedicated emergency department would not have to be expressed verbally in all cases, but in some cases should be inferred from what a prudent layperson observer would conclude from an individual's appearance or behavior. While there may be a request (either through the individual or a prudent layperson), thereby triggering an EMTALA obligation on the part of the hospital, this policy does not mean that the hospital must maintain emergency medical screening or treatment capabilities in each department or at each door of the hospital, nor anywhere else on hospital property other than the dedicated emergency department. If an individual presents at an on-campus area of the hospital other than the dedicated emergency department in an attempt to gain access to the hospital for emergency care, EMTALA would mandate that the hospital (as a whole) would provide for screening and stabilizing the individual. For example, upon presentation of an individual requesting emergency care, if the department to which the individual presents cannot readily provide screening and, if needed, stabilization services, the department may arrange for appropriate staff to provide these services. Care required to be provided under EMTALA should be provided in the most appropriate setting, as determined by the hospital. Example 2: An individual bleeding profusely from a severe scalp laceration enters a hospital through the main entry for hospital visitors, and says to one of the receptionists: “I need help.” The receptionist sees that the individual's head is bleeding and, noting his request, arranges to have the individual taken to the dedicated emergency department. Minutes later, the staff from the emergency department arrive and transport the individual to the hospital's emergency department to complete the screening and to give any necessary stabilizing treatment. *Application:* The individual presented at an on-campus area of the hospital other than the dedicated emergency department (in this case, the main entry for hospital visitors), with his head bleeding profusely, asking for help. The receptionist, a prudent layperson observing the individual, believed that the individual was seeking emergency examination or treatment, thereby triggering an EMTALA obligation on the part of the hospital. (We note that EMTALA would have been triggered even if no verbal request had been made, since the individual's appearance indicated the clear possibility of an emergency medical condition.) Since the main entry for hospital visitors did not have emergency examination or treatment capabilities, the receptionist appropriately called the hospital's emergency department to summon emergency department staff to provide emergency care for that individual. Once the emergency department staff arrived and transported the individual to the hospital's emergency department, and provided him with the emergency care needed and stabilized the individual, the hospital had satisfied its EMTALA obligation to that individual. Again, we solicit comments from hospitals and physicians that give examples of ways in which hospitals presently react to situations such as for the example noted above. Most individuals who come to hospitals as outpatients come for many nonemergency purposes; under most circumstances, EMTALA would not apply. We are proposing that EMTALA would not apply to such an individual who then experiences what may be an emergency medical condition if the individual is an outpatient (as that term is defined at 42 CFR § 410.2) who has come to the hospital outpatient department for the purpose of keeping a previously scheduled appointment. We would consider such an individual to be an outpatient if he or she has begun an encounter (as that term is defined at § 410.2) with a health professional at the outpatient department. Because such individuals are patients of the hospital already, that is, they have a previously established relationship with the hospital, and have come to the hospital for previously scheduled medical appointments, we believe it is inappropriate that they be considered to have “come to the hospital” for purposes of EMTALA. However, we note that such an outpatient under this proposal who experiences what may be an emergency medical condition after the start of an encounter with a health professional would have all protections afforded to patients of a hospital under the Medicare hospital conditions of participation (as discussed in section V.J.13. of this proposed rule). Hospitals that fail to provide treatment to these patients could face termination of their Medicare provider agreements for a violation of the conditions of participation. In addition, as patients of a health care provider, these individuals are accorded protections under State statutes or common law as well as under general rules of ethics governing the medical professions. Example 3: A patient who had been discharged from inpatient status following knee replacement surgery comes to the hospital outpatient department for a physical therapy session which had been scheduled 2 weeks earlier. While undergoing therapy, the patient complains of chest pains and lightheadedness. Acting under protocols established by the hospital, staff of the outpatient department contact the hospital's dedicated emergency department, which dispatches appropriate personnel to the department. The patient is taken to the hospital's dedicated emergency department for examination. Upon arrival in the dedicated emergency department, she is given a medical screening examination, which reveals that she has an emergency medical condition related to coronary artery disease. She is stabilized in the dedicated emergency department and is released to the care of her daughter. *Application:* In this case, the individual is an outpatient. While she is in a physical therapy session in an outpatient department of the hospital, she experiences what may be an emergency medical condition—chest pains and lightheadedness. This outpatient is under the care of the hospital; she is in a previously scheduled physical therapy appointment and clearly has a previously established relationship with the hospital. In addition, the encounter with hospital staff has begun since her condition arose while she was undergoing therapy. Therefore, although the individual may be experiencing what may be an emergency medical condition, the hospital is not obligated under EMTALA. However, the hospital appropriately provided treatment for this patient, as required under the Medicare conditions of participation (specifically, 42 CFR § 482.55, which requires the hospital to fulfill its condition of participation responsibility for emergency care by contacting the hospital's dedicated emergency department and providing care to the individual through staff of that department). We solicit comments from hospitals and physicians as to what current practices are when an outpatient with a previously scheduled appointment experiences an emergency medical condition. We are proposing to retitle the definition of “property” at § 489.24(b) to “hospital property” and relocate it as a separate definition. In addition, we are proposing to clarify which areas and facilities are not considered hospital property. 9. Scope of EMTALA Applicability to Hospital Inpatients While most issues regarding EMTALA arise in connection with ambulatory patients, questions have occasionally been raised about whether EMTALA applies to inpatients. In late 1998, the United States Supreme Court considered a case ( *Roberts* v. *Galen of Virginia* ) 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 Supreme Court that the Department of Health and Human Services
(DHHS)would develop a regulation clarifying its position on that issue. After reviewing the issue in the light of the EMTALA statute, we are proposing that EMTALA would apply to inpatients only under limited circumstances, as described in the following paragraphs. As noted earlier, once a hospital has incurred an EMTALA obligation with respect to an individual, that obligation continues while the individual remains at the hospital, so that any transfer to another medical facility or discharge of the individual must be in compliance with the rules restricting transfer until the individual is stabilized under existing § 489.24(d). In many cases, medical judgment will dictate that a patient be admitted to the hospital for further treatment on an inpatient basis because the patient's emergency medical condition has not yet been stabilized. In these cases, the hospital continues to be obligated under section 1867, irrespective of the inpatient admission. Admitting an individual whose emergency medical condition has not been stabilized does not relieve the hospital of further responsibility to the individual under this section. An individual's emergency medical condition will be considered to have been stabilized only when the criteria in § 489.24(b) are met; that is, the individual's condition must be such that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during a transfer of the individual from the facility or, if the patient is a pregnant woman who is having contractions, that the woman has delivered the child and the placenta. Consistent with the above policy, we emphasize that an admission to inpatient status cannot be used to evade EMTALA responsibilities. Indeed, permitting inpatient admission to end EMTALA obligations would provide an obvious means of circumventing these requirements that would seemingly contradict the point of the statute to protect emergency patient health and safety. This point should be particularly evident in the case of a woman in labor, a central focus of the statute. Such women are frequently admitted, and the statute clearly contemplated protecting them until completion of the delivery (that is, stabilization). In addition, if an inpatient who had been admitted from the dedicated emergency department with an unstabilized emergency medical condition was never stabilized as an inpatient and is transferred, we would still apply EMTALA in reviewing the transfer. In this context, stability for transfer reflects a complex medical judgment that can be made only based on review of all relevant information in each particular case, including all conditions that could cause the patient to be medically unstable. A patient who goes in and out of apparent stability with sufficient rapidity or frequency would not be considered “stabilized” within the meaning of § 489.24; transient stability of such a patient does not relieve the hospital of its EMTALA obligation. Such a patient would continue to be covered by EMTALA until the patient's overall medical stability with respect to all conditions is achieved. Except for the limited circumstances described above, we are proposing to clarify that EMTALA does not apply to hospital inpatients. We believe EMTALA does not apply to hospital inpatients because we interpret section 1867 of the Act by reading the statutory language as a whole, with the requirements of paragraphs (b), “Necessary Stabilizing Treatment for Emergency Medical Conditions and Labor,” and (c), “Restricting Transfer Until Individual is Stabilized,” applying only to those individuals who satisfy the threshold requirement of coming to the hospital and requesting emergency care (as interpreted in this proposed regulation). This interpretation is based upon the statutory language and the legislative history. First, the Congress defined “emergency medical condition” at section 1867(e)(1) of the Act by referring solely to “acute symptoms,” which are self-identified, and did not mention other potentially relevant indications, in particular, signs or objective data. “Signs” are observable findings that are identified or confirmed by a clinician based on examination and use of objective data (for example, physiologic measurements, x-ray results). When a patient's condition deteriorates in the inpatient setting, awareness of a situation potentially requiring emergency care is based on any symptoms, signs, and objective data, reflecting a situation that is not captured by the targeted definition at section 1867(e)(1) of the Act. If the Congress had intended EMTALA to apply to transfers at any time during an inpatient stay, it would not have used a definition of emergency medical condition that focuses exclusively on symptoms and that uniquely defines the individual's status at the time of his or her initial presentation to the hospital, not his or her status as an inpatient. Furthermore, the definition of “appropriate transfer” in paragraph (c)(2) of section 1867 of the Act includes a variety of terms (observation, signs, symptoms, preliminary diagnosis) associated with patient information that is gathered at the initial stage of clinical intervention, when the course of treatment is just beginning. Thus, it would appear to be clear that the authors of this legislation understood the precise meanings of these clinical terms and utilized them accordingly. Further indication that Congress intended this result is the language in section 1867(b)(1)(A) of the Act (stabilization), which requires that the hospital provide “for such further medical examination” as necessary to stabilize. Congress' use of the word “further” acknowledges that there was some initial treatment that occurred in the emergency department. In addition, the legislative history of EMTALA is replete with references to the problem of individuals denied emergency medical care at hospital emergency rooms, whereas there is no explicit reference to similar problems faced by hospital inpatients. ( *See,* for example, 131 Cong. Rec. 28.587 and 28.588 (1985)). When the Congress considered the need for EMTALA legislation, it noted that Medicare-participating hospitals were bound to meet hospital conditions of participation, but that no specific requirements then existed for appropriate treatment of emergency patients. ( *See* H.R. Rept. No. 241 (I)(1985), reprinted in 1986 U.S.C.C.A.N. 579, 605.) Arguably, the Congress also considered other protections available to hospital inpatients (for example, private causes of action). This interpretation that EMTALA was not intended to apply to transfers at any time during an inpatient's stay is further supported by the language of the appropriate transfer provisions of section 1867(c) of the Act. While that paragraph does refer to individuals at a “hospital,” rather than individuals at an “emergency department,” the same paragraph also makes reference to actions to be taken by “a physician * * * physically present in the emergency department.” This explicit mention of a hospital emergency department, even in a paragraph that generally cites an individual at a “hospital,” supports the view that EMTALA was not intended to apply to admitted inpatients who may become unstable subsequent to admission, but only to patients who initially come to the hospital's emergency department with an emergency medical condition, and only until the condition has been stabilized. Finally, we note that once a hospital admits an individual as a patient, that hospital has a variety of other legal, licensing, and professional obligations with respect to the continued proper care and treatment of such patients. a. Admitted Emergency Patients. A related issue concerns whether a hospital may satisfy its EMTALA obligations to an admitted emergency inpatient only by effectuating an actual stable discharge or appropriate transfer. We are proposing to clarify that even when an admitted emergency patient is not actually transferred, a determination may be made as to whether or not the patient has been stabilized such that he or she could be transferred at a certain point without likely material deterioration of the patient's condition, as defined in section 1867(e)(3)(B) of the Act. Under our proposed policy, if the admitted emergency patient could have been transferred as “stable” under the statute and the period of stability is documented by relevant clinical data in the patient's medical record, the hospital has satisfied its EMTALA obligation by meeting the statutory requirement of providing stabilizing treatment to the point of stability for transfer, and the hospital's obligation under EMTALA ends, even though the patient may remain in inpatient status at the hospital. If, after stabilization, the individual who was admitted as an inpatient again has an apparent decline of his or her medical condition, either as a result of the injury or illness that created the emergency for which he or she initially came to the dedicated emergency department or as a result of another injury or illness, the hospital must comply with the conditions of participation under 42 CFR Part 482, but has no further responsibility under EMTALA with respect to the individual. We also note that, just because a hospital may stabilize a patient for purposes of ending its EMTALA obligation to that patient, this does not relieve the hospital of any further health and safety obligations as to that patient under the Medicare program. While they remain patients in that hospital, these patients are still protected by a number of Medicare health and safety standards (conditions of participation), as explained further below. In addition, as explained above, nothing under EMTALA in any way changes a hospital's other legal, licensing, and professional obligations with respect to the continued proper care and treatment of its patients. Example 4: A patient comes to Hospital C's emergency department and requests treatment for an emergency medical condition. The patient knows he has severe heart disease and his chest pains have become more frequent. The patient receives an appropriate medical screening examination and is found to have an emergency medical condition, as indicated by a pain pattern and EKG abnormalities consistent with unstable angina. Stabilizing treatment in the emergency department on an outpatient basis, consisting of oxygen, nitrates and heparin, is initiated. After several hours of outpatient care, the emergency physician determines that the patient is still not stable for purposes of discharge to his home. The emergency physician concludes that the patient can be treated most effectively by being admitted to Hospital C where he is currently being treated as an outpatient. The patient is admitted as an inpatient for further treatment. The attending physician knows that patients with indications for coronary angioplasty are usually transferred to Hospital D in another city because Hospital D has specialized capabilities that are unavailable at admitting Hospital C. A trip to Hospital D typically requires 2 hours travel by ground ambulance. The physician determines that the patient is stable for purposes of this type of transfer; that is, such a transfer is not likely to result in a material deterioration of the patient's condition, and documents relevant clinical data in the patient's medical record. Even though patients with this degree of coronary arterial disease and acute infarction risk are usually transferred, the patient opposes transfer and wants to remain in the local community. In accordance with the wishes of the patient and his family, the attending physician agrees to treat the patient in Hospital C while informing the patient of the risks involved. *Application:* In this situation, the admitted patient is not stable for purposes of discharge to his home but the attending physician determined that the patient is stable for the type of transfer usually undertaken by Hospital C for patients with unstable angina considered for angioplasty. This stabilization, which is documented by relevant clinical data in the patient's medical record, ends Hospital C's EMTALA obligation to the patient, and that obligation would not be reinstated by any subsequent deterioration in the patient's condition. We are proposing to redesignate paragraph
(c)of § 489.24 as paragraph (d), and include these stabilization requirements under a new proposed § 489.2(d)(2). (Proposed redesignated paragraph
(d)would be revised further as explained in section V.K.9.b. of this preamble.) b. Admitted Elective (Nonemergency) Patients. Most hospital admissions do not consist of emergency cases. In most cases, a patient who comes to the hospital and requests admission does so to obtain elective (nonemergency) diagnosis or treatment for a medical condition. Questions have arisen, however, as to whether a hospital would be bound under EMTALA in the situation in which an admitted nonemergency inpatient experiences a deterioration of his or her medical condition. Under our interpretation of section 1867 of the Act as described above, we believe EMTALA was intended to provide protection to patients coming to a hospital to seek care for an emergency condition. Therefore, we believe that the EMTALA requirements do not extend to admitted nonemergency inpatients. These patients are protected by a number of the Medicare hospital conditions of participation, as explained further under section V.K.13. of this preamble. These patients are further protected by a hospital's other legal, licensing, and professional obligations with respect to the continued proper care and treatment of its patients. We are proposing to also include these requirements under the proposed redesignated § 489.24(d)(2). 10. Applicability of EMTALA to Provider-Based Entities On April 7, 2000, we published a final rule specifying the criteria that must be met for a determination regarding provider-based status (65 FR 18504). The regulations in that the April 2000 final rule were subsequently revised to incorporate changes mandated by section 404 of Public Law 106-554 (66 FR 59856, November 30, 2001). However, those revisions did not substantively affect hospitals' obligations with respect to off-campus departments. a. Applicability of EMTALA to Off-Campus Hospital Departments. In the April 7, 2000 final rule (65 FR 18504), we also clarified the applicability of EMTALA to hospital departments not located on the main provider campus. At that time, we revised § 489.24 to include a new paragraph
(i)to specify the antidumping obligations of hospitals with respect to individuals who come to off-campus hospital departments for the examination or treatment of a potential emergency medical condition. As explained in the preamble to the April 7, 2000 final rule, we made this change because we believed it was consistent with the intent of section 1867 of the Act to protect individuals who present on hospital property (including off-campus hospital property) for emergency medical treatment. Since publication of the April 7, 2000 final rule, it has become clear that many hospitals and physicians continue to have significant concerns with our policy on the applicability of EMTALA to these off-campus locations. After further consideration, we are proposing to clarify the scope of EMTALA's applicability in this scenario to those off-campus departments that are treated by Medicare under § 413.65(b) to be departments of the hospital, and that are equipped and staffed areas that are used a significant portion of the time for the initial evaluation and treatment of outpatients for emergency medical conditions. That is, we are proposing to narrow the applicability of EMTALA to only those off-campus departments that are “dedicated emergency departments” as defined in proposed revised § 489.24(b). This proposed definition would include such departments whether or not the words “emergency room” or “emergency department” were used by the hospital to identify the departments. The definition would also be interpreted to encompass those off-campus hospital departments that would be perceived by a prudent layperson as appropriate places to go for emergency care. Therefore, we are proposing to revise the definition of “Hospital with an emergency department” at § 489.24(b) to account for these off-campus dedicated emergency departments and to also amend the definition of “Comes to the emergency department” at § 489.24(b) to include this same language. We believe this proposed change would enhance the quality of emergency care by facilitating the prompt delivery of emergency care in those cases, thus permitting individuals to be referred to nearby facilities with the capacity to offer appropriate emergency care. In general, we expect that off-campus departments that meet the proposed definitions stated above would in practice be functioning as “off-campus emergency departments.” Therefore, we believe it is reasonable to expect the hospital to assume, with respect to these off-campus departments, all EMTALA obligations that the hospital must assume with respect to the main hospital campus emergency department. For instance, the screening and stabilization or transfer requirements described in section V.K.1. of this preamble (“Background”) would extend to the off-campus emergency departments, as well as to any such departments on the main hospital campus. In conjunction with this proposed change in the extent of EMTALA applicability with respect to off-campus facilities, we are also proposing to delete all of existing § 489.24(i), which, as noted above, was established in the April 7, 2000 final rule. We are proposing to delete this paragraph in its entirety because its primary purpose is to describe a hospital's EMTALA obligations with respect to patients presenting to off-campus departments that do not routinely provide emergency care. Under the proposals outlined above, however, a hospital would have no EMTALA obligation with respect to individuals presenting to such departments. Therefore, it would no longer be necessary to impose the requirements in existing § 489.24(i). Even though off-campus provider-based departments that do not routinely offer services for emergency medical conditions would not be subject to EMTALA, some individuals may occasionally come to them to seek emergency care. Under such circumstances, we believe it would be appropriate for the department to call an emergency medical service
(EMS)if it is incapable of treating the patient, and to furnish whatever assistance it can to the individual while awaiting the arrival of EMS personnel. Consistent with the hospital's obligation to the community and similar to our requirements under § 482.12(f)(2) that apply to hospitals that do not provide emergency services, we would expect the hospital to have appropriate protocols in place for dealing with individuals who come to off-campus nonemergency facilities to seek emergency care. To clarify a hospital's responsibility in this regard, we are proposing to revise § 482.12(f) by adding a new paragraph
(3)to state that if emergency services are provided at the hospital but are not provided at one or more off-campus departments of the hospital, the governing body of the hospital must assure that the medical staff of the hospital has written policies and procedures in effect with respect to the off-campus department(s) for appraisal of emergencies and referral when appropriate. (We note that, in a separate document (62 FR 66758, December 16, 1997), we proposed to relocate the existing § 482.12(f) requirement to a new section of Part 482. Any change to the existing § 482.12(f) that is adopted as a result of the proposal described above will be taken into account in finalizing the December 19, 1997 proposal.) However, the hospital would not incur an EMTALA obligation with respect to the individual. In summary, we are proposing in existing § 489.24(b) to revise the definitions of “comes to the emergency department” and “hospital with an emergency department”, and to include these off-campus departments in our new definition of “dedicated emergency department.” We welcome comments on whether this new term is needed or if the term “emergency department” could be defined more broadly to encompass other departments that provide urgent or emergent care services. We are proposing to delete all of existing § 489.24(i) and to make conforming revisions to § 413.65(g)(1). b. On-Campus Provider-Based Applicability. At existing § 413.65(g)(1), we state, in part, that if any individual comes to any hospital-based entity (including an RHC) located on the main hospital campus, and a request is made on the individual's behalf for examination or treatment of a medical condition, the entity must comply with the antidumping rules at § 489.24. Since provider-based entities, as defined in § 413.65(b), are not under the certification and provider number of the main provider hospital, this language, read literally, would appear to impose EMTALA obligations on providers other than hospitals, a result that would not be consistent with section 1867, which restricts EMTALA applicability to hospitals. To avoid confusion on this point and to prevent any inadvertent extension of EMTALA requirements outside the hospital setting, we are proposing to clarify that EMTALA applies in this scenario to only those *departments* on the hospital's main campus that are provider-based; EMTALA would not apply to provider-based *entities* (such as RHCs) that are on the hospital campus. In addition, we are proposing in § 489.24(b) to revise the definition of “Comes to the emergency department” to include an individual who presents on hospital property, in which “hospital property” is in part defined as “the entire main hospital campus as defined at § 413.65(b) of this chapter, including the parking lot, sidewalk, and driveway, but excluding other areas or structures that may be located within 250 yards of the hospital's main building but are not part of the hospital, such as physician offices, RHCs, SNFs, or other entities that participate separately in Medicare, or restaurants, shops, or other nonmedical facilities.” We are specifically seeking comments on this proposed revised definition. Generally, this proposed language would clarify that EMTALA does not apply to provider-based entities, whether or not they are located on a hospital campus. This language is also consistent with our policy as stated in questions and answers published on the CMS website: *www.cms.gov* (CMS EMTALA guidance, 7/20/01, Q/A # 1) that clarifies that EMTALA does not apply to other areas or structures located on the hospital campus that are not part of the hospital, such as fast food restaurants or independent medical practices. If this proposed change limiting EMTALA applicability to only those on-campus departments of the hospital becomes finalized, we believe that if an individual comes to an on-campus provider-based entity or other area or structure on the campus not applicable under the new policy and presents for emergency care, it would be appropriate for the entity to call the emergency medical service if it is incapable of treating the patient, and to render whatever assistance it can to the individual while awaiting the arrival of emergency medical service personnel. However, the hospital on whose campus the entity is located would not incur an EMTALA obligation with respect to the individual. We welcome comments from providers and other interested parties on the proper or best way to organize hospital resources to react to situations on campus where an individual patient or prospective patient requires immediate medical attention. We are proposing in § 489.24(b) to revise the definition of “Comes to emergency department” (specifically, under proposed new paragraph (1)) and make conforming changes at § 413.65(g)(1). 11. EMTALA and On-Call Requirements We have frequently received inquiries concerning the applicability of EMTALA for physicians on call. We believe there are a number of misconceptions in the provider industry concerning the extent to which EMTALA requires physicians to provide on-call coverage. Therefore, we are including a section in this preamble that clarifies what kinds of obligations physicians have to provide on-call coverage under EMTALA. Section 1866(a)(1)(I)(iii) of the Act states, as a requirement for participation in the Medicare program, that hospitals 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 emergency screening or 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. The CMS State Operations Manual
(SOM)further clarifies a hospital's responsibility for the on-call physician. The SOM (Appendix V, page V-15, Tag A404) states: • Each hospital has the discretion to maintain the on-call list in a manner to best meet the needs of its patients. • Physicians, including specialists and subspecialists (for example, neurologists), are not required to be on call at all times. 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. Thus, hospitals are required to maintain a list of physicians on call at any one time and physicians or hospitals, or both, may be responsible under the EMTALA statute to provide emergency care if a physician who is on the on-call list fails to or refuses to appear within a reasonable period of time. However, Medicare does not set requirements on how frequently a hospital's staff of on-call physicians are expected to be available to provide on-call coverage. We are aware that practice demands in treating other patients, conferences, vacations, days off, and other similar factors must be considered in determining the availability of staff. We also are aware that some hospitals, particularly those in rural areas, have stated that they incur relatively high costs of compensating physician groups for providing on-call coverage to their emergency departments, and that doing so can strain their already limited financial resources. CMS allows hospitals flexibility to comply with EMTALA obligations by maintaining a level of on-call coverage that is within their capability. We understand that some hospitals exempt senior medical staff physicians from being on call. This exemption is typically written into the hospital's medical staff bylaws or the hospital's rules and regulations, and recognizes a physician's active years of service (20 or more years) or age (that is, 60 years of age or older), or a combination of both. We wish to clarify that providing such exemptions to members of hospitals' medical staff does not necessarily violate EMTALA. On the contrary, we believe that the hospital is responsible for maintaining an on-call list in a manner that best meets the needs of its patients as long as the exemption does not affect patient care adversely. Thus, CMS allows hospitals flexibility in the utilization of their emergency personnel. We also note that there is no predetermined “ratio” that CMS uses to identify how many days that a hospital must provide medical staff on-call coverage based on the number of physicians on staff for that particular specialty. In particular, CMS has no rule stating that whenever there are at least three physicians in a specialty, the hospital must provide 24 hour/7 day coverage. Generally, in determining EMTALA compliance, CMS will consider all relevant factors, including the number of physicians on staff, other demands on these physicians, the frequency with which the hospital's patients typically require services of on-call physicians, and the provisions the hospital has made for situations in which a physician in the specialty is not available or the on-call physician is unable to respond. Example 5: Hospital D has 75 beds and is located in a rural area. The hospital provides on-call coverage of orthopedic services on all weekdays and the first 3 weekends of each month. On the fourth weekend of one month, an individual presents at Hospital D's dedicated emergency department and requests examination for a medical condition. The emergency physician on duty screens the individual and finds that she has an orthopedic emergency medical condition requiring the services of an orthopedist. Hospital D does not have on-call orthopedic physician coverage on this date and, therefore, transfers the individual to an urban hospital 20 miles away for necessary treatment. The transfer is arranged in accordance with procedures that Hospital D has for meeting patient needs when a particular specialty is not available or the physician cannot respond for reasons beyond his or her control. *Analysis:* Hospital D incurred an EMTALA obligation when the individual presented at Hospital D's dedicated emergency department and requested examination for a medical condition. At that time, Hospital D did not have on-call coverage to provide necessary stabilizing treatment for what was an orthopedic emergency medical condition, even though an orthopedic physician was on-call at other times. The emergency physician at Hospital D weighed the risks involved to transfer the individual to an urban hospital with capabilities to treat the individual and found that it would be more beneficial to the individual to transfer him or her to the urban hospital 20 miles away, than to provide screening and stabilizing treatment within Hospital D's capabilities (which, at that time, did not include orthopedic services). Hospital D has satisfied its EMTALA obligation by providing screening services within its capability, followed by an appropriate transfer, under procedures developed in advance. To clarify our policies on EMTALA requirements regarding the availability of on-call physicians, we are proposing to add to § 489.24 a new paragraph
(j)to specify that each hospital has the discretion to maintain the on-call list in a manner to best meet the needs of its patients. This paragraph would further specify that physicians, including specialists and subspecialists (for example, neurologists), 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. 12. EMTALA Applicability to Hospital-Owned Ambulances We stated in the June 22, 1994 final rule (59 FR 32098) that if an individual is in an ambulance owned and operated by a hospital, the individual is considered to have come to the hospital's emergency department, even if the ambulance is not on hospital property. This policy, currently set forth at § 489.24(b), was necessary because we were concerned that some hospitals that owned and operated ambulances at that time were transporting individuals who had called for an ambulance to other hospitals, thereby evading their EMTALA responsibilities to the individuals. Concerns have since been raised by the provider industry about applications of this policy to ambulances that are owned by hospitals but are operating under communitywide EMS protocols that may require the hospital-owned and other ambulances to transport individuals to locations other than the hospitals that own the ambulances. For instance, we understand that some community protocols require ambulances to transport individuals to the nearest hospital to the patient geographically, whether or not that hospital owns the ambulance. To avoid imposing requirements that are inconsistent with local EMS requirements, we are proposing to clarify, at proposed revised § 489.24(b) in the definition of “Comes to the emergency department”, an exception to our existing rule requiring EMTALA applicability to hospitals that own and operate ambulances. Our proposal would account for hospital-owned ambulances operating under communitywide EMS protocols. Under our proposal, the rule on hospital-owned ambulances and EMTALA does not apply if the ambulance is operating under a communitywide EMS protocol that requires it to transport the individual to a hospital other than the hospital that owns the ambulance. In this case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property. 13. Conditions of Participation for Hospitals We are reminding hospitals and others that while this proposed regulation would make it clear that stabilizing an emergency inpatient relieves the hospital of its EMTALA obligations, it does not relieve the hospital of all further responsibility for the patient who is admitted or indicate that the hospital is thus free to improperly discharge or transfer him or her to another facility. Inpatients who experience acute medical conditions receive protections under the hospital conditions of participation, which are found at 42 CFR part 482. In addition, as noted earlier in this preamble, we believe that outpatients who experience what may be an emergency medical condition after the start of an encounter with a health professional would have all protections afforded to patients of a hospital under the Medicare conditions of participation. There are six conditions of participation that provide these protections: emergency services, governing body, discharge planning, quality assurance, medical staff, and outpatient services. We are not proposing in this proposed rule to make changes to any of the conditions of participation. If a hospital inpatient develops an acute medical condition and the hospital is one that provides emergency services, the hospital is required to ensure that it meets the emergency needs of the patient in accordance with accepted standards of practice. Similarly, regardless of whether the hospital provides emergency services, if an inpatient develops an acute medical condition, the governing body condition of participation (§ 482.12(f)(2), which applies to all Medicare-participating hospitals) would apply. This condition of participation requires that the hospital governing body must ensure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. The discharge planning condition of participation (§ 482.43, which applies to all Medicare-participating hospitals) requires hospitals to have a discharge planning process that applies to all patients. This condition of participation ensures that patient needs are identified and that transfers and referrals reflecting adequate discharge planning are made by the hospital. If an inpatient develops an acute medical condition and the hospital either does not offer emergency services or does not have the capability to provide necessary treatment, a transfer to another hospital with the capabilities to treat the emergency medical condition could be warranted. Hospitals are required to meet the discharge planning condition of participation in carrying out such a transfer. The hospital condition of participation governing medical staff (§ 482.22) requires that the hospital have an organized medical staff that operates under bylaws approved by the governing body and is responsible to the governing body for the quality of medical care provided to patients by the hospital. Should the medical staff not be held accountable to the governing body for problems regarding a lack of provision of care to an inpatient who develops an emergency medical condition, this lack of accountability may be reviewed under the medical staff condition of participation, as well, and may result in a citation of noncompliance at the medical staff condition level for the hospital. Finally, the quality assurance condition of participation (§ 482.21, which applies to all Medicare-participating hospitals) requires the governing body to ensure that there is an effective, hospital-wide quality assurance program to evaluate the provision of patient care. In order to comply with this condition of participation, the hospital must evaluate the care it provides hospital-wide. Complaints regarding a lack of provision of care to an inpatient who develops an emergency medical condition must be addressed under the hospital's quality assurance program and may be reviewed under the quality assurance condition of participation. A hospital's failure to meet the conditions of participation requirements cited above may result in a finding of noncompliance at the condition level for the hospital and lead to termination of the hospital's Medicare provider agreement. K. Provider-Based Entities 1. Background a. The April 7, 2000 Final Rule Since the beginning of the Medicare program, some providers, which we refer to as “main providers,” have functioned as a single entity while owning and operating multiple provider-based departments, locations, and facilities that were treated as part of the main provider for Medicare purposes. Having clear criteria for provider-based status is important because this designation can result in additional Medicare payments for services furnished at the provider-based facility, and may also increase the coinsurance liability of Medicare beneficiaries for those services. In the April 7, 2000 **Federal Register** (65 FR 18504), we published a final rule specifying the criteria that must be met for a determination regarding provider-based status. The regulations at § 413.65(a)(2) define provider-based status as “the relationship between a main provider and a provider-based entity or a department of a provider, remote location of a hospital, or satellite facility, that complies with the provisions of this section.” The regulations at existing § 413.65(b)(2) state that before a main provider may bill for services of a facility as if the facility is provider-based, or before it includes costs of those services on its cost report, the facility must meet the criteria listed in the regulations at § 413.65(d). Among these criteria are the requirements that the main provider and the facility must have common licensure (when appropriate), the facility must operate under the ownership and control of the main provider, and the facility must be located in the immediate vicinity of the main provider. The effective date of these regulations was originally October 10, 2000, but was subsequently delayed and is now in effect for new facilities or organizations for cost reporting periods beginning on or after January 10, 2001, as explained further below. Program instructions on provider-based status issued before that date, found in Section 2446 of the Provider Reimbursement Manual, Part 1 (PRM-1), Section 2004 of the Medicare State Operations Manual (SOM), and CMS Program Memorandum
(PM)A-99-24, will apply to any facility for periods before the new regulations become applicable to it. (Some of these instructions will not be applied because they have been superseded by specific legislation on provider-based status, as described in section V.K.3. of this preamble). b. Frequently Asked Questions Regarding Provider-Based Issues Following publication of the April 7, 2000 final rule, we received many requests for clarification of policies on specific issues related to provider-based status. In response, we published a list of “Frequently Asked Questions” and the answers to them on the CMS website at *www.hcfa.gov/medlearn/provqa.htm.* (This document can also be obtained by contacting any of the CMS (formerly, HCFA) Regional Offices.) These questions and answers did not revise the regulatory criteria, but do provide subregulatory guidance for their implementation. c. Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554) On December 21, 2000, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
(BIPA)of 2000 (Public Law 106-554) was enacted. Section 404 of BIPA contains provisions that significantly affect the provider-based regulations at § 413.65. Section 404 includes a grandfathering provision for facilities treated as provider-based on October 1, 2000; alternative criteria for meeting the geographic location requirement; and criteria for temporary treatment as provider-based.
(1)Two-Year “Grandfathering” Under section 404(a) of BIPA, any facilities or organizations that were “treated” as provider-based in relation to any hospital or CAH on October 1, 2000, will continue to be treated as such until October 1, 2002. For the purpose of this provision, we interpret “treated as provider-based” to include those facilities with formal CMS determinations, as well as those facilities without formal CMS determinations that were being paid as provider-based as of October 1, 2000. As a result, existing provider-based facilities and organizations may retain that status without meeting the criteria in the existing regulations under §§ 413.65(d), (e), (f), and
(h)until October 1, 2002. These provisions concern provider-based status requirements, joint ventures, management contracts, and services under arrangement. Thus, the provider-based facilities and organizations affected under section 404(a) of BIPA are not required to submit an application for or obtain a provider-based status determination in order to continue receiving reimbursement as provider-based during this period. These provider-based facilities and organizations are not exempt from the EMTALA responsibilities of provider-based facilities and organizations set forth at § 489.24, which we are proposing to revise as discussed above, or from the other obligations of hospital outpatient departments and hospital-based entities in existing § 413.65(g), such as the responsibility of off-campus facilities to provide written notices to Medicare beneficiaries of coinsurance liability. These rules are not preempted by the grandfathering provisions of section 404 of BIPA because they do not set forth criteria that must be met for provider-based status as a department of a hospital, but instead identify responsibilities that flow from that status. These responsibilities become effective for hospitals on the first day of the hospital's cost reporting period beginning on or after January 10, 2001.
(2)Geographic Location Criteria Section 404(b) of BIPA provides that those facilities or organizations that are not included in the grandfathering provision at section 404(a) are deemed to comply with the “immediate vicinity” requirements of the existing regulations under § 413.65(d)(7) if they are located not more than 35 miles from the main campus of the hospital or CAH. Therefore, those facilities located within 35 miles of the main provider satisfy the immediate vicinity requirement as an alternative to meeting the “75/75 test” under existing § 413.65(d)(7). In addition, BIPA provides that certain facilities or organizations are deemed to comply with the requirements for geographic proximity (either the “75/75 test” or the “35-mile test”) if they are owned and operated by a main provider that is a hospital with a disproportionate share adjustment percentage greater than 11.75 percent and is
(1)owned or operated by a unit of State or local government,
(2)a public or private nonprofit corporation that is formally granted governmental powers by a unit of State or local government, or
(3)a private hospital that has a contract with a State or local government that includes the operation of clinics of the hospital to ensure access in a well-defined service area to health care services for low-income individuals who are not entitled to benefits under Medicare or Medicaid. These geographic location criteria will continue indefinitely. While those facilities or organizations treated as provider-based on October 1, 2000 are covered by the 2-year grandfathering provision noted above, the geographic location criteria at section 404(b) of BIPA and the existing regulations at § 413.65(d)(7) will apply to facilities or organizations not treated as provider-based as of that date, effective with the hospital's cost reporting period beginning on or after January 10, 2001. On October 1, 2002, the statutory moratorium on application of these criteria to the grandfathered facilities will expire. In this proposed rule, we are proposing a further delay, as discussed below.
(3)Criteria for Temporary Treatment as Provider-Based Section 404(c) of BIPA also provides that a facility or organization that seeks a determination of provider-based status on or after October 1, 2000, and before October 1, 2002, shall be treated as having provider-based status for any period before a determination is made. Thus, recovery for overpayments will not be made retroactively once a request for a determination during that time period has been made. For hospitals that do not qualify for grandfathering under section 404(a) of BIPA, a request for provider-based status should be submitted to the appropriate CMS Regional Office. Until a uniform application is available, at a minimum, the request should include the identity of the main provider and the facility or organization for which provider-based status is being sought and supporting documentation for purposes of applying the provider-based status criteria in effect at the time the application is submitted. Once such a request has been submitted on or after October 1, 2000, and before October 1, 2002, CMS will treat the facility or organization as being provider-based from the date it began operating as provider-based until the effective date of a CMS determination that the facility or organization is not provider-based. Facilities requesting a provider-based status determination on or after October 1, 2002, will not be covered by the provision concerning temporary treatment as provider-based in section 404(c) of BIPA. Thus, as stated in § 413.65(n), the CMS Regional Offices will make provider-based status effective as of the earliest date on which a request for determination has been made and all requirements for provider-based status in effect as of the date of the request are shown to have been met, not on the date of the formal CMS determination. Under existing regulations at § 413.65(j), if a facility or organization does not qualify for provider-based status and CMS learns that the provider has treated the facility or organization as provider-based without having obtained a provider-based determination under applicable regulations, CMS will review all payments and may seek recovery for overpayments, including overpayments made for the period of time between submission of the request or application for provider-based status and the issuance of a formal CMS determination. (As explained in the previous paragraph, such retroactive recovery of payments would not be made for any period to the extent it is prohibited by section 404(c) of BIPA.) d. The August 24, 2001 and November 30, 2001 Published Regulations In August 24, 2001 **Federal Register** (66 FR 44672), we proposed to revise the provider-based regulations to reflect the changes mandated by section 404 of BIPA and to make other technical and clarifying changes in those regulations. In the November 30, 2001 **Federal Register** (66 FR 59856), following consideration of public comments received on the August 24, 2001 proposal, we published a final rule that revised the provider-based regulations. However, the only substantive changes in the provider-based regulations were those required by the BIPA legislation. 2. Proposed Changes In the preamble to the proposed rule published on August 24, 2001 (66 FR 44709), we stated our intent to reexamine the EMTALA regulations and, in particular, to reconsider the appropriateness of applying EMTALA to off-campus locations. We announced that we planned to review these regulations with a view toward ensuring that these locations are treated in ways that are appropriate to the responsibility for EMTALA compliance of the hospital as a whole. We also pointed out that, at the same time, we want to ensure that those departments that Medicare pays as hospital-based departments are appropriately integrated with the hospital as a whole. In addition, since the statutory grandfathering provision in the BIPA legislation remains in effect only until October 1, 2002, many hospital representatives have contacted CMS to request more guidance because they are concerned that their facilities are not in compliance with existing regulations and would not be able to continue billing as provider-based once the grandfathering provision expires. These hospital representatives are also concerned that the organizational and contractual changes needed to meet current provider-based requirements could take several months to complete. Moreover, resolution of some of the issues surrounding the provider-based regulations is needed in order to allow development of a uniform application form to enable the CMS Regional Offices to efficiently process the multitudes of requests for provider-based determinations that we expected as the grandfathering period expires. To address the provider-based issues raised by the hospital industry and to allow for an orderly and uniform implementation strategy once grandfathering ends, we are proposing the following regulatory changes: a. Scope of Provider-Based Requirements (§ 413.65(a)) Since publication of the April 2000 final rule, we have received many questions about which specific facilities or organizations are subject to the provider-based requirements. In the “Frequently Asked Questions” posted on the CMS website, we identified a number of facility types for which provider-based determinations would not be made, since such determinations would not affect either Medicare payment or Medicare beneficiary liability or scope of benefits. The regulations at § 413.65(a) were further revised to incorporate the exclusion of these facility types from review under the provider-based criteria. We now are proposing to further revise § 413.65(a)(1)(ii) to state that provider-based determinations will not be made with respect to independent diagnostic testing facilities that furnish only services paid under a fee schedule, such as facilities that furnish only screening mammography services, as defined in section 1861(jj) of the Act, facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only some combination of these services. A provider-based determination would not be appropriate for a facility that furnishes only screening mammography because of a change made by section 104 of BIPA. That legislation, which amended section 1848(j)(3) of the Act, mandates that all payment for screening mammography services furnished on or after January 1, 2000, be made under the Medicare Physician Fee Schedule (MPFS). Under the MPFS methodology, Medicare payment for the service, regardless of the setting in which it is furnished, is set at the lesser of the fee schedule amount or the actual charge; and no Part B deductible applies. Regardless of the setting, Part B coinsurance is assessed at 20 percent of the lesser of the fee schedule amount or the actual charge. Because the status of a facility as provider-based or freestanding would not affect the amount of Medicare or Medicaid payment, the beneficiary's scope of benefits, or the beneficiary's liability for coinsurance or deductible amounts, it is not necessary to make a provider-based determination regarding facilities that furnish only screening mammography. We are also proposing to revise § 413.65(a)(1)(ii) by adding a new paragraph
(J)to state that we will not make provider-based determinations with respect to departments of providers (for example, laundry or medical records departments) that do not furnish types of health care services for which separate payment could be claimed under Medicare or Medicaid. (Such services frequently are referred to as “billable” services.) As explained more fully below, we would not make determinations with respect to these departments because their status (that is, whether they are provider-based or not) would have no impact on Medicare or Medicaid payment or on the scope of benefits or beneficiary liability under either program. Despite the previous clarifications described above, providers, associations, and their representatives have continued to state that they are confused as to which facilities or organizations will be the subject of provider-based determinations. In this document, we are proposing to further clarify the types of facilities that are subject to the provider-based rules, by making several changes to the definitions of key terms in § 413.65(a)(2). First, we are proposing to revise the definition of “department of a provider” to remove the reference to a physician office as being a department of a provider. While a hospital outpatient department, in fact, may furnish services that are clinically indistinguishable from those of physician offices, physician offices and provider departments are paid through separate methods under Medicare and beneficiaries may be liable for different coinsurance amounts. Thus, it is essential to distinguish between these facility types, and we believe avoiding confusion on this issue requires us to remove the reference to a hospital department as a physician office. We also are proposing to revise § 413.65(a)(2) to state that a “department of a provider”, “provider-based entity”, or “remote location of a hospital” comprises both the specific physical facility that serves as the site of services of a type for which separate payment could be claimed under the Medicare or Medicaid programs, and the personnel and equipment needed to deliver the services at that facility. We believe this change would help to clarify that we would make determinations with respect to entities considered in their role as sources of health care services and not simply as physical locations. We also wish to clarify that we do not intend to make provider-based determinations with respect to various organizational components or units of providers that may be designated as “departments” or “organizations” but do not themselves furnish types of services for which separate payment could be claimed under Medicare or Medicaid. Examples of components for which we would not make provider-based determinations include the medical records, housekeeping, and security departments of a hospital. Such departments do perform functions that are essential to the provision of inpatient and outpatient hospital services, but the departments do not provide health care services for which Medicare or Medicaid benefits are provided under title XVIII or title XIX of the Act, and for which separate payment therefore could be claimed, assuming certification and other applicable requirements were met, to one or both programs. Therefore, neither Medicare or Medicaid program liability nor beneficiary liability or scope of benefits would be affected by the ability or inability of these departments to qualify as “provider-based.” (We also would not make a provider-based determination with respect to any facility or organization that furnishes only types of health care services for which separate payment could be claimed under either Medicare or Medicaid, even if the facility or organization met all requirements for provider-based status. For example, if a hospital that is not eligible for DSH payments under Medicare or Medicaid or for IME payments under Medicare were to establish a dedicated facility providing only types of cosmetic surgery or experimental therapies that could not be covered under either Medicare or Medicaid, no determination would be made with respect to that facility.) By contrast, Medicare or Medicaid payment (or both) to hospital departments that provide diagnostic or therapeutic radiology services to outpatients, or primary care, ophthalmology, or other specialty services to outpatients are affected by provider-based status, as would beneficiary liability for Medicare coinsurance amounts. Therefore, we would make provider-based determinations for these departments. Similarly, if two acute care hospitals that have approved graduate medical education
(GME)programs were to merge to form a single, multicampus hospital consisting of the main hospital campus and a remote location, it would be appropriate to make a determination as to whether the remote location is provider-based with respect to the main hospital campus. Such a determination would be needed because each hospital with an approved residency training program has its own hospital-specific cap on the number of residents (or FTE cap), its own PRA, and its own Medicare utilization used for purposes of receiving Medicare GME payments. A merger of the two hospitals would aggregate the two hospitals' individual FTE caps into a merged FTE cap under the main hospital's provider number, and would require recalculation of the hospital's PRA and a merging of these entities' respective Medicare utilization, resulting in a level of Medicare GME payment to the merged hospital that exceeds the sum of the payments that would be made to each hospital as separate entities. Thus, a provider-based determination would be appropriate and necessary in such a case, even though payment for services by both facilities would be made under the Medicare acute care hospital inpatient prospective payment system. In deciding whether to make a provider-based determination with respect to a particular facility, it would not be significant that the facility might have a low rate of Medicare utilization, might be utilized by only Medicare or only Medicaid patients, or might not have admitted any Medicare or Medicaid patients in a particular period. The fact that the facility furnishes types of services that are billable under Medicare or Medicaid, or both, would be sufficient to make a determination appropriate. We are proposing to retain the rules that a department of a provider or a remote location of a hospital (such as, for example, one campus of a multicampus hospital) may not by itself be qualified to participate in Medicare as a provider under the regulations on provider agreements in § 489.2, and the Medicare conditions of participation do not apply to a department as an independent entity. However, we are proposing to delete the requirement at § 413.65(a)(2) that such a department may not be licensed to provide services in its own right. Some States require separate licensing of facilities that Medicare would treat as a department of a hospital or other provider. In these States, we would not require a common license. We would retain the provision that, for purposes of Part 413, the term “department of a provider” does not include an RHC or, except as specified in § 413.65(m), an FQHC. Questions have arisen regarding whether the provider-based criteria in § 413.65 are applicable in determining payment for ambulance services. Medicare is converting payment for ambulance services to a fee schedule, as described in a final rule published on February 27, 2002 (67 FR 9100). The ambulance fee schedule is effective April 1, 2001, and involves a transition period. During this transition period, the status of an ambulance supplier as provider-based could influence the amount of Medicare payment. However, the specific provider-based criteria in § 413.65 were not developed for ambulance suppliers, and we believe that many of these criteria could not reasonably be applied to them. Therefore, we are not proposing to apply the criteria at § 413.65 to ambulance services. b. Further Delay in Effective Date of Provider-Based Rules As noted earlier, § 413.65(b) was recently revised to reflect the “grandfathering” provision in section 404(a)(1) of BIPA. Under that provision, if a facility was treated as provider-based in relation to a hospital or CAH on October 1, 2000, it will continue to be considered provider-based in relation to that hospital or CAH until October 1, 2002. It now appears likely that any new provider-based rules that may be adopted as the result of this rulemaking effort will not be published in final before mid-summer of 2002. To allow hospitals and other facilities the time they need to make contractual and organizational changes to comply with the new rules, and to ensure that CMS Regional Offices and contractors are able to provide for an orderly transition to the new provider-based rules, we believe an additional delay in the effective date of the provider-based criteria is needed. Therefore, we are proposing to revise § 413.65(b)(2) to state that if a facility was treated as provider-based in relation to a hospital or CAH on October 1, 2000, it will continue to be considered provider-based in relation to that hospital or CAH until the start of the hospital's first cost reporting period beginning on or after July 1, 2003. We are proposing to further provide that the requirements, limitations, and exclusions specified in § 413.65(d) through
(j)(as proposed to be redesignated) will not apply to that hospital or CAH for that facility until the start of the hospital's first cost reporting period beginning on or after July 1, 2003. For purposes of paragraph (b)(2), a facility would be considered as having been provider-based on October 1, 2000, if on that date it either had a written determination from CMS that it was provider-based, or was billing and being paid as a provider-based department or entity of the hospital. We are proposing to make the new requirements effective on October 1, 2002, with respect to provider-based status for facilities not qualifying for the grandfathering provision. c. Revision of Application Requirement Existing regulations at § 413.65(b)(2) establish an explicit application requirement for all facilities seeking provider-based status, except for grandfathered facilities and those treated as provider-based pending a determination on an application filed on or after October 1, 2000, and before October 1, 2002. Under existing § 413.65(b)(3), a main provider or a facility must contact CMS, and the facility must be determined by CMS to be provider-based, before the main provider bills for services of the facility as if the facility were provider-based, or before it includes costs of those services on its cost report. Many providers and provider representatives have expressed concern that the requirement to file an application will increase paperwork burden for hospitals unnecessarily. In response to these concerns, we are proposing to revise the application requirements as follows: First, we would delete the existing application requirement under § 413.65(b)(3). We are proposing to revise this section to state that except where payment is required to be made under BIPA, as specified in proposed revised § 413.65(b)(2) and (b)(5), if a potential main provider seeks an advance determination of provider-based status for a facility that is located on the main campus of the potential main provider, the provider would be required to submit an attestation stating that its facility meets the criteria in § 413.65(d) and, if it is a hospital, also attest that its facility will fulfill the obligations of hospital outpatient departments and hospital-based entities, as described in proposed § 413.65(g). The provider also would be required to maintain documentation of the basis for its attestations and to make that documentation available to CMS upon request. We note that, under our proposal, there would no longer be an explicit requirement that a provider-based approval be obtained before a facility is treated as provider-based for billing or cost reporting purposes. However, under the proposed revisions to existing § 413.65(k) (Correction of errors) as described below, CMS would provide a delay in the effective date for any facility that is found not to meet the provider-based criteria following a previous advance determination, if the reason the provider-based criteria are not met is a material change in the provider-facility relationship that was properly reported to CMS. The removal of provider-based status would be effective as of the first cost reporting period following notification of the redetermination, but not less than 6 months after the date of notification. We are further proposing that if the facility is not located on the main campus of the potential main provider, the provider that wishes to obtain an advance determination of provider-based status would be required to submit an attestation stating that its facility meets the criteria in proposed revised §§ 413.65(d) and
(e)and, if the facility is operated as a joint venture or under a management contract, the requirements in proposed §§ 413.65(f) and (h), as applicable. If the potential main provider is a hospital, the hospital also would be required to attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in proposed revised § 413.65(g). The provider seeking such an advance determination would be required to supply documentation of the basis for its attestations to CMS at the time it submits its attestations. We believe the use of a self-attestation process would strike an appropriate balance between the legitimate interests of hospitals in reducing paperwork and reporting, and the equally legitimate need of CMS to ensure proper accountability for compliance with the qualification requirements for a status that typically leads to a higher level of Medicare or Medicaid payment. We note that, under these proposed revisions to the application procedures at § 413.65(b), a hospital would not be explicitly required to submit an application and receive a provider-based determination for a facility before the time at which the hospital may bill for services at that facility as provider-based. However, we are considering, alternatively, retaining the existing regulations at § 413.65(b)(2) which state that, except where payment is required to be made under BIPA as specified in proposed revised §§ 413.65(b)(2) and (b)(5), hospitals are explicitly required to submit provider-based applications, and to withhold billing as provider-based until CMS determines that a facility meets the provider-based rules. We are soliciting comments on the appropriateness of this or other alternative application procedures. d. Requirements Applicable to All Facilities or Organizations Under existing § 413.65, all facilities seeking provider-based status with respect to a hospital or other main provider must meet a common set of requirements. These include requirements relating to common licensure (paragraph (d)(1)), operation under the ownership and control of the main provider (paragraph (d)(2)), administration and supervision (paragraph (d)(3)), integration of clinical services (d)(4)), financial integration (paragraph (d)(5)), public awareness (paragraph (d)(6)), and location in the immediate vicinity of the main provider (paragraph (d)(7)). (In addition, as described more fully below, specific rules applicable to all facilities rule out provider-based status for facilities operated as joint ventures by two or more providers (paragraph (e)) and limit the types of management contracts that facilities seeking provider-based status may operate under (paragraph (f)).) Since publication in final of the existing provider-based rules in April 2000, hospitals and other providers have expressed concern that the requirements outlined above are overly restrictive and do not allow them enough flexibility to enter into appropriate business arrangements with other facilities. We understand these concerns, and agree that Medicare rules should not restrict legitimate business arrangements that do not lead to abusive practices or disadvantage Medicare beneficiaries. At the same time, we believe our existing rules provide a high level of assurance that a facility complying with them is, in fact, an integral and subordinate part of the facility with which it is based, and do not accord provider-based status to facilities that are not integral and subordinate to a main provider, but in fact have only a nominal relationship with that provider. After considering all comments received on these issues, we believe that further changes in the provider-based rules would be appropriate. In particular, we agree with those who argue that a facility's or organization's location relative to the main campus of the provider is relevant to the integration that is likely to exist between the facility or organization and the main provider. For example, if a facility or organization is located on the main campus of a provider, is operated under the main provider's State license, is medically and financially integrated with that provider, and is held out to the public and other payers as a part of that provider, we believe the necessary degree of integration of the facility or organization into the main provider can be assumed to exist. We also are concerned that further prescribing the types of management contracts or other business arrangements that may exist between the main provider and the facility or organization would unnecessarily restrict its flexibility to establish cost-effective agreements without significantly enhancing the integration of the facility or organization into the main provider. Therefore, we are proposing to simplify the requirements applicable to facilities or organizations located on the campus of the main provider (as campus is defined in existing regulations at § 413.65(a)(2)). Under our proposal, all facilities seeking provider-based status, including both on-campus and off-campus facilities, would be required to comply with the existing requirements regarding licensure, clinical services integration, financial integration, and public awareness. (These requirements are currently codified at §§ 413.65(d)(1), (d)(4), (d)(5), and (d)(6) and, under this proposed rule, would be redesignated as paragraphs (d)(1) through (d)(4), respectively, of § 413.65.) With respect to financial integration, existing regulations at § 413.65(d)(5) require that the financial operations of the facility or organization be fully integrated within the financial system of the main provider, as evidenced by shared income and expenses between the main provider and the facility or organization. The regulations also require that costs of a provider-based facility or organization be reported in a cost center of the provider, and that the financial status of any provider-based facility or organization be incorporated and readily identified in the main provider's trial balance. Some hospital representatives have questioned the appropriateness of requiring that the costs of a remote location of a hospital be reported in a single cost center, noting that such costs ordinarily would appear in multiple cost centers of the main provider, with (for example) employee health and welfare costs of the remote location being included in the corresponding cost center of the main provider. In recognition of this concern, we are proposing to revise the requirement to state that the costs of a facility or organization that is a hospital department must be reported in a cost center of the provider, and that costs of a provider-based facility or organization other than a hospital department must be reported in the appropriate cost center or cost centers of the main provider. Paragraph
(d)of § 413.65 would be retitled “Requirements applicable to all facilities or organizations” and, as indicated by its revised title, would set forth those core requirements that any facility or organization would have to meet to qualify for provider-based status. We are proposing to delete from this paragraph
(d)the requirements in existing paragraphs (d)(2) and (d)(3) relating to operation under the ownership and control of the main provider and administration and supervision because we are proposing to no longer apply these requirements to on-campus facilities or organizations. These requirements would be moved to paragraph
(e)as described below to reflect the proposed limitation of their applicability to off-campus departments. The core requirements for all facilities or organizations, including facilities located on the main campus, also would not include the requirement regarding location in the immediate vicinity of the main provider (existing § 413.65(d)(7)). Because any facilities or organizations located on the campus of the main provider automatically meet the requirement regarding location in the immediate vicinity (existing § 413.65(d)(7)), the requirement is only of relevance to off-campus facilities or organizations. For clarity, we are proposing to relocate the requirement to paragraph
(e)as described below. We also are proposing to require, in paragraph (d)(5) of § 413.65, all hospital outpatient departments and hospital-based entities, including those located on campus and those located off the campus of the main provider hospital, to fulfill the obligations currently codified and proposed to be retained at § 413.65(g) in order to qualify for provider-based status. (Fulfillment of these obligations is currently required under § 413.65(g).) As explained further below, we also are proposing other changes to paragraph (g). e. Additional Requirements Applicable to Off-Campus Facilities or Organizations We recognize that facilities or organizations located off the main provider campus may also be sufficiently integrated with the main provider to justify provider-based designation. However, the off-campus location of the facilities or organizations may make such integration harder to achieve, and such integration should not simply be presumed to exist. Therefore, to ensure that off-campus facilities or organizations seeking provider-based status are appropriately integrated, we are proposing to retain for these facilities or organizations certain requirements that we are proposing to remove for on-campus facilities or organizations. These requirements are set forth in proposed new § 413.65(e). The requirements set forth in proposed paragraphs (e)(1), (e)(2), and (e)(3) include the requirements on operation under the ownership and control of the main provider (existing § 413.65(d)(2)), administration and supervision (existing § 413.65(d)(3)), and location (existing § 413.65(d)(7)). We also are proposing to include language in proposed new § 413.65(e) to state more clearly that a facility or organization seeking provider-based status must be located in the same State or, when consistent with the laws of both States, in adjacent States. f. Joint Ventures Consistent with our views as expressed earlier in this preamble regarding the assumption that a higher degree of integration can be presumed for on-campus facilities or organizations and in recognition of the need to promote reasonable cooperation among providers and avoid costly duplication of specialty services, we are proposing to revise the regulations on joint ventures (currently set forth under § 413.65(e)) to limit their scope to facilities or organizations not located on the campus of any potential main provider. Specifically, we would redesignate § 413.65(e) as § 413.65(f) and revise it to state that a facility or organization that is not located on the campus of the potential main provider cannot be considered provider-based if the facility or organization is owned by two or more providers engaged in a joint venture. We also are proposing to make minor changes to the second sentence of the redesignated paragraph
(f)to clarify its meaning. g. Clarification of Obligations of Hospital Outpatient Departments and Hospital-Based Entities Existing regulations impose specific obligations for hospital outpatient departments and hospital-based entities, but do not specify the sanction that applies if the facility or organization does not fulfill its obligations. To clarify policy on this issue and emphasize the importance of compliance with the requirements in this area, we are proposing to revise existing § 413.65(g) to state that to qualify for provider-based status in relation to a hospital, a facility or organization must comply with these requirements. In regard to these obligations, we are proposing to make three changes in existing 413.65(g). First, for reasons explained in section V.J. of this preamble, we are proposing to revise paragraph (g)(1) by deleting the second sentence of that paragraph. In paragraph (g)(2), we are proposing to delete the reference to site-of-service reductions and instead refer to more accurately determined physician payment amounts, in order to more accurately describe how payment under the physician fee schedule is determined. In addition, we are proposing to revise the first sentence of paragraph (g)(7) to clarify that the notice requirements in it do not apply where a beneficiary is examined or treated for a medical condition in compliance with the antidumping rules in § 489.24. This clarification is needed because we believe it would be a violation of the antidumping requirements if examination or treatment required under § 489.24 was delayed in order to permit notification of the beneficiary or the beneficiary's authorized representative. We would further revise § 413.65(g)(7) to state that notice is required once the beneficiary has been appropriately screened and the existence of an emergency has been ruled out or the emergency condition has been stabilized. h. Management Contracts Under existing regulations, facilities or organizations operated under management contracts may be considered provider-based only if they meet specific requirements in § 413.65(f) (proposed to be redesignated as § 413.65(h)). In particular, staff of the facility or organization, other than management staff, may not be employed by the management company but must be employed either by the provider or by another organization, other than the main provider, which also employs the staff of the main provider. Under existing regulations, these requirements apply equally to on-campus and off-campus facilities or organizations. Consistent with our intent to simplify provider-based requirements for on-campus facilities or organizations, we are proposing to restrict the applicability of proposed redesignated paragraph
(h)to off-campus facilities or organizations. In addition, we are proposing two additional changes that we believe are needed to respond to questions that are raised frequently about the regulation. First, we would specify that a facility or organization operated under a management contract may be considered provider-based only if the main provider (or an organization that also employs the staff of the main provider and that is not the management company) employs the staff of the facility or organization who are directly involved in the delivery of patient care, except for management staff and staff who furnish patient care services of a type that would be paid for by Medicare under a fee schedule established by regulations at 42 CFR Part 414. We would not specify who may employ other support staff, such as maintenance or security personnel, and who are not directly involved in providing patient care, nor would we require licensed professional caregivers such as physicians, physician assistants, or certified registered nurse anesthetists to become provider employees. We also are proposing to revise the regulations to clarify at § 413.65(h)(2) that so-called “leased” employees (that is personnel who are actually employed by the management company but provide services for the provider under a staff leasing arrangement) are not considered to be employees of the provider for purposes of this provision. i. Inappropriate Treatment of a Facility or Organization as Provider-Based Below we describe the steps that we would take if we discover that a facility is billing as provider-based without having requested a determination, or if the facility received a provider-based determination but the main provider did not inform CMS of a subsequent material change that affected the provider-based status of its facility.
(1)Inappropriate Billing The existing regulations at § 413.65(i) state that if we discover that a provider is billing inappropriately, we will recover the difference between the amount of payments that actually were made and the amount of payments that CMS estimates should have been made in the absence of a determination of provider-based status. Existing § 413.65(j)(2) states that we would adjust future payments to approximate as closely as possible the amounts that would be paid, in the absence of a provider-based determination, if all other requirements for billing are met. In addition, existing § 413.65(j)(5) describes a procedure under which CMS would continue payments to a provider for services of a facility or organization that had been found not to be provider-based, at an adjusted rate calculated as described in existing paragraph (j)(2), for up to 6 months in order to permit the facility or organization adequate time to meet applicable enrollment and other billing requirements. While CMS is not legally obligated to continue payments in this matter, we believe it would be appropriate to do so, on a time-limited basis, to allow for an orderly transition to either provider-based or freestanding status for the facility and to avoid disruption in the delivery of services to patients, particularly Medicare patients, who may be relying on the facility for their medical care. We are proposing to adopt a policy concerning recoupment and continuation of payment that closely parallels the policy stated in existing regulations at § 413.65(j). Under proposed § 413.65(j)(1), if CMS learns that a provider has treated a facility or organization as provider-based and the provider did not request an advance determination of provider-based status from CMS under proposed § 413.65(b)(3), and CMS determines that the facility or organization did not meet the requirements for provider-based status under proposed § 413.65(d) through (i), as applicable (or, in any period before the effective date of these regulations, the provider-based requirements in effect under Medicare program regulations or instructions), CMS would take several actions. First, we are proposing to issue notice to the provider, in accordance with proposed paragraph (j)(3), that payments for past cost reporting periods may be reviewed and recovered as described in proposed paragraph (j)(2)(ii), that future payments for services in or at the facility or organization will be adjusted as described in proposed paragraph (j)(4), and that continued payments to the provider for services of the facility or organization will be made only in accordance with proposed paragraph (j)(5). In addition, as detailed in proposed § 413.65(j)(1)(ii), CMS would, except for providers protected under section 404(a) or
(c)of BIPA (implemented at § 413.65(b)(2) and (b)(5)) or the exception for good faith effort at existing § 413.65(i)(2) and (i)(3)), recover the difference between the amount of payments that actually was made to that provider for services at the facility or organization and an estimate of the payments that CMS would have made to that provider for services at the facility or organization in the absence of compliance with the requirements for provider-based status. We are proposing to make recovery for all cost reporting periods subject to reopening in accordance with §§ 405.1885 and 405.1889. Also, we are proposing to adjust future payments to approximate the amounts that would be paid for the same services furnished by a freestanding facility. Recovery of past payments would be limited in certain circumstances. If a provider did not request a provider-based determination for a facility by October 1, 2002, but is included in the grandfathering period under § 413.65(b)(2), we are proposing to recoup all payments subject to the reopening rules at §§ 405.1885 and 405.1889, but not for any period before the provider's cost reporting period beginning on or after July 1, 2003.
(2)Good Faith Effort We are proposing to retain the existing exception for good faith effort (proposed redesignated § 413.65(j)(2)). Under this exception, we would not recover any payments for any period before the beginning of the hospital's first cost reporting period beginning on or after January 10, 2001 (the effective date of the existing provider-based regulations for providers not grandfathered under § 413.65(b)(2)) if during all of that period— • The requirements regarding licensure and public awareness at § 413.65(d)(1) and proposed redesignated (d)(4) were met; • All facility services were billed as if they had been furnished by a department of a provider, a remote location of a hospital, a satellite facility, or a provider-based entity of the main provider; and • All professional services of physicians and other practitioners were billed with the correct site-of-service indicator, as described at proposed redesignated and revised § 413.65(h)(2). Under proposed § 413.65(j)(5), CMS would continue payment to a provider for services of a facility or organization for a limited period of time, in order to allow the facility or organization or its practitioners to meet necessary enrollment and other requirements for billing on a freestanding basis. Specifically, the notice of denial of provider-based status sent to the provider would ask the provider to notify CMS in writing, within 30 days of the date the notice is issued, as to whether the provider intends to seek an advance determination of provider-based status for the facility or organization, or whether the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services as a freestanding facility. If the provider indicates that it will not be seeking an advance determination or that the facility or organization or its practitioners will not be seeking to enroll, or if CMS does not receive a response within 30 days of the date the notice was issued, all payments under proposed paragraph (j)(5) would end as of the 30th day after the date of notice. If the provider indicates that it will be seeking an advance determination, or that the facility or organization or its practitioners will be seeking to meet enrollment and other requirements for billing for services in a freestanding facility, payment for services of the facility or organization would continue, at the adjusted amount described in proposed paragraph (j)(4) for as long as is required for all billing requirements to be met (but not longer than 6 months). Continued payment would be allowed only if the provider or the facility or organization or its practitioners submits, as applicable, a complete request for an advance provider-based determination or a complete enrollment application and provide all other required information within 90 days after the date of notice; and the facility or organization or its practitioners furnishes all other information needed by CMS to process the request for provider-based status or, as applicable, the enrollment application and verify that other billing requirements are met. If the necessary applications or information are not provided, CMS would terminate all payment to the provider, facility, or organization as of the date CMS issues notice that necessary applications or information have not been submitted. j. Temporary Treatment as Provider-Based and Correction of Errors Under proposed revised § 413.65(k), we would specify the procedures for payment for the period between the time a request is submitted until a provider-based determination is made, and the steps we would take if we discover that a facility for which a provider previously received a provider-based determination no longer meets the requirements for provider-based status. First, we are proposing that, if a provider submits a complete request for a provider-based determination for a facility that has not previously been found by CMS to have been inappropriately treated as provider-based under proposed revised § 413.65(j), the provider may bill and be paid for services at the facility as provider-based from the date of the application until the date that we determine that the facility or organization does not meet the provider-based rules under § 413.65. If CMS determines that the requirements for provider-based status are not met, CMS will recover the difference between the amount of payments that actually was made since the date the complete request for a provider-based determination was submitted and the amount of payments that CMS estimates should have been made in the absence of compliance with the provider-based requirements. We would consider a request “complete” only if it included all information we need to make an advance determination of provider-based status under § 413.65(b)(3). Second, similar to what we specify in existing § 413.65(k), if we determine that a facility or organization that previously received a provider-based determination no longer qualifies for provider-based status, and the failure to qualify for provider-based status resulted from a material change in the relationship between the provider and the facility or organization that the provider reported to CMS as is required under § 413.65(c), treatment of the facility or organization as provider-based ceases with the date that CMS determines that the facility or organization no longer qualifies for provider-based status. Third, if we determine that a facility or organization that had previously received a provider-based determination no longer qualifies for provider-based status, and if the failure to qualify for provider-based status resulted from a material change in the relationship between the provider and the facility or organization that the provider did not report to CMS, as required under § 413.65(c), we are proposing to take the actions with respect to notice to the provider, adjustment of payments, and continuation of payment described in proposed paragraphs (j)(3), (j)(4), and (j)(5). In short, we would treat such cases in the same way as if the provider had never obtained an advance determination. However, with respect to recovery of past payments for providers included in the grandfathering provision at proposed revised § 413.65(b)(2), we would not recover payments for any period before the provider's first cost reporting period beginning on or after July 1, 2003. Also, we are proposing that the exception for good faith effort concerning recovery of overpayments under proposed revised §§ 413.65(j)(2) described above would apply to any period before the beginning of the hospital's first cost reporting period beginning on or after January 10, 2001. k. Technical Amendments We are proposing to correct a typographical error in the heading of paragraph
(m)of § 413.65 so that it reads “FQHCs and ‘look alikes’ ”. In paragraph
(n)of § 413.65, we are proposing to add a cross-reference to the requirements for provider-based status described in paragraph (b), for purposes of specifying the effective date of provider-based status. L. CMS Authority Over Reopening of Intermediary Determinations and Intermediary Hearing Decisions on Provider Reimbursement Our existing regulations provide various means for the reopening and revision of an intermediary determination or an intermediary hearing decision on provider reimbursement by the fiscal intermediary or the intermediary hearing officer(s) responsible for the determination or the hearing decision, respectively. (In this discussion, we will use the term “intermediary” to refer to, as applicable, the intermediary responsible for an intermediary determination (see §§ 405.1801(a) and 405.1803) or the intermediary hearing officer or panel of intermediary hearing officers responsible for an intermediary hearing decision (see §§ 405.1817 and 405.1831.)) Section 405.1885(a) provides that an intermediary “may” reopen an intermediary determination or an intermediary hearing decision, on its own initiative or at the request of a provider, within 3 years of the date of the notice of the intermediary determination or intermediary hearing decision. However, while § 405.1885(a) provides the intermediary with some discretion about whether to reopen an intermediary determination or an intermediary hearing decision, we have always considered the intermediary's discretion to be limited by any directives that may be issued by CMS. Thus, although § 405.1885(a) provides that the intermediary “may” reopen, that provision neither states nor implies that the Secretary lacks authority to direct the intermediary to reopen or not reopen a specific matter. Furthermore, CMS has prescribed, in Medicare Provider Reimbursement Manual, Part I (“PRM”), section 2931.2, criteria that guide the intermediary's reopening actions under “405.1885(a) in the absence of a particular directive from CMS. Also, given that the intermediaries are CMS' contractors, we have always believed that, under basic principles of agency law, we have inherent authority to direct the actions of our own agents with respect to reopening matters under “405.1885(a), just as for any other aspect of program administration. *See also* 42 U.S.C. 1395h and 1395kk(a); and 42 CFR 421.1(c), 421.5(b), 421.100(f), 421.124(a), and 421.126(b). Under § 405.1885(b), an intermediary determination or an intermediary hearing decision “shall be reopened and revised by the intermediary if, within the aforementioned 3-year period, the Centers for Medicare & Medicaid Services notifies the intermediary that such determination or decision is inconsistent with the applicable law, regulations, or general instructions issued by the Centers for Medicare & Medicaid Services.” We have always considered the CMS notice, which is a precondition of mandatory intermediary reopening under § 405.1885(b), to be one in which we explicitly direct the intermediary to reopen. We have never considered a notice or other document from CMS that only states or implies that an intermediary determination or an intermediary hearing decision is inconsistent with law, regulations, CMS ruling, or CMS general instructions, sufficient to require intermediary reopening under § 405.1885(b). Moreover, our understanding has always been that the phrase “law, regulations, or general instructions” in § 405.1885(b) refers to the legal provisions in effect, as we understand such legal provisions, at the time the intermediary rendered the determination or hearing decision. Conversely, we have never considered changes in, or judicial explications of, “law, regulations, or general instructions,” that occur after the intermediary rendered the determination or hearing decision, sufficient to require intermediary reopening under § 405.1885(b). Also, § 405.1885(b) refers to the Secretary's agreement with an intermediary; we believe such agreement requires the intermediary to apply the law, regulations, CMS rulings, and CMS general instructions in effect, as we understand such legal provisions, when the intermediary determination or hearing decision was rendered. Accordingly, we have not instructed intermediaries to reopen and recover reimbursement, or to reopen and award additional reimbursement, due to a subsequent change in law or policy, whether the subsequent change is made in response to judicial precedent or otherwise. Section 405.1885(c) provides: “Jurisdiction for reopening a determination or decision rests exclusively with that administrative body that rendered the last determination or decision.” We have always interpreted § 405.1885(c) to provide that authority to reopen an intermediary determination or an intermediary hearing decision is vested exclusively with the responsible intermediary, as distinct from the Provider Reimbursement Review Board
(PRRB)and the Administrator of CMS (in the context of reviewing PRRB decisions (see § 405.1875)) which may not reopen an intermediary determination or hearing decision and may not review an intermediary's denial of reopening. However, we have never considered the intermediary's authority to reopen an intermediary determination or hearing decision, which is exclusive under § 405.1885(c) only as to the PRRB and the Administrator of CMS (in the context of reviewing PRRB decisions), to limit CMS' authority to direct the actions of its own agents with respect to reopening matters. *See Your Home Visiting Nurse Services, Inc.* v. *Shalala,* 525 U.S. 449, 452-53 (1999). (Section 405.1885(c) divests the PRRB of “appellate jurisdiction to review the intermediary's refusal” to reopen, but does not limit the Secretary's authority to direct an intermediary's “original jurisdiction” in the reopening area). As discussed previously, the regulations do not constrain CMS' authority to direct the intermediary to reopen or not reopen a specific matter; instead, CMS has placed generally applicable limits on the intermediary's discretion through the reopening criteria prescribed in section 2931.2 of the PRM. In addition, we have always believed that, under basic principles of agency law, the intermediary's discretion over a particular reopening matter is no less circumscribed by any directives that may be issued by CMS than would be the case for any other aspect of program administration. Two recent court decisions conflict with our longstanding interpretation of the forgoing provisions of the reopening regulations. In *Monmouth Medical Center* v. *Thompson* , 257 F.3d 807 (D.C. Cir. 2001), the court found that a statement in a CMS ruling, changing CMS' interpretation of the statute in response to circuit court precedent, constituted a directive to the intermediary under § 405.1885(b) to reopen, notwithstanding an explicit directive in the CMS ruling that the change in interpretation was to be applied only prospectively. The court ordered the intermediary to reopen over the Secretary's objection. We disagree with the court's decision, which we believe does not comport with our settled interpretation (discussed above) of § 405.1885(b). Therefore, we are proposing to revise § 405.1885(b) to make clear that, in order to trigger the intermediary's obligation to reopen, the notice from CMS to the intermediary must explicitly direct the intermediary to reopen based on a finding that an intermediary determination or an intermediary hearing decision is inconsistent with the law, regulations, CMS ruling, or CMS general instructions in effect, and as we understood those legal provisions, at the time the determination or decision was rendered. We are also proposing to clarify § 405.1885 to reflect our longstanding interpretation (discussed above) that a change of legal interpretation or policy by CMS in a regulation, CMS ruling, or CMS general instruction, whether made in response to judicial precedent or otherwise, is not a basis for reopening an intermediary determination or an intermediary hearing decision under this section. The *Monmouth Medical Center* decision was followed in *Bartlett Memorial Medical Center* v. *Thompson* , 171 F. Supp. 2d 1215 (W.D. Okla. 2001). In a subsequent order in the *Bartlett Memorial Medical Center* case, the court concluded that a CMS ruling, which prohibited intermediary reopening on a particular reimbursement issue, improperly interfered with the intermediary's discretion under § 405.1885(c) over provider requests for reopening under § 405.1885(a). Accordingly, the court ordered the intermediary to act on the provider reopening requests without regard to the CMS ruling or any other involvement of the Secretary. We disagree with the court's decision, which we believe is contrary to our settled interpretation (discussed above) of § 405.1885(a) and (c). We believe the court's decision is also inconsistent with CMS' inherent authority to direct the activities of its own contractor-agents, the fiscal intermediaries, with respect to particular reopening matters, just as with any other aspect of program administration. Therefore, we are proposing, in a new paragraph
(e)of § 405.1885 (the existing paragraph is proposed to be redesignated as paragraph (f)), to clarify that, notwithstanding an intermediary's discretion to reopen or not reopen under paragraphs
(a)and
(c)of § 405.1885, CMS may direct an intermediary to reopen, or not to reopen, an intermediary determination or an intermediary hearing decision in accordance with paragraphs
(a)and
(c)of this section. To illustrate our proposal, revised § 405.1885(e) would clarify that CMS has full authority to direct an intermediary to reopen, or not to reopen, an intermediary determination or an intermediary hearing decision under § 405.1885(a) and
(c)based on the reopening criteria of “new and material evidence” or “clear and obvious error.” *See* PRM § 2931.2. VI. Proposed Changes to the Prospective Payment System for Capital-Related Costs A. Background 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.” Under the statute, the Secretary has broad authority in establishing and implementing the capital prospective payment system. We initially implemented the capital prospective payment system in the August 30, 1991 final rule (56 FR 43358), in which we established a 10-year transition period to change the payment methodology for Medicare inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). Federal fiscal year
(FY)2001 was the last year of the 10-year transition period established to phase in the prospective payment system for hospital capital-related costs. Beginning in FY 2001, capital prospective payment system payments were based solely on the Federal rate for the vast majority of hospitals. The basic methodology for determining capital prospective payments based on 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 Adjustment for Hospitals Located in Alaska and Hawaii) × (1 + DSH Adjustment Factor + IME Adjustment Factor) Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year that are specified in § 412.312(c) of existing regulations. (Refer to the August 1, 2001 final rule (66 FR 39910) for a summary of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals both during and after the transition period, and the policy for providing special exceptions.) B. New Hospitals Under the prospective payment system for capital-related costs, at § 412.300(b), a new hospital is defined as a hospital that is newly participating in the Medicare program (under current or previous ownership) for less than 2 years (see 56 FR 43418, August 30, 1991). During the 10-year transition period, under § 412.324(b), a new hospital was exempt from capital prospective payment system for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Effective with its third cost reporting period, a new hospital was paid under the appropriate transition methodology (either hold-harmless or fully prospective) for the remainder of the transition period. (If the hold-harmless methodology was applicable, hold-harmless payments would be made for 8 years, even if they extend beyond the 10-year transition period, which ended beginning with cost reporting periods beginning during FY 2002.) This payment provision was implemented to provide special protection to new hospitals during the transition period in response to concerns that prospective payments under a DRG system may not be adequate initially to cover the capital costs of newly built hospitals. These hospitals may not have sufficient occupancy in those initial 2 years and may have incurred significant capital startup costs, so that capital prospective payment system payments may not be sufficient. For instance, hospitals newly participating in the Medicare program may not initially have adequate Medicare utilization. Because capital prospective payment system payments are made on a per discharge basis, a hospital only receives payments for its capital-related costs upon discharge of its Medicare patients. In addition, these hospitals did not have an opportunity to reserve previous years' capital prospective payment system payments to finance capital projects. While the regulations provided for payments based on a percentage of costs for new hospitals for the first 2 years during the 10-year transition period, no provision was made for new hospitals once the 10-year transition was completed. However, we believe that the rationale for the policy applies equally to new hospitals even after the completion of the 10-year transition period. Accordingly, we are proposing, under § 412.304(c)(2), to provide special payment to new hospitals for cost reporting periods beginning on or after October 1, 2002. That is, we would pay new hospitals, as defined under § 412.300(b), 85 percent of their reasonable costs for their first 2 years of operation. Effective with their third year of operation, a new hospital would be paid based on the Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital prospective payment system). We believe this proposal would provide for more appropriate payments to new hospitals for their capital-related costs since initial capital expenditures may reasonably exceed the capital prospective payment system per discharge payment based on the Federal rate. The capital prospective payment Federal rate is based on industry-wide average capital costs rather than the experience of a new hospital. We believe this proposed policy would allow new hospitals to provide efficiency in the delivery of services and still make reasonable payments for their capital expenditures. As was the case during the 10-year transition period, this proposed new hospital exemption would only be available to those hospitals that have not received reasonable cost-based payments under the Medicare program in the past, and would need special protection during their initial period of operation. This proposed exemption from the capital prospective payment system for the first 2 years of operation would not apply to a hospital that is “new” as an acute care hospital but that has operated in the past (under current or previous ownership) and has an historical Medicare asset base. Furthermore, a hospital that replaces its entire facility (regardless of a change of ownership) would not qualify for the new hospital exemption even though it may experience a significant change in its asset base. Thus, in accordance with § 412.300(b), a new hospital exemption would not apply in the following situations: • A hospital that builds new or replacement facilities at the same or a new location, even if a change of ownership or a new leasing arrangement is involved; • A hospital that closes and then reopens under the same or different ownership; • A hospital that has been in operation for more than 2 years but has been participating in the Medicare program for less than 2 years; or • A hospital that changes status from a prospective payment system-excluded hospital (paid under the TEFRA methodology) or another hospital prospective payment system (such as the inpatient rehabilitation facility prospective payment system) to a hospital that is subject to the capital prospective payment system for acute care hospitals. C. Extraordinary Circumstances When we implemented the capital prospective payment system in FY 1992, a number of commenters requested that we provide for a separate exceptions payment to account for extraordinary circumstances beyond a hospital's control that would require the hospital to make unanticipated major capital expenditures (56 FR 43411, August 30, 1991). In response to the commenters' request, we provided in the regulations at § 412.348(f) 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. Extraordinary circumstances include, but are not limited to, a flood, a fire, or an earthquake. For more detailed information regarding this policy, refer to the August 30, 1991 **Federal Register** (56 FR 43411). To clarify that this policy regarding additional payments for extraordinary circumstances also applies to periods beginning on or after October 1, 2001, we are proposing to revise § 412.312 by adding a new paragraph
(e)to specify that payment is made for extraordinary circumstances as provided for in § 412.348(f) for cost reporting periods after the transition period, that is, on or after October 1, 2001. D. Restoration of the 2.1 Percent Reduction to the Standard Federal Capital Prospective Payment System Payment Rate Section 1886(g)(1)(A) of the Act, as amended by section 4402 of Public Law 105-33, requires the Secretary to reduce the unadjusted standard Federal capital prospective payment system payment rate (and the unadjusted hospital-specific rate) by 2.1 percent for discharges on or after October 1, 1997, and through September 30, 2002, in addition to applying the budget neutrality factor used to determine the Federal capital prospective payment system payment rate in effect on September 30, 1995. The budget neutrality factor effective for September 30, 1995, was 0.8432 (59 FR 45416). Therefore, application of the budget neutrality factor (as specified under section 1886(g)(1)(A) of the Act) was equivalent to a 15.68 percent reduction to the unadjusted standard Federal capital prospective payment system payment rate and the unadjusted hospital-specific rate in effect on September 30, 1997. The additional 2.1 reduction to the rates in effect on September 30, 1997 resulted in a total reduction of 17.78 percent. Accordingly, under the statute, the additional 2.1 percent reduction no longer applies to discharges occurring after September 30, 2002 (§ 412.308(b)(5)). Therefore, we are proposing to revise § 412.308(b) to add a new paragraph (b)(6) to restore the 2.1 percent reduction to the unadjusted standard Federal capital prospective payment system payment rate (as provided under § 412.308(c)) for discharges occurring on or after October 1, 2002, to the level that it would have been without the reduction. (Since FY 2001 was the final year of the 10-year transition period, we no longer update the hospital-specific rate and, therefore, we also no longer restore the 2.1 percent reduction to that rate as provided under § 412.328(e)(1).) As described in the August 29, 1997 final rule (62 FR 46012), we determined the reduction factor for FY 1998 by deducting both the FY 1995 budget neutrality factor (0.1568) and the 2.1 percent reduction (0.021) from 1 (1− 0.1568−0.021 = 0.8222). We then applied the 0.8222 to the unadjusted standard Federal rate. Therefore, to determine the adjustment factor needed to restore the 2.1 percent reduction, we would divide the amount of the adjustment without the 2.1 percent reduction (1−0.1568 = 0.8432) by the amount of the adjustment with the 2.1 percent reduction (0.8222). Accordingly, we are proposing to restore the 2.1 percent reduction for discharges occurring on or after October 1, 2002, under proposed § 413.308(b)(6), by applying a factor of 1.02554 (0.8432/0.8222) to the unadjusted standard Federal capital prospective payment system payment rate under § 412.308(c), that was in effect on September 30, 2002. E. Clarification of Special Exceptions Policy Under the special exceptions provisions at § 412.348(g), an additional payment may be made through the 10th year beyond the end of the capital prospective payment system transition period for eligible hospitals that meet
(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 described at § 412.348(g)(4); and
(2)a project size requirement as described at § 412.348(g)(5). In accordance with § 412.348(g)(7), hospitals are eligible to receive special exceptions payments for the 10 years after the cost reporting year in which they complete their project, which can be no later than the hospital's cost reporting period beginning before October 1, 2001. During the 10-year capital prospective payment system transition period, regular exceptions under §§ 412.348(b) through
(e)paid the same as or more (between 70 percent and 90 percent of costs, depending on the type of hospital) than the special exceptions provision under § 412.348(g) (70 percent for all eligible hospitals). Therefore, it was not until cost reporting periods beginning on or after October 1, 2001 (the end of the transition period) that eligible hospitals could actually begin receiving additional payments under the special exceptions provision. As we stated in the July 30, 1999 final rule (64 FR 41528), we believe that, since any substantive changes to this policy could have a significant impact, the appropriate forum for addressing the special exceptions policy is through the legislative process in Congress rather than the regulations process. Since hospitals are beginning to receive additional payments under this provision, we have received several questions regarding current policy at § 412.348(g). Therefore, while we are not proposing any changes to the special exceptions policy, we are providing the following clarifications to the existing regulations. Under § 412.348(g)(1), to be eligible for special exception payments, a hospital must be either a sole community hospital (SCH), an urban hospital with at least 100 beds that has a disproportionate share
(DSH)percentage of at least 20.2 percent or qualify for DSH payments under § 412.106(c)(2), or a hospital with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Because a hospital's SCH status, DSH patient percentage, and combined utilization may fluctuate from one cost reporting year to the next, the special exceptions eligibility criteria are applied for each cost reporting period throughout the 10-year special exceptions period. A hospital receives special exceptions payments only for those years in the 10-year period in which it meets the eligibility requirements in § 412.348(g)(1). Therefore, a hospital might be eligible for a special exception payment in one year, not be eligible the next year, and then subsequently qualify during the 10-year special exceptions period. The project need criteria in § 412.348(g)(2) also state that a hospital must obtain any required approval from a State or local planning authority. However, in States where a certificate of need or approval is not required by the State or local planning authority, the hospital must provide the fiscal intermediary with appropriate documentation (such as project plans from the hospital's board of directors) that demonstrates that the requirements of § 412.348(g)(3) concerning the age of assets test and § 412.348(g)(4) concerning the excess capacity test for urban hospitals are met. We understand that a State planning authority and a hospital may define a project differently. Accordingly, we would allow the hospital to use either the definition provided by the project within the certificate of need (in States where a certificate of need is required), or other appropriate documentation provided from the hospital's project plans (such as project plans as specified in the minutes of the meetings of the hospital's board of directors). In determining a hospital's special exceptions payment amount, as described in § 412.348(g)(8), for each cost reporting period, the cumulative payments made to the hospital under the capital prospective payment system are compared to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to the capital prospective payment system. This comparison is offset by any amount by which the hospital's current year Medicare inpatient operating and capital prospective payment system payments (excluding 75 percent of its operating DSH payments) exceed its Medicare inpatient operating and capital costs (or its Medicare inpatient margin). The minimum payment level is 70 percent for all hospitals, regardless of class, as set forth in § 412.348(g)(6), for the duration of the special exceptions provision. In order to assist our fiscal intermediaries in determining the end of the 10-year period in which an eligible hospital will no longer be entitled to receive special exception payments, § 412.348(g)(9) requires that hospitals eligible for special exception payments submit documentation to the intermediary indicating the completion date of their project (the date the project was put in use for patient care) that meets the project need and project size requirements outlined in §§ 412.348(g)(2) through (g)(5). In order for an eligible hospital to receive special exception payments, this documentation had to be submitted in writing to the intermediary by the later of October 1, 2001, or within 3 months of the end of the hospital's last cost reporting period beginning before October 1, 2001, during which a qualifying project was completed. VII. Proposed Changes for Hospitals and Hospital Units Excluded From the Acute Care Hospital Inpatient Prospective Payment System A. Payments to Excluded Hospitals and Hospital Units (§§ 413.40(c), (d), and (f)) 1. Payments to Existing Excluded Hospitals and Hospital Units Section 1886(b)(3)(H) of the Act (as amended by section 4414 of Public Law 105-33) established caps on the target amounts for certain existing hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002. For this period, the caps on the target amounts apply to the following three classes of excluded hospitals or units: psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals. In accordance with section 1886(b)(3)(H)(i) of the Act and effective for cost reporting periods beginning on or after October 1, 2002, payments to these classes of existing excluded hospitals or hospital units are no longer subject to caps on the target amounts. In accordance with existing §§ 413.40(c)(4)(ii) and (d)(1)(i) and (ii), these excluded hospitals and hospital units continue to be paid on a reasonable cost basis, and payments are based on their Medicare inpatient operating costs, not to exceed the ceiling. The ceiling would be computed using the hospital's or unit's target amount from the previous cost reporting period updated by the rate-of-increase specified in § 413.40(c)(3)(viii) of the regulations. 2. Updated Caps for New Excluded Hospitals and Units Section 1886(b)(7) of the Act establishes a payment methodology for new psychiatric hospitals and units, new rehabilitation hospitals and units, and new long-term care hospitals. A discussion of how the payment limitation was calculated can be found in the August 29, 1997 final rule with comment period (62 FR 46019); the May 12, 1998 final rule (63 FR 26344); the July 31, 1998 final rule (63 FR 41000); and the July 30, 1999 final rule (64 FR 41529). Under the statutory methodology, a “new” hospital or unit is a hospital or unit that falls within one of the three classes of hospitals or units (psychiatric, rehabilitation or long-term care) that first receives payment as a hospital or unit excluded from the acute care hospital inpatient prospective payment system on or after October 1, 1997. The amount of payment for a “new” hospital or unit would be determined as follows: • Under existing § 413.40(f)(2)(ii), for the first two 12-month cost reporting periods, the amount of payment is the lesser of:
(1)the operating costs per case; or
(2)110 percent of the national median (as estimated by the Secretary) of the target amounts for the same class of hospital or unit for cost reporting periods ending during FY 1996, updated by the hospital market basket increase percentage to the fiscal year in which the hospital or unit first receives payments under section 1886 of the Act, as adjusted for differences in area wage levels. • Under existing § 413.40(c)(4)(v), for cost reporting periods following the hospital's or unit's first two 12-month cost reporting periods, the target amount is equal to the amount determined under section 1886(b)(7)(A)(i) of the Act for the third period, updated by the applicable hospital market basket increase percentage. The proposed amounts included in the following table reflect the updated 110 percent of the national median target amounts proposed for each class of new excluded hospitals and hospital units for cost reporting periods beginning during FY 2003. These figures are updated to reflect the proposed projected market basket increase percentage of 3.4 percent. This projected percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient hospital services (as projected by the CMS Office of the Actuary based on its historical experience with the hospital inpatient prospective payment system). For a new provider, the labor-related share of the target amount is multiplied by the appropriate geographic area wage index, without regard to prospective payment system reclassifications, and added to the nonlabor-related share in order to determine the per case limit on payment under the statutory payment methodology for new providers. Class of excluded hospital or unit FY 2003 proposed labor-related share FY 2003 proposed nonlabor-related share Psychiatric $7,047 $2,801 Long-Term Care 17,269 6,866 Effective for cost reporting periods beginning on or after October 1, 2002, this payment limitation is no longer applicable to new rehabilitation hospitals and units since they will be paid under the inpatient rehabilitation facility prospective payment system. 3. Establishment of a Prospective Payment System for Inpatient Rehabilitation Hospitals and Units Section 1886(j) of the Act, as added by section 4421(a) of Public Law 105-33, provided the phase-in of a case-mix adjusted prospective payment system for inpatient hospital services furnished by a rehabilitation hospital or a rehabilitation hospital unit (referred to in the statute as rehabilitation facilities) for cost reporting periods beginning on or after October 1, 2000 and before October 1, 2002, with a fully implemented prospective payment system for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Public Law 106-113 to require the Secretary to use a discharge as the payment unit under the prospective payment system for inpatient hospital services furnished by rehabilitation facilities and to establish classes of patient discharges by functional-related groups. Section 305 of Public Law 106-554 further amended section 1886(j) of the Act to allow rehabilitation facilities 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 prospective payment system for inpatient rehabilitation facilities, effective for cost reporting periods beginning on or after January 1, 2002. Under the inpatient rehabilitation prospective payment system, for cost reporting periods beginning on or after January 1, 2002, and before October 1, 2002, payment will consist of 33 1/3 percent of the facility-specific payment amount (based on the reasonable cost-based reimbursement methodology) and 66 2/3 percent of the adjusted Federal prospective payment. For cost reporting periods beginning on or after October 1, 2002, payment will be based entirely on the Federal prospective payment rate determined under the inpatient rehabilitation facility prospective payment system. 4. Implementation of a Prospective Payment System for Long-Term Care Hospitals In accordance with the requirements of section 123 of Public Law 106-113, as modified by section 307(b) of Public Law 106-554, we are proposing (as published in the March 22, 2002 proposed rule (67 FR 13415)) the establishment of a per discharge, DRG-based prospective payment system for long-term care hospitals as described in section 1886(d)(1)(B)(iv) of the Act for cost reporting periods beginning on or after October 1, 2002. As part of the implementation process, we are proposing a 5-year transition period from reasonable cost-based reimbursement to the long-term care hospital prospective payment system Federal rate. We are also proposing that a long-term care hospital may elect to be paid based on 100 percent of the Federal prospective rate. Under the March 22, 2002 proposed rule, a blend of the reasonable cost-based reimbursement percentage and the prospective payment Federal rate percentage would be used to determine a long-term care hospital's total payment under the prospective payment system during the transition period. We would expect long-term care hospitals to be paid under the full Federal prospective rate for cost reporting periods beginning on or after October 1, 2006. B. Criteria for Exclusion of Satellite Facilities from the Hospital Inpatient Prospective Payment System Existing regulations at 42 CFR 412.22(e) define a hospital-within-a-hospital as a hospital that occupies space in the same building as another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital. Section 412.22(h), relating to satellites of hospitals excluded from the acute care hospital inpatient prospective payment system, defines a satellite facility as a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital. Section 412.25(e), relating to satellites of excluded hospital units, defines a satellite facility as a part of a hospital unit that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital. Because of the similarities between the definitions of the two types of satellite facilities and the definition of a hospital-within-a-hospital, questions have been raised as to whether satellite facilities must meet the “hospital-within-a-hospital” criteria in § 412.22(e) regarding having a governing body, chief medical officer, medical staff, and chief executive officer that are separate from those of the hospital with which space is shared. Although the separateness of satellite facilities of excluded hospitals and satellite facilities of excluded units of hospitals is not explicitly required under existing regulations, we believe these two types of satellite facilities are similar enough to hospitals-within-hospitals to warrant application of more closely related criteria to all of them. Specifically, satellite facilities are like hospitals-within-hospitals in that the satellites are physically located in acute care hospitals that are paid for their inpatient services under the acute care hospital inpatient prospective payment system. Moreover, both satellite facilities and hospitals-within-hospitals provide inpatient hospital care that is paid for at higher rates than would apply if the facility were treated by Medicare as a part of the acute care hospital. In view of these facts, it is important that we establish clear criteria for ensuring that these facilities are not merely units of the hospitals in which they are located, but are, in fact, organizationally and functionally separate from those hospitals. Therefore, we are proposing to revise § 412.22(h)(2) to specify that, effective for cost reporting periods beginning on or after October 1, 2002, a hospital having a satellite facility would qualify for exclusion from the acute care hospital inpatient prospective payment system only if that satellite facility is not under the authority or control of the governing body or chief executive officer of the hospital in which it is located, and it furnishes inpatient care through the use of medical personnel who are not under the authority or control of the medical staff or chief medical officer of the hospital in which it is located. We also are proposing to revise § 412.25(e)(2)(iii) to state that, effective for cost reporting periods beginning on or after October 1, 2002, a hospital unit having a satellite facility would qualify for exclusion from the acute care hospital inpatient prospective payment system only if it is not under the authority or control of the governing body or chief executive officer of the hospital in which it is located, and it furnishes inpatient care through the use of medical personnel who are not under the authority or control of the medical staff or chief medical officer of the hospital in which it is located. C. Critical Access Hospitals
(CAHs)1. Background Section 1820 provides for a nationwide Medicare Rural Hospital Flexibility Program (MRHF). (MRHF replaced the 7-State Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) program.) Under section 1820 of the Act, as amended, certain rural providers may be designated as critical access hospitals
(CAHs)under the MRHF program if they meet qualifying criteria and the conditions for designation specified in the statute. Implementing regulations for section 1820 of the Act are located at 42 CFR Part 485, Subpart F. 2. Election of Optional Payment Method Under existing regulations at 42 CFR 413.70(b), CAHs may elect to be paid for services to their outpatients under an optional method. Facilities making this election are paid an amount for each outpatient visit that is the sum of the reasonable costs of facility services, as determined under applicable regulations, and, for professional services otherwise payable to the physician or other practitioner, 115 percent of the amounts that otherwise would be paid for the services if the CAH had not elected payment under the optional method. To enable intermediaries to make these payments accurately and to avoid possible delays in or duplications of payment, we specify in § 413.70(b)(3) that each CAH electing payment under the optional method must inform the intermediary in writing of that election annually, at least 60 days before the start of the affected cost reporting period (65 FR 47100, August 1, 2000, and 66 FR 31272, June 13, 2001). Since the publication of this regulation, some CAHs have expressed concern that requiring a 60-day advance notice of the election of the optional payment method limits their flexibility, and have suggested that a shorter advance notice period would be appropriate. We have contacted our fiscal intermediaries to obtain feedback on the feasibility of changing the period of advance notification, since the fiscal intermediaries would need to make appropriate bill processing changes to allow any shorter time for notification of election of the optional method. Some fiscal intermediaries stated that requiring less than 60 days' advance notice is impractical, while others believed that needed changes could be made with as little as 2 weeks' advance notice. Given the diversity of feedback on this issue and our desire to allow CAHs as much flexibility as possible, we are proposing to revise § 412.30(b)(3) to allow the required advance notice period to be determined by each individual fiscal intermediary for the CAHs it services, as long as the required advance notice is not less than 14 days or more than 60 days before the start of each affected cost reporting period. 3. Use of the Resident Assessment Instrument
(RAI)by CAHs Among the existing regulations implementing section 1820 of the Act are specific conditions that a hospital must meet to be designated as a CAH. To help protect the health and safety of Medicare patients who are being furnished post-hospital skilled nursing facility
(SNF)level of care in a CAH, our regulations require CAHs to comply with some, but not all, of the Medicare SNF conditions of participation at 42 CFR part 483, subpart B. Specifically, the regulations at § 485.645(d) provide that in order for a CAH to use its beds to provide post-hospital SNF care, the CAH must be in substantial compliance with nine of the SNF requirements contained in part 483, subpart B. Included among the nine requirements are requirements for comprehensive assessments, comprehensive care plans, and discharge planning as specified in § 483.20(b), (k), and (l). (We note that the existing § 485.645(d)(6) incorrectly cites these regulation cross-references as “§ 483.20(b), (d), and (e).” When we revised § 483.20 on December 23, 1997 (63 FR 53307), we inadvertently did not make conforming cross-reference changes in § 485.645(d)(6). In this proposed rule, we are proposing to make these conforming cross-reference changes.) Section 483.20(b) provides that a facility must make a comprehensive assessment of a resident's needs using the resident assessment instrument (RAI), specified by the State, on all its swing-bed patients. We have received inquiries regarding the need for CAHs to use the RAI for patient assessment and care planning. The inquirers consider the RAI a lengthy and burdensome instrument and pointed out that CMS currently does not require CAHs to report data from the RAI for quality or payment purposes. We required former RPCHs to use the RAI for the assessment of swing-bed patients to avoid the possibility of negative outcomes that might extend the length of stays in these hospitals, which provided limited services. In addition, we believed that the use of the RAI would help to ensure that patient needs are met when patients are in the facility for an extended period of time. Swing-bed hospitals were not required to use any patient assessment instrument because we believed that the hospital conditions of participation included requirements that were appropriate safeguards to protect the health and safety of Medicare patients. Currently, the regulations at § 483.20(f) require all long-term care facilities to collect and submit assessment data from the RAI to the State for quality and payment purposes. There are no such collection and submission requirements for CAHs. We have gathered information from the provider community, State surveyors, and staff involved in the development of quality indicators and prospective payment system rates for SNFs to determine the feasibility of continuing to require CAHs to comply with the requirement for use of the RAI for patient assessments. Based on the information received, we have determined that there are no specific patient benefits involved in requiring CAHs to use the RAI for patient assessment purposes. In the interest of reducing burden, where possible, and based on our analysis of the current significance of the requirement for use of the RAI for patient assessments in CAHs, we believe it is appropriate to propose the elimination of the requirement for CAHs to complete an RAI without jeopardizing patient health and safety. A CAH would still be required to capture assessment data for its SNF patients but would have the flexibility to document the assessment data in the medical record in a manner appropriate for its facility. We believe there are sufficient safeguards in the CAH regulations to ensure the health and safety of each SNF patient in a CAH. The facility would still be required to develop a comprehensive care plan for each SNF patient that includes measurable objectives and a timetable to meet a patient's medical, nursing, and psychosocial needs that are identified in an assessment. Also, a post-discharge plan of care would address post-hospital care needs of the patient. All of this information (assessment, plan of care, and discharge plans) must be maintained in the patient's medical record. We are proposing to revise § 485.645 to specify that CAHs are required to complete a comprehensive assessment, comprehensive care plan, and discharge planning in accordance with the requirements of § 483.20(b), (k), and (l), except that the CAH is not required to use the RAI specified by the State, and is not required to comply with the requirements for frequency, scope, and number of assessments prescribed in § 413.343(b). VIII. MedPAC Recommendations We have reviewed the March 1, 2002 report submitted by MedPAC to Congress and have given it careful consideration in conjunction with the proposals set forth in this document. MedPAC's recommendations for payments for Medicare inpatient hospital services in its March 2002 report focused mainly on accounting for changes in input prices for the hospital market basket (Recommendation 2A) and on increases in the base rate for inpatient hospital services by applying the annual update factors (Recommendations 2B-1 and 2B-2). In Recommendation 2A, MedPAC recommended that the Secretary should use wage and benefit proxies that most closely match the training and skill requirements of health care occupations in all input price indexes used for updating payments. MedPAC further indicated that, in determining index weights, measures specific to the health sector and to occupation categories in which health care plays a major role should be emphasized. Our proposal to rebase and revise the hospital market basket, including cost category weights and price proxies, that is used in determining the update factors for payments for inpatient hospital services is presented in section IV. of this proposed rule. Recommendations 2B-1 and 2B-2 concerning the update factor for inpatient hospital operating costs and for hospitals and hospital distinct-part units excluded from the acute care hospital inpatient prospective payment system are discussed in Appendix C to this proposed rule. IX. Other Required Information A. Requests for Data From the Public In order to respond promptly to public requests for data related to the prospective payment system, we have established a process under which commenters can gain access to raw data on an expedited basis. Generally, the data are available in computer tape or cartridge format; however, some files are available on diskette as well as on the Internet at *http://www.hcfa.gov/stats/pufiles.htm.* Data files, and the cost for each, 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, Maryland 21207-0520,
(410)786-3691. Files on the Internet may be downloaded without charge. 1. Expanded Modified MedPAR-Hospital (National) The Medicare Provider Analysis and Review (MedPAR) file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in the United States. (The file is a Federal fiscal year file, that is, discharges occurring October 1 through September 30 of the requested year.) The records are stripped of most data elements that would permit identification of beneficiaries. The hospital is identified by the 6-position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the **Federal Register** on December 24, 1984 (49 FR 49941), and amended by the July 2, 1985 notice (50 FR 27361). The national file consists of approximately 11,420,000 records. Under the requirements of these notices, an agreement for use of CMS Beneficiary Encrypted Files must be signed by the purchaser before release of these data. For all files requiring a signed agreement, please write or call to obtain a blank agreement form before placing an order. Two versions of this file are created each year. They support the following: • Notice of Proposed Rulemaking
(NPRM)published in the **Federal Register** . This file, scheduled to be available by the end of April, is derived from the MedPAR file with a cutoff of 3 months after the end of the fiscal year (December file). • Final Rule published in the **Federal Register** . The FY 2001 MedPAR file used for the FY 2003 final rule will be cut off 6 months after the end of the fiscal year (March file) and is scheduled to be available by the end of April. *Media:* Tape/Cartridge. *File Cost:* $3,655.00 per fiscal year. *Periods Available:* FY 1988 through FY 2001. 2. Expanded Modified MedPAR-Hospital (State) The State MedPAR file contains records for 100 percent of Medicare beneficiaries using hospital inpatient services in a particular State. The records are stripped of most data elements that will permit identification of beneficiaries. The hospital is identified by the 6-position Medicare billing number. The file is available to persons qualifying under the terms of the Notice of Proposed New Routine Uses for an Existing System of Records published in the December 24, 1984 **Federal Register** notice, and amended by the July 2, 1985 notice. This file is a subset of the Expanded Modified MedPAR-Hospital (National) as described above. Under the requirements of these notices, an agreement for use of CMS Beneficiary Encrypted Files must be signed by the purchaser before release of these data. Two versions of this file are created each year. They support the following: • NPRM published in the **Federal Register** . This file, scheduled to be available by the end of April, is derived from the MedPAR file with a cutoff of 3 months after the end of the fiscal year (December file). • Final Rule published in the **Federal Register** . The FY 2001 MedPAR file used for the FY 2003 final rule will be cut off 6 months after the end of the fiscal year (March file) and is scheduled to be available by the end of April. *Media:* Tape/Cartridge. *File Cost:* $1,130.00 per State per year. *Periods Available:* FY 1988 through FY 2001. 3. CMS Wage Data This file contains the hospital hours and salaries for FY 1999 used to create the proposed FY 2003 prospective payment system wage index. The file will be available by the beginning of January for the NPRM and the beginning of May for the final rule. Processing year Wage data year PPS fiscal year 2002 1999 2003 2001 1998 2002 2000 1997 2001 1999 1996 2000 1998 1995 1999 1997 1994 1998 1996 1993 1997 1995 1992 1996 1994 1991 1995 1993 1990 1994 1992 1989 1993 1991 1988 1992 These files support the following: • NPRM published in the **Federal Register** . • Final Rule published in the **Federal Register** . *Media:* Diskette/most recent year on the Internet. *File Cost:* $165.00 per year. *Periods Available:* FY 2003 PPS Update. 4. 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 2003 PPS Update. 5. 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 Area (MSA). *Media:* Diskette/Internet. *File Cost:* $165.00 per year. *Periods Available:* FY 2003 PPS Update. 6. Reclassified Hospitals New Wage Index (Formerly: Reclassified Hospitals by Provider Only) This file contains a list of hospitals that were reclassified for the purpose of assigning a new wage index. Two versions of these files are created each year. They support the following: • NPRM published in the **Federal Register** . • Final Rule published in the **Federal Register** . *Media:* Diskette/Internet. *File Cost:* $165.00 per year. *Periods Available:* FY 2003 PPS Update. 7. 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, and PPS-XVII Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-XVII Hospital Data Set Files (refer to item 9 below).) 8. 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, and PPS-XVII Capital Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-XVII Hospital Data Set Files (refer to item 9 below).) 9. PPS-XIII to PPS-XVII Hospital Data Set The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare-certified hospital by the Medicare fiscal intermediary to CMS. The data set are 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 10. Provider-Specific File This file is a component of the PRICER program used in the fiscal intermediary's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements. *Media:* Diskette/Internet. *File Cost:* $265.00. *Periods Available:* FY 2003 PPS Update. 11. CMS Medicare Case-Mix Index File This file contains the Medicare case-mix index by provider number as published in each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following: • NPRM published in the **Federal Register** . • Final rule published in the **Federal Register** . *Media:* Diskette/most recent year on Internet. *Price:* $165.00 per year/per file. *Periods Available:* FY 1985 through FY 2001. 12. DRG Relative Weights (Formerly Table 5 DRG) This file contains a listing of DRGs, DRG narrative description, relative weights, and geometric and arithmetic mean lengths of stay as published in the **Federal Register** . The hard copy image has been copied to diskette. There are two versions of this file as published in the **Federal Register:** • NPRM. • Final rule. *Media:* Diskette/Internet. *File Cost:* $165.00. *Periods Available:* FY 2003 PPS Update. 13. 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 2003 PPS Update. 14. AOR/BOR Tables This file contains data used to develop the DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by DRG for length of stay and standardized charges. The BOR tables are “Before Outliers Removed” and the AOR is “After Outliers Removed.” (Outliers refers to statistical outliers, not payment outliers.) Two versions of this file are created each year. They support the following: • NPRM published in the **Federal Register** . • Final rule published in the **Federal Register** . *Media:* Diskette/Internet. *File Cost:* $165.00. *Periods Available:* FY 2003 PPS Update. 15. Prospective Payment System
(PPS)Standardizing File This file contains information that standardizes the charges used to calculate relative weights to determine payments under the prospective payment system. Variables include wage index, cost-of-living adjustment (COLA), case-mix index, disproportionate share, and the Metropolitan Statistical Area (MSA). The file supports the following: • NPRM published in the **Federal Register** . • Final rule published in the **Federal Register** . *Media:* Internet. *File cost:* No charge. *Periods Available:* FY 2003 PPS Update. For further information concerning these data tapes, contact the CMS Public Use Files Hotline at
(410)786-3691. Commenters interested in obtaining or discussing any other data used in constructing this rule should contact Stephen Phillips at
(410)786-4548. B. Information Collection Requirements 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. However, the majority of the collection requirements contained in this proposed rule are currently approved. Section IX.B.1. below lists the OMB approval numbers and the current expiration dates for the collection requirements, referenced by 42 CFR Part, in this proposed rule that are currently approved. In addition, as summarized below, section IX.B.2. of this proposed rule outlines the proposed collection requirements referenced in this proposed rule for which we are seeking public comment, as required under the PRA of 1995. 1. Currently Approved Requirements Regulation references in 42 CFR OMB approval No. Current expiration date Part 412 0938-0691 0938-0050 0938-0573 September 30, 2002. May 31, 2004. September 30, 2002. Part 413 0938-0050 0938-0667 0938-0477 May 31, 2004. October 31, 2002. June 30, 2002. Part 489 0938-0667 October 31, 2002. 2. Proposed Requirements for Public Comment Section 412.230 Criteria for an Individual Hospital Seeking Redesignation to Another Rural Area or an Urban Area. Appropriate Wage Data As specified in this section, a new hospital must accumulate and provide at least 1 year of wage data to CMS for the purposes of applying for reclassification. While this collection requirement is subject to the PRA, we believe the burden associated with this requirement is exempt from the PRA as stipulated under 5 CFR 1320.3(b)(2) and (b)(3). Section 413.65 Requirements for a Determination That a Facility or an Organization Had Provider-Based Status Responsibility for Obtaining Provider-Based Determinations As summarized in this section, a potential main provider seeking an advance determination of provider-based status for a facility that is located on the main campus of the potential main provider would be required to submit an attestation stating that the facility meets the criteria in paragraph
(d)of this section and, if it is a hospital, also attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph
(g)of this section. In addition, the provider seeking such an advance determination would be required to maintain documentation of the basis for its attestations and to make that documentation available to CMS upon request. We believe the burden associated with these requirements is estimated to average 1.5 hours per provider, for approximately 3,000 providers per year, for an annual burden of 4,500 annual burden hours. This estimate is based on fact the providers currently maintain the necessary data and that minimal effort would be required to locate and review the appropriate data. Clinical Services The clinical services of the facility or organization seeking provider-based status and the main provider would be required to maintain an unified retrieval system (or cross reference) of the main provider for all patient medical records for those patients treated in the facility or organization. While this collection requirement is subject to the PRA, we believe the burden associated with this requirement is exempt from the PRA as stipulated under 5 CFR 1320.3(b)
(2)and (b)(3). Section 482.12 Conditions of Participation: Governing Body Standard: Emergency Services If emergency services are provided at the hospital but are not provided at one or more off-campus departments of the hospital, the governing body of the hospital would be required to assure that the medical staff have written policies and procedures in effect with respect to the off-campus department(s) for appraisal of emergencies and referral when appropriate. While this collection requirement is subject to the PRA, we believe the burden associated with this requirement is exempt from the PRA as stipulated under 5 CFR 1320.3(b)(2) and (b)(3). Section 489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases Application to Inpatients—Admitted Emergency Patients If a hospital admits an individual with an unstable emergency medical condition for stabilizing treatment, as an inpatient, and stabilizes that individual's emergency medical condition, the period of stability would be required to be documented by relevant clinical data in the individual's medical record, before the hospital has satisfied its special responsibilities under this section with respect to that individual. While this collection requirement is subject to the PRA, we believe the burden associated with this requirement is exempt from the PRA as stipulated under 5 CFR 1320.3(b)(2) and (b)(3). If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following: Centers for Medicare & Medicaid Services, Office of Information Services, Information Technology Investment Management Group, Attn.: John Burke, Attn: CMS-1203-P, Room N2-14-26, 7500 Security Boulevard, Baltimore, MD 21244-1850. Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Allison Eydt, CMS Desk Officer Attn: CMS-1203-P. C. Public Comments Because of the large number of items of correspondence we normally receive on a proposed rule, we are not able to acknowledge or respond to them individually. However, in preparing the final rule, we will consider all comments concerning the provisions of this proposed rule that we receive by the date and time specified in the “DATES” section of this preamble and respond to those comments in the preamble to that rule. We emphasize that section 1886(e)(5) of the Act requires the final rule for FY 2003 to be published by August 1, 2002, and we will consider only those comments that deal specifically with the matters discussed in this proposed rule. List of Subjects 42 CFR Part 405 Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping requirements, Rural areas, X-rays. 42 CFR Part 412 Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 413 Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 482 Grant program-health, Hospitals, Medicaid, Medicare, Reporting and recordkeeping requirements. 42 CFR Part 485 Grant programs-health, Health facilities, Medicaid, Medicare, Reporting and recordkeeping requirements. 42 CFR Part 489 Health facilities, Medicare, Reporting and recordkeeping requirements. For the reasons stated in the preamble of this proposed rule, 42 CFR chapter IV is proposed to be amended as follows: PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED A. Part 405 is amended as follows: 1. The authority citation for Part 405, Subpart R continues to read as follows: Authority: Secs. 205, 1102, 1814(b), 1815(a), 1833, 1861(v), 1871, 1872, 1878, and 1886 of the Social Security Act (42 U.S.C. 405, 1302, 1395f(b), 1395g(a), 1395l, 1395x(v), 1395hh, 1395ii, 1395oo, and 1395ww). 2. Section 405.1885 is amended by revising paragraph (b), redesignating paragraph
(e)as paragraph (f), and adding a new paragraph (e), to read as follows: § 405.1885 Reopening a determination or decision. (b)(1) An intermediary determination or an intermediary hearing decision shall be reopened and revised by the intermediary if, within the aforementioned 3-year period, CMS—
(i)Provides notice to the intermediary that the intermediary determination or the intermediary hearing decision is inconsistent with the applicable law, regulations, CMS ruling, or CMS general instructions in effect, and as CMS understood those legal provisions, at the time the determination or decision was rendered by the intermediary; and
(ii)Explicitly directs the intermediary to reopen and revise the intermediary determination or the intermediary hearing decision.
(2)A change of legal interpretation or policy by CMS in a regulation, CMS ruling, or CMS general instruction, whether made in response to judicial precedent or otherwise, is not a basis for reopening an intermediary determination or an intermediary hearing decision under this section.
(e)Nothwithstanding an intermediary's discretion to reopen or not reopen an intermediary determination or an intermediary hearing decision under paragraphs
(a)and
(c)of this section, CMS may direct an intermediary to reopen, or not to reopen, an intermediary determination or an intermediary hearing decision in accordance with paragraphs
(a)and
(c)of this section. PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES B. Part 412 is amended as follows: 1. The authority citation for Part 412 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). § 412.4 [Amended] 2. In § 412.4 (f)(1), the reference “paragraph
(b)or (c)” is removed and “paragraph (b)(1) or (c)” is added in its place. 3. Section 412.22 is amended by— a. Revising the introductory text of paragraph (h)(2). b. Republishing the introductory text of paragraph (h)(2)(iii). c. Redesignating paragraphs (h)(2)(iii)(A) through
(F)as paragraphs (h)(2)(iii)(B) through (G), respectively. d. Adding new paragraph (h)(2)(iii)(A). § 412.22 Excluded hospitals and hospital units: General rules.
(h)*Satellite facilities.* * * *
(2)Except as provided in paragraph (h)(3) of this section, effective for cost reporting periods beginning on or after October 1, 1999, a hospital that has a satellite facility must meet the following criteria in order to be excluded from the acute care hospital inpatient prospective payment systems for any period:
(iii)The satellite facility meets all of the following requirements:
(A)Effective for cost reporting periods beginning on or after October 1, 2002, it is not under the authority or control of the governing body or chief executive officer of the hospital in which it is located, and it furnishes inpatient care through the use of medical personnel who are not under the authority or control of the medical staff or chief medical officer of the hospital in which it is located. 4. Section 412.25 is amended by— a. Revising the introductory text of paragraph (e)(2). b. Republishing the introductory text of paragraph (e)(2)(iii). c. Redesignating paragraphs (e)(2)(iii)(A) through
(F)as paragraphs (e)(2)(iii)(B) through (G), respectively. d. Adding new paragraph (e)(2)(iii)(A). § 412.25 Excluded hospitals units: Common requirements.
(e)*Satellite facilities.* * * *
(2)Except as provided in paragraph (e)(3) of this section, effective for cost reporting periods beginning on or after October 1, 1999, a hospital that has a satellite facility must meet the following criteria in order to be excluded from the acute care hospital inpatient prospective payment systems for any period:
(iii)The satellite facility meets all of the following requirements:
(A)Effective for cost reporting periods beginning on or after October 1, 2002, it is not under the authority or control of the governing body or chief executive officer of the hospital in which it is located, and it furnishes inpatient care through the use of medical personnel who are not under the authority or control of the medical staff or chief medical officer of the hospital in which it is located. § 412.63 [Amended] 5. Section 412.63 is amended by— a. In paragraph (x)(2)(i)(A), removing the phrase “tabulating the hospital's data” and adding in its place “tabulating its data”. b. Removing paragraphs (x)(3) and (x)(4). c. Redesignating paragraph (x)(5) as paragraph (x)(3). 6. Section 412.80 is amended by revising paragraph (a)(2) to read as follows: § 412.80 Outlier cases: General provisions.
(a)*Basic rule.* * * *
(2)*Discharges occurring on or after October 1, 1997 and before October 1, 2001.* For discharges occurring on or after October 1, 1997 and before October 1, 2001, except as provided in paragraph
(b)of this section concerning transfers, CMS provides for additional payment, beyond standard DRG payments, to a hospital for covered inpatient hospital services furnished to a Medicare beneficiary if the hospital's charges for covered services, adjusted to operating costs and capital costs by applying cost-to-charge ratios, as described in § 412.84(h), exceed the DRG payment for the case, payments for indirect costs of graduate medical education (§ 412.105), and payments for serving disproportionate share of low-income patients (§ 412.106), plus a fixed dollar amount (adjusted for geographic variation in costs) as specified by CMS. 7. Section 412.92 is amended by revising paragraph (c)(2), to read as follows: § 412.92 Special treatment: Sole community hospitals.
(c)*Terminology.* * * *
(2)The term *like hospital* means a hospital furnishing short-term, acute care. Effective with cost reporting periods beginning on or after October 1, 2002, if a hospital seeking sole community hospital designation can demonstrate that no more than 3 percent of the services it provides overlap with the services provided by a nearby hospital that would otherwise be considered a like hospital under this definition, CMS will not consider the nearby hospital to be a like hospital. 8. Section 412.105 is amended by— A. Republishing the introductory text of paragraph (a). B. Revising paragraph (a)(1). C. Revising paragraph (b). D. Revising paragraph (f)(1)(vi). E. Making the following cross-reference changes in paragraph (f)(1): i. In paragraph (f)(1)(vii), the reference “§ 413.86(g)(12)” is removed and “§ 413.86(g)(13)” is added in its place. ii. In paragraph (f)(1)(viii), the reference “§ 413.86(g)(7)” is removed and “§ 413.86(g)(8)” is added in its place. iii. In paragraph (f)(1)(ix), the reference “§§ 413.86(g)(8)(i) and (g)(8)(ii) of this subchapter” is removed and “§ 413.86(g)(9)(i) and (g)(9)(ii) of this subchapter” is added in its place; the reference “§§ 413.86(g)(8)(i) and (g)(8)(iii)(B) of this subchapter” is removed and “§ 413.86(g)(9)(i) and (g)(9)(iii)(B) of this subchapter” is added in its place; and the reference “§§ 413.86(g)(8)(i) and (g)(8)(iii)(A) of this subchapter” is removed and “§ 413.86(g)(9)(i) and (g)(9)(iii)(A) of this subchapter” is added it its place. iv. In paragraph (f)(1)(x), the reference “§ 413.86(g)(12)” is removed and “§ 413.86(g)(13)” is added in its place; and the reference “§ 413.86(g)(11)” is removed and “§ 413.86(g)(12)” is added in its place. v. In paragraph (f)(1)(xi), the reference “§ 413.86(g)(9)” is removed and “§ 413.86(g)(10)” is added in its place. vi. In paragraph (f)(1)(xii), the reference “§ 413.86(g)(10)” is removed and “§ 413.86(g)(11)” is added in its place. The revisions read as follows: § 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
(a)*Basic data* . CMS determines the following for each hospital:
(1)The hospital's ratio of full-time equivalent residents (except as limited under paragraph
(f)of this section) to the number of beds (as determined under paragraph
(b)of this section).
(i)Except for the special circumstances for affiliated groups and new programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section for cost reporting periods beginning on or after October 1, 1997, and for the special circumstances for closed hospitals or closed programs described in paragraph (f)(1)(ix) of this section for cost reporting periods beginning on or after October 1, 2002, this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of allopathic and osteopathic full-time equivalent residents as described in paragraph (f)(1)(iv) of this section, and adding to the capped numerator any dental and podiatric full-time equivalent residents.
(ii)The exception for new programs described in paragraph (f)(1)(vii) of this section applies to each new program individually for which the full-time equivalent cap may be adjusted based on the period of years equal to the minimum accredited length of each new program.
(iii)The exception for closed hospitals and closed programs described in paragraph (f)(1)(ix) of this section applies only in the first cost reporting period in which the receiving hospital trains the displaced full-time equivalent residents.
(iv)In the cost reporting period following the last year the receiving hospital's full-time equivalent cap is adjusted for the displaced resident(s), the resident-to-bed ratio cap in paragraph (a)(1) of this section is calculated as if the displaced full-time equivalent residents had not trained at the receiving hospital in the prior year.
(b)*Determination of number of beds* .
(1)For purposes of this section, subject to the provisions of paragraph (b)(2) of this section, the number of beds in a hospital is determined by counting the number of available bed days during the cost reporting period, not including beds or bassinets in the healthy newborn nursery, custodial care beds, or beds in excluded distinct part hospital units, and dividing that number by the number of days in the cost reporting period.
(2)Effective for discharges occurring on or after October 1, 2002, a hospital's number of beds is equal to the lower of the number of beds as determined under paragraph (b)(1) of this section, or the average daily census (as determined in accordance with § 412.322(a)(2) of this chapter) divided by 35 percent.
(f)*Determining the total number of full-time equivalent residents for cost reporting periods beginning on or after July 1, 1991* .
(1)* * *
(vi)Hospitals that are part of the same affiliated group (as defined in § 413.86(b) of this subchapter) may elect to apply the limit at paragraph (f)(1)(iv) of this section on an aggregate basis, as specified in § 413.86(g)(7) of this chapter. 9. Section 412.108 is amended by revising paragraph
(b)to read as follows: § 412.108 Special treatment: Medicare-dependent, small rural hospitals.
(b)*Classification procedures* .
(1)The fiscal intermediary determines whether a hospital meets the criteria specified in paragraph
(a)of this section.
(2)A hospital must submit a written request along with qualifying documentation to its fiscal intermediary to be considered for MDH status based on the criterion under paragraph (a)(1)(iii)(C) of this section.
(3)The fiscal intermediary will make its determination and notify the hospital within 90 days from the date that it receives the hospital's request and all of the required documentation.
(4)A determination of MDH status made by the fiscal intermediary is effective 30 days after the date the fiscal intermediary provides written notification to the hospital. An approved MDH status determination remains in effect unless there is a change in the circumstances under which the status was approved.
(5)The fiscal intermediary will evaluate on an ongoing basis, whether or not a hospital continues to qualify for MDH status. This evaluation includes an ongoing review to ensure that the hospital continues to meet all of the criteria specified in paragraph
(a)of this section.
(6)If the fiscal intermediary determines that a hospital no longer qualifies for MDH status, the change in status will become effective 30 days after the date the fiscal intermediary provides written notification to the hospital.
(7)A hospital may reapply for MDH status following its disqualification only after it has completed another cost reporting period that has been audited and settled. The hospital must reapply for MDH status in writing to its fiscal intermediary and submit the required documentation.
(8)If a hospital disagrees with an intermediary's determination regarding the hospital's initial or ongoing MDH status, the hospital may notify its fiscal intermediary and submit other documentable evidence to support its claim that it meets the MDH qualifying criteria.
(9)The fiscal intermediary's initial and ongoing determination is subject to review under subpart R of Part 405 of this chapter. The time required by the fiscal intermediary to review the request is considered good cause for granting an extension of the time limit for the hospital to apply for that review. 10. Section 412.113 is amended by revising paragraphs (c)(2)(ii) and (c)(2)(iii) to read as follows: § 412.113 Other payments.
(c)*Anesthesia services furnished by hospital employed nonphysician anesthetists or obtained under arrangements. * * **
(2)* * *
(ii)To maintain its eligibility for reasonable cost payment under paragraph (c)(2)(i) of this section in calendar years after 1989, a qualified hospital or CAH must demonstrate prior to January 1 of each respective year that for the prior year its volume of surgical procedures requiring anesthesia service did not exceed 500 procedures; or, effective October 1, 2002, did not exceed 800 procedures.
(iii)A hospital or CAH that did not qualify for reasonable cost payment for nonphysician anesthetist services furnished in calendar year 1989 can qualify in subsequent years if it meets the criteria in paragraphs (c)(2)(i)(A), (B), and
(D)of this section, and demonstrates to its intermediary prior to the start of the calendar year that it met these criteria. The hospital or CAH must provide data for its entire patient population to demonstrate that, during calendar year 1987 and the year immediately preceding its election of reasonable cost payment, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 500 procedures, or, effective October 1, 2002, did not exceed 800 procedures. 11. Section 412.230 is amended by adding a new paragraph (e)(2)(iii) to read as follows: § 412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
(e)*Use of urban or other rural area's wage index* . * * *
(2)*Appropriate wage data* . * * *
(iii)For purposes of this paragraph (e)(2), if a new owner does not accept assignment of the existing hospital's provider agreement in accordance with § 489.18 of this chapter, the hospital will be treated as a new provider with a new provider number. In this case, the wage data associated with the previous owner of the hospital cannot be used in calculating the new hospital's 3-year average hourly wage. Once a new hospital has accumulated at least 1 year of wage data, it is eligible to apply for reclassification on the basis of those data. 12. Section 412.273 is amended by— A. Revising the section heading. B. Revising paragraph (b)(2). C. Redesignating paragraph
(d)as paragraph (e). D. Add a new paragraph (d). § 412.273 Withdrawing an application, terminating an approved 3-year reclassification, or canceling a previous withdrawal or termination.
(b)*Request for termination of approved 3-year wage index reclassifications* . * * *
(2)*Reapplication within the approved 3-year period* .
(i)If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, it may 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.
(ii)A hospital may apply for reclassification for purposes of the wage index to a different area (that is, an area different from the one to which it was originally reclassified for the 3-year period). If the application is approved, the reclassification will be effective for 3 years. Once a 3-year reclassification becomes effective, a hospital may no longer cancel a withdrawal or termination of another 3-year reclassification, regardless of whether the withdrawal or termination request is made within 3 years from the date of the withdrawal or termination.
(iii)In a case in which a hospital with an existing 3-year wage index reclassification applies to be reclassified to another area, its existing 3-year reclassification will be terminated when a second 3-year wage index reclassification goes into effect for payments for discharges on or after the following October 1.
(d)*Process for canceling a previous withdrawal or termination* . A hospital may cancel a previous withdrawal or termination by submitting written notice of its intent to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year, as specified in § 412.256(a)(2). 13. Section 412.304 is amended by revising paragraph
(c)to read as follows: § 412.304 Implementation of the capital prospective payment system.
(c)*Cost reporting periods beginning on or after October 1, 2001* .
(1)*General.* Except as provided in paragraph (c)(2) of this section, for cost reporting periods beginning on or after October 1, 2001, the capital payment amount is based solely on the Federal rate determined under § 412.308(a) and
(b)and updated under § 412.308(c).
(2)*Payment to new hospitals.* For cost reporting periods beginning on or after October 1, 2002—
(i)A new hospital, as defined under § 412.300(b), is paid 85 percent of its allowable Medicare inpatient hospital capital-related costs through its cost report ending at least 2 years after the hospital accepts its first patient.
(ii)For the third year and subsequent years, the hospital is paid based on the Federal rate as described under § 412.312. 14. Section 412.308 is amending by adding a new paragraph (b)(6) to read as follows: § 412.308 Determining and updating the Federal rate.
(b)*Standard Federal rate.* * * *
(6)For discharges occurring on or after October 1, 2002, the 2.1 percent reduction provided for under paragraph (b)(5) of this section is eliminated from the unadjusted standard Federal rate in effect on September 30, 2002, used to determine the Federal rate each year under paragraph
(c)of this section. 15. Section 412.312 is amended by adding a new paragraph
(e)to read as follows: § 412.312 Payment based on the Federal rate.
(e)*Payment for extraordinary circumstances.* Payment for extraordinary circumstances is made as provided for in § 412.348(f) for cost reporting periods beginning on or after October 1, 2001. PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES C. Part 413 is amended as follows: 1. The authority citation for part 413 is revised to read as follows: Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 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), 1395hh, 1395rr, 1395tt, and 1395ww). 2. Section 413.65 is amended by— A. Revising paragraph (a)(1)(ii)(G) and adding a new paragraph (a)(1)(ii)(J). B. Revising the definition of “Department of a provider”, “Provider-based entity”, and “Remote location of a hospital” under paragraph (a)(2). C. Revising paragraphs (b)(2), (b)(3), and (d). D. Removing paragraph (j). E. Redesignating paragraphs
(h)and
(i)as paragraphs
(i)and (j), respectively. F. Redesignating paragraph
(f)as paragraph (h). G. Redesignating paragraph
(e)as paragraph (f). H. Adding a new paragraph (e). I. Revising redesignated paragraph (f). J. Revising the introductory text of paragraph (g), and paragraphs (g)(1), (g)(2), and (g)(7). K. Revising redesignated paragraphs (h), (i), and (j). L. Revising paragraph (k). M. Revising the heading of paragraph (m). N. Revising paragraph (n). § 413.65 Requirements for a determination that a facility or an organization had provider-based status.
(a)*Scope and definitions.*
(1)*Scope.* * * *
(ii)This section does not apply to the following facilities:
(G)Independent diagnostic testing facilities furnishing only services paid under a fee schedule, such as facilities that furnish only screening mammography services (as defined in section 1861(jj) of the Act), facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only some combination of these services.
(J)Departments of providers that perform functions necessary for the successful operation of the providers but do not furnish services of a type for which separate payment could be claimed under Medicare or Medicaid (for example, laundry or medical records departments).
(2)*Definitions.* * * * *Department of a provider* means a facility or organization that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A department of a provider comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A department of a provider may not by itself be qualified to participate in Medicare as a provider under § 489.2 of this chapter, and the Medicare conditions of participation do not apply to a department as an independent entity. For purposes of this part, the term “department of a provider” does not include an RHC or, except as specified in paragraph
(m)of this section, an FQHC. *Provider-based entity* means a provider of health care services, or an RHC as defined in § 405.2401(b) of this chapter, that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, and administrative and financial control of the main provider, in accordance with the provisions of this section. A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A provider-based entity may, by itself, be qualified to participate in Medicare as a provider under § 489.2 of this chapter, and the Medicare conditions of participation do apply to a provider-based entity as an independent entity. *Remote location of a hospital* means a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity. For purposes of this part, the term “remote location of a hospital” does not include a satellite facility as defined in § 412.22(h)(1) and § 412.25(e)(1) of this chapter.
(b)*Responsibility for obtaining provider-based determinations.* * * *
(2)If a facility was treated as provider-based in relation to a hospital or CAH on October 1, 2000, it will continue to be considered provider-based in relation to that hospital or CAH until the start of the hospital's first cost reporting period beginning on or after July 1, 2003. The requirements, limitations, and exclusions specified in paragraphs (d), (e), (f), (g), (h), and (i), of this section will not apply to that hospital or CAH until the start of the hospital's first cost reporting period beginning on or after July 1, 2003. For purposes of this paragraph (b)(2), a facility is considered as provider-based on October 1, 2000 if, on that date, it either had a written determination from CMS that it was provider-based, or was billing and being paid as a provider-based department or entity of the hospital. (3)(i) Except as specified in paragraphs (b)(2) and (b)(5) of this section, if a potential main provider seeks an advance determination of provider-based status for a facility that is located on the main campus of the potential main provider, the provider would be required to submit an attestation stating that the facility meets the criteria in paragraph
(d)of this section and if it is a hospital, also attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph
(g)of this section. The provider seeking such an advance determination would also be required to maintain documentation of the basis for its attestations and to make that documentation available to CMS upon request.
(ii)If the facility is not located on the main campus of the potential main provider, the provider seeking an advance determination would be required to submit an attestation stating that the facility meets the criteria in paragraphs
(d)and
(e)of this section, and if the facility is operated as a joint venture or under a management contract, the requirements of paragraph
(f)or paragraph
(h)of this section, as applicable. If the potential main provider is a hospital, the hospital also would be required to attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph
(g)of this section. The provider would be required to supply documentation of the basis for its attestations to CMS at the time it submits its attestations.
(d)*Requirements applicable to all facilities or organizations.* Any facility or organization for which provider-based status is sought, whether located on or off the campus of a potential main provider, must meet all of the following requirements to be determined by CMS to have provider-based status:
(1)*Licensure.* The department of the provider, the remote location of a hospital, or the satellite facility and the main provider are operated under the same license, except in areas where the State requires a separate license for the department of the provider, the remote location of a hospital, or the satellite facility, or in States where State law does not permit licensure of the provider and the prospective department of the provider, the remote location of a hospital, or the satellite facility under a single license. If a State health facilities' cost review commission or other agency that has authority to regulate the rates charged by hospitals or other providers in a State finds that a particular facility or organization is not part of a provider, CMS will determine that the facility or organization does not have provider-based status.
(2)*Clinical services.* The clinical services of the facility or organization seeking provider-based status and the main provider are integrated as evidenced by the following:
(i)Professional staff of the facility or organization have clinical privileges at the main provider.
(ii)The main provider maintains the same monitoring and oversight of the facility or organization as it does for any other department of the provider.
(iii)The medical director of the facility or organization seeking provider-based status maintains a reporting relationship with the chief medical officer or other similar official of the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the medical director of a department of the main provider and the chief medical officer or other similar official of the main provider, and is under the same type of supervision and accountability as any other director, medical or otherwise, of the main provider.
(iv)Medical staff committees or other professional committees at the main provider are responsible for medical activities in the facility or organization, including quality assurance, utilization review, and the coordination and integration of services, to the extent practicable, between the facility or organization seeking provider-based status and the main provider.
(v)Medical records for patients treated in the facility or organization are integrated into a unified retrieval system (or cross reference) of the main provider.
(vi)Inpatient and outpatient services of the facility or organization and the main provider are integrated, and patients treated at the facility or organization who require further care have full access to all services of the main provider and are referred where appropriate to the corresponding inpatient or outpatient department or service of the main provider.
(3)*Financial integration.* The financial operations of the facility or organization are fully integrated within the financial system of the main provider, as evidenced by shared income and expenses between the main provider and the facility or organization. The costs of a facility or organization that is a hospital department are reported in a cost center of the provider, costs of a provider-based facility or organization other than a hospital department are reported in the appropriate cost center or cost centers of the main provider, and the financial status of any provider-based facility or organization is incorporated and readily identified in the main provider's trial balance.
(4)*Public awareness.* The facility or organization seeking status as a department of a provider, a remote location of a hospital, or a satellite facility is held out to the public and other payers as part of the main provider. When patients enter the provider-based facility or organization, they are aware that they are entering the main provider and are billed accordingly.
(5)*Obligations of hospital outpatient departments and hospital-based entities.* In the case of a hospital outpatient department or a hospital-based entity, the facility or organization must fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph
(g)of this section.
(e)*Additional requirements applicable to off-campus facilities or organizations.* Except as described in paragraphs (b)(2) and (b)(5) of this section, any facility or organization for which provider-based status is sought that is not located on the campus of a potential main provider must meet both the requirements in paragraph
(d)of this section and all of the following additional requirements, in order to be determined by CMS to have provider-based status.
(1)*Operation under the ownership and control of the main provider.* The facility or organization seeking provider-based status is operated under the ownership and control of the main provider, as evidenced by the following:
(i)The business enterprise that constitutes the facility or organization is 100 percent owned by the provider.
(ii)The main provider and the facility or organization seeking status as a department of the provider, a remote location of a hospital, or a satellite facility have the same governing body.
(iii)The facility or organization is operated under the same organizational documents as the main provider. For example, the facility or organization seeking provider-based status must be subject to common bylaws and operating decisions of the governing body of the provider where it is based.
(iv)The main provider has final responsibility for administrative decisions, final approval for contracts with outside parties, final approval for personnel actions, final responsibility for personnel policies (such as fringe benefits or code of conduct), and final approval for medical staff appointments in the facility or organization.
(2)*Administration and supervision.* The reporting relationship between the facility or organization seeking provider-based status and the main provider must have the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its existing departments, as evidenced by compliance with all of the following requirements:
(i)The facility or organization is under the direct supervision of the main provider.
(ii)The facility or organization is operated under the same monitoring and oversight by the provider as any other department of the provider, and is operated just as any other department of the provider with regard to supervision and accountability. The facility or organization director or individual responsible for daily operations at the entity—
(A)Maintains a reporting relationship with a manager at the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and its existing departments; and
(B)Is accountable to the governing body of the main provider, in the same manner as any department head of the provider.
(iii)The following administrative functions of the facility or organization are integrated with those of the provider where the facility or organization is based: billing services, records, human resources, payroll, employee benefit package, salary structure, and purchasing services. Either the same employees or group of employees handle these administrative functions for the facility or organization and the main provider, or the administrative functions for both the facility or organization and the entity are—
(A)Contracted out under the same contract agreement; or
(B)Handled under different contract agreements, with the contract of the facility or organization being managed by the main provider.
(3)*Location.* The facility or organization is located within a 35-mile radius of the main campus of the hospital or CAH that is the potential main provider, except when the requirements in paragraph (e)(3)(i), (e)(3)(ii), or (e)(3)(iii) of this section are met:
(i)The facility or organization is owned and operated by a hospital or CAH that has a disproportionate share adjustment (as determined under § 412.106 of this chapter) greater than 11.75 percent or is described in § 412.106(c)(2) of this chapter implementing section 1886(e)(5)(F)(i)(II) of the Act and is—
(A)Owned or operated by a unit of State or local government;
(B)A public or nonprofit corporation that is formally granted governmental powers by a unit of State or local government; or
(C)A private hospital that has a contract with a State or local government that includes the operation of clinics located off the main campus of the hospital to assure access in a well-defined service area to health care services for low-income individuals who are not entitled to benefits under Medicare (or medical assistance under a Medicaid State plan).
(ii)The facility or organization demonstrates a high level of integration with the main provider by showing that it meets all of the other provider-based criteria and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with CMS, and for each subsequent 12-month period—
(A)At least 75 percent of the patients served by the facility or organization reside in the same zip code areas as at least 75 percent of the patients served by the main provider;
(B)At least 75 percent of the patients served by the facility or organization who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of an RHC seeking provider-based status received inpatient hospital services from the hospital that is the main provider); or
(C)If the facility or organization is unable to meet the criteria in paragraph (e)(3)(ii)(A) or paragraph (e)(3)(ii)(B) of this section because it was not in operation during all of the 12-month period described in paragraph (e)(3)(ii) of this section, the facility or organization is located in a zip code area included among those that, during all of the 12-month period described in paragraph (e)(3)(ii) of this section, accounted for at least 75 percent of the patients served by the main provider.
(iv)A facility or organization may qualify for provider-based status under this section only if the facility or organization and the main provider are located in the same State or, when consistent with the laws of both States, in adjacent States.
(v)An RHC that is otherwise qualified as a provider-based entity of a hospital that is located in a rural area, as defined in § 412.62(f)(1)(iii) of this chapter, and has fewer than 50 beds, as determined under § 412.105(b) of this chapter, is not subject to the criteria in paragraphs (e)(3)(i) through (e)(3)(iii) of this section.
(f)*Provider-based status for joint ventures.* A facility or organization that is not located on the campus of the potential main provider cannot be considered provider-based if the facility or organization is owned by two or more providers engaged in a joint venture. For example, where a hospital has jointly purchased or jointly created a facility under joint venture arrangements with one or more other providers, and the facility is not located on the campus of the hospital or the campus of any other provider engaged in the joint venture arrangement, no party to the joint venture arrangement can claim the facility as provider-based.
(g)*Obligations of hospital outpatient departments and hospital-based entities.* To qualify for provider-based status in relation to a hospital, a facility or organization must comply with the following requirements:
(1)The following departments must comply with the antidumping rules of § 489.20(l), (m), (q), and
(r)and § 489.24 of this chapter:
(i)Any facility or organization that is located on the main hospital campus and is treated by Medicare under this section as a department of the hospital; and
(ii)Any facility or organization that is located off the main hospital campus that is treated by Medicare under this section as a department of the hospital and is a dedicated emergency department, as defined in § 489.24(b) of this chapter.
(2)Physician services furnished in hospital outpatient departments or hospital-based entities (other than RHCs) must be billed with the correct site-of-service so that appropriate physician and practitioner payment amounts can be determined under the rules of part 414 of this chapter.
(7)When a Medicare beneficiary is treated in a hospital outpatient department of hospital-based entity (other than an RHC) that is not located on the main provider's campus, and the treatment is not required to be provided by the antidumping rules in § 489.24 of this chapter, the hospital must provide written notice to the beneficiary, before the delivery of services, of the amount of the beneficiary's potential financial liability (that is, that the beneficiary will incur a coinsurance liability for an outpatient visit to the hospital as well as for the physician service, and of the amount of that liability).
(i)The notice must be one that the beneficiary can read and understand.
(ii)If the exact type and extent of care needed is not known, the hospital may furnish a written notice to the patient that explains that the beneficiary will incur a coinsurance liability to the hospital that he or she would not incur if the facility were not provider-based.
(iii)The hospital may furnish an estimate based on typical or average charges for visits to the facility, while stating that the patient's actual liability will depend upon the actual services furnished by the hospital.
(iv)If the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on his or her own rights, the notice must be provided, before the delivery of services, to the beneficiary's authorized representative.
(v)In cases where a hospital outpatient department provides examination or treatment that is required to be provided by the antidumping rules of § 489.24 of this chapter, notice, as described in this paragraph (g)(7), must be given as soon as possible after the existence of an emergency has been ruled out or the emergency condition has been stabilized.
(h)*Management contracts.* A facility or organization that is not located on the campus of the potential main provider and otherwise meets the requirements of paragraphs
(d)and
(e)of this section, but is operated under management contracts, must also meet all of the following criteria:
(1)The main provider (or an organization that also employs the staff of the main provider and that is not the management company) employs the staff of the facility or organization who are directly involved in the delivery of patient care, except for management staff and staff who furnish patient care services of a type that would be paid for by Medicare under a fee schedule established by regulations at Part 414 of this chapter. “Leased” employees (that is, personnel who are actually employed by the management company but provide services for the provider under a staff leasing or similar agreement) are not considered to be employees of the provider for purposes of this paragraph.
(2)The administrative functions of the facility or organization are integrated with those of the main provider, as determined under criteria in paragraph (e)(2)(iii) of this section.
(3)The main provider has significant control over the operations of the facility or organization as determined under criteria in paragraph (e)(2)(ii) of this section.
(4)The management contract is held by the main provider itself, not by a parent organization that has control over both the main provider and the facility or organization.
(i)*Furnishing all services under arrangement.* A facility or organization may not qualify for provider-based status if all patient care services furnished at the facility or organization are furnished under arrangements.
(j)*Inappropriate treatment of a facility or organization as provider-based.*
(1)*Determination and review.* If CMS learns that a provider has treated a facility or organization as provider-based and the provider did not request an advance determination of provider-based status from CMS under paragraph (b)(3) of this section and CMS determines that the facility or organization did not meet the requirements for provider-based status under paragraphs
(d)through
(i)of this section, as applicable (or, in any period before the effective date of these regulations, the provider-based requirements in effect under Medicare program regulations or instructions), CMS will—
(i)Issue notice to the provider in accordance with paragraph (j)(3) of this section, adjust the amount of future payments to the provider for services of the facility or organization in accordance with paragraph (j)(4) of this section, and continue payments to the provider for services of the facility or organization only in accordance with paragraph (j)(5) of this section; and
(ii)Except as otherwise provided in paragraphs (b)(2), (b)(5), or (j)(2) of this section, recover the difference between the amount of payments that actually was made and the amount of payments that CMS estimates should have been made, in the absence of compliance with the provider-based requirements, to that provider for services at the facility or organization for all cost reporting periods subject to reopening in accordance with §§ 405.1885 and 405.1889 of this chapter.
(2)*Exception for good faith effort.* CMS will not recover any payments for any period before the beginning of the hospital's first cost reporting period beginning on or after January 10, 2001, if, during all of that period—
(i)The requirements regarding licensure and public awareness in paragraphs (d)(1) and (d)(4) of this section were met;
(ii)All facility services were billed as if they had been furnished by a department of a provider, a remote location of a hospital, a satellite facility, or a provider-based entity of the main provider; and
(iii)All professional services of physicians and other practitioners were billed with the correct site-of-service indicator, as described in paragraph (g)(2) of this section.
(3)*Notice to provider.* CMS will issue written notice to the provider that payments for past cost reporting periods may be reviewed and recovered as described in paragraph (j)(1)(ii) of this section, and that future payments for services in or of the facility or organization will be adjusted as described in paragraph (j)(4) of this section.
(4)*Adjustment of payments.* CMS will adjust future payments to the provider or the facility or organization, or both, to approximate as closely as possible the amounts that would be paid for the same services furnished by a freestanding facility.
(5)*Continuation of payment.*
(i)The notice of denial of provider-based status sent to the provider will ask the provider to notify CMS in writing, within 30 days of the date the notice is issued, of whether the provider intends to seek an advance determination of provider-based status for the facility or organization under paragraph (b)(3) of this section or whether the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services in a freestanding facility.
(ii)If the provider indicates that it will not be seeking an advance determination for the facility or organization under paragraph
(b)of this section or that the facility or organization or its practitioners will not be seeking to enroll, or if CMS does not receive a response within 30 days of the date the notice was issued, all payment under this paragraph (j)(5) will end as of the 30th day after the date of notice.
(iii)If the provider indicates that it will be seeking an advance determination for the facility or organization under paragraph
(b)of this section or that the facility or organization or its practitioners will be seeking to meet enrollment and other requirements for billing for services in a freestanding facility, payment for services of the facility or organization will continue, at the adjusted amounts described in paragraph (j)(4) of this section, for as long as is required for all billing requirements to be met (but not longer than 6 months) if the provider or the facility or organization or its practitioners—
(A)Submits, as applicable, a complete request for an advance determination of provider-based status or a complete enrollment application and provide all other required information within 90 days after the date of notice; and
(B)Furnishes all other information needed by CMS to process the request for provider-based status or the enrollment application, as applicable, and verifies that other billing requirements are met.
(v)If the necessary applications or information are not provided, CMS will terminate all payment to the provider, facility, or organization as of the date CMS issues notice that necessary applications or information have not been submitted.
(k)*Temporary treatment as provider-based and correction of errors.*
(1)If a provider submits a complete request for a provider-based determination for a facility or organization that has not previously been found by CMS to have been inappropriately treated as provider-based under paragraph
(j)of this section, the provider may bill and be paid for services of the facility or organization as provider-based from the date of the application until the date that CMS determines that the facility or organization does not meet the provider-based rules. If CMS subsequently determines that the requirements for provider-based status are not met, CMS will recover the difference between the amount of payments that actually was made since the date the complete request for a provider-based determination was submitted and the amount of payments that CMS estimates should have been made in the absence of compliance with the provider-based requirements. For purposes of this paragraph (k), a complete request is one that includes all information needed to permit CMS to make an advance determination under paragraph (b)(3) of this section.
(2)If CMS determines that a facility or organization that had previously been determined to be provider-based under paragraph
(b)of this section no longer qualifies for provider-based status, and the failure to qualify for provider-based status resulted from a material change in the relationship between the provider and the facility or organization that the provider did report to CMS as required under paragraph
(c)of this section, treatment of the facility or organization as provider-based ceases with the date that CMS determines that the facility or organization no longer qualifies for provider-based status.
(3)If CMS determines that a facility or organization that had previously been determined to be provider-based under paragraph
(b)of this section no longer qualifies for provider-based status, and if the failure to qualify for provider-based status resulted from a material change in the relationship between the provider and the facility or organization that the provider did not report to CMS, as required under paragraph
(c)of this section, CMS will take the actions with respect to notice to the provider, adjustment of payments, and continuation of payment described in paragraphs (j)(3), (j)(4), and (j)(5) of this section, and will recover past payments to the provider to the extent described in paragraph (j)(1)(ii) of this section.
(m)*FQHCs and “look alikes”.* * * *
(n)*Effective date of provider-based status.* Provider-based status for a facility or organization is effective on the earliest date on which a request for provider-based status, as described in paragraph
(b)of this section, has been made and all of the requirements of this part have been met. 3. Section 413.70 is amended by revising paragraph (b)(3)(i) to read as follows: § 413.70 Payment for services of a CAH.
(b)*Payment for outpatient services furnished by CAH.*
(3)*Election to be paid reasonable costs for facility services plus fee schedule for professional services.*
(i)A CAH may elect to be paid for outpatient services in any cost reporting period under the method described in paragraphs (b)(3)(ii) and (b)(3)(iii) of this section. This election must be made in writing, made on an annual basis, and delivered to the intermediary servicing the CAH by a date determined by that intermediary, which may be no less than 14 days and no more than 60 days before the start of each affected cost reporting period. An election of this payment method, once made for a cost reporting period, remains in effect for all of that period and applies to all services furnished to outpatients during that period. 4. Section 413.86 is amended by— A. Adding a definition of “Affiliation agreement” in alphabetical order under paragraph (b). B. Revising the last sentence of the introductory text of paragraph (e)(5)(i). C. Revising paragraph (e)(5)(i)(B). D. Adding a new paragraph (e)(5)(i)(C). E. Redesignating paragraphs (g)(5)(iv), (g)(5)(v), and (g)(5)(vi) as paragraphs (g)(5)(v), (g)(5)(vi), and (g)(5)(vii), respectively. F. Republishing the introductory text of paragraph (g)(5) and adding a new paragraph (g)(5)(iv). G. Redesignating paragraphs (g)(7) through (g)(12) as paragraphs (g)(8) through (g)(13), respectively. H. Adding a new paragraph (g)(7). I. Making the following cross-reference changes: i. In redesignated paragraph (g)(5)(vii), “paragraph (g)(8)” is removed and “paragraph (g)(9)” is added in its place. ii. In paragraph (g)(6), “paragraph (g)(12)” is removed and “paragraph (g)(13)” is added in its place. iii. In redesignated paragraphs (g)(8)(iv) and (g)(8)(v), “paragraph (g)(7)” is removed and “paragraph (g)(8)” is added in its place. iv. In redesignated paragraph (g)(9)(i), “paragraph (g)(8)” is removed and “paragraph (g)(9)” is added in its place. v. In the introductory text of redesignated paragraph (g)(9)(iii), “paragraph (g)(8)(iii)(B)” is removed and “paragraph (g)(9)(iii)(B)” is added in its place; and “paragraph (g)(8)(iii)(A)” is removed and “paragraph (g)(9)(iii)(A)” is added in its place. vi. In redesignated paragraph (g)(9)(iii)(A)( *2* ), “paragraph (g)(8)(iii)(B)( *2* )” is removed and “paragraph (g)(9)(iii)(B)( *2* )” is added in its place. vii. In the introductory text of redesignated paragraph (g)(12), “paragraph (g)(11)(i) through (g)(11)(vi)” is removed and “paragraph (g)(12)(i) through (g)(12)(vi)” is added in its place. The additions and revisions read as follows: § 413.86 Direct graduate medical education payments.
(b)*Definitions.* * * * *Affiliation agreement* means a written, signed, and dated agreement by responsible representatives of each respective hospital in an affiliated group, as defined in this section, that specifies—
(1)The term of the agreement (which, at a minimum is one year), beginning on July 1 of a year;
(2)Each participating hospital's direct and indirect FTE caps existing at the time of affiliation;
(3)The adjustment to each hospital's FTE caps in each year that the affiliation agreement is in effect, for both direct GME and IME, that reflects a positive adjustment to one hospital's direct and indirect FTE caps that is offset by a negative adjustment to the other hospital's (or hospitals') direct and indirect FTE caps of at least the same amount; and
(4)The names of the participating hospitals and their Medicare provider numbers.
(e)*Determining per resident amounts for the base period.* * * *
(5)*Exceptions* —(i) *Base period for certain hospitals.* * * * The per resident amount is based on the lower of the amount specified in paragraph (e)(5)(i)(A) or in paragraph (e)(5)(i)(B) of this section, subject to the provisions of paragraph (e)(5)(i)(C) of this section.
(B)Except as specified in paragraph (e)(5)(i)(C) of this section— ( *1* ) For base periods that begin before October 1, 2002, the updated weighted mean value of per resident amounts of all hospitals located in the same geographic wage area, as that term is used in the prospective payment system under part 412 of this chapter. ( *2* ) For base periods beginning on or after October 1, 2002, the weighted mean value of per resident amounts of all hospitals located in the same geographic wage area is calculated using all per resident amounts (including primary care and obstetrics and gynecology and nonprimary care) and FTE resident counts from the most recently settled cost reports of those teaching hospitals.
(C)If, under paragraph (e)(5)(i)(B)( *1* ) or (e)(5)(i)(B)( *2* ) of this section, there are fewer than three existing teaching hospitals with per resident amounts that can be used to calculate the weighted mean value per resident amount, for base periods beginning on or after October 1, 1997, the per resident amount equals the updated weighted mean value of per resident amounts of all hospitals located in the same census region as that term is used in § 412.62(f)(1)(i) of this chapter.
(g)*Determining the weighted number of FTE residents.* * * *
(5)For purposes of determining direct graduate medical education payment—
(iv)Hospitals that are part of the same affiliated group (as described under paragraph
(b)of this section) may elect to apply the limit on an aggregate basis as described under paragraph (g)(7) of this section.
(7)A hospital may receive a temporary adjustment to its FTE cap, which is subject to the averaging rules under paragraph (g)(5)(iii) of this section, to reflect residents added or subtracted because the hospital is participating in an affiliated group (as defined under paragraph
(b)of this section). Under this provision—
(i)Each hospital in the affiliated group must submit the affiliation agreement, as defined under paragraph
(b)of this section, to the CMS fiscal intermediary servicing the hospital and send a copy to CMS's Central Office no later than July 1 of the residency program year during which the affiliation agreement will be in effect.
(ii)There must be a rotation of a resident(s) among the hospitals participating in the affiliated group during the term of the affiliation agreement such that more than one of the hospitals count the proportionate amount of the time spent by the resident(s) in their FTE resident counts. No resident may be counted in the aggregate as more than one FTE.
(iii)The net effect of the adjustments (positive or negative) on the affiliated hospitals' aggregate FTE cap for each affiliation agreement must not exceed zero.
(iv)If the affiliation agreement terminates for any reason, the FTE cap of each hospital in the affiliated group will revert to the individual hospital's pre-affiliation FTE cap that is determined under the provisions of paragraph (g)(4) of this section. PART 482—CONDITIONS FOR PARTICIPATION FOR HOSPITALS D. Part 482 is amended as follows: 1. The authority citation for part 482 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1320 and 1395hh). 2. Section 482.12 is amended by adding a new paragraph (f)(3), to read as follows: § 482.12 Condition of participation: Governing body.
(f)*Standard: Emergency services.* * * *
(3)If emergency services are provided at the hospital but are not provided at one or more off-campus departments of the hospital, the governing body of the hospital must assure that the medical staff has written policies and procedures in effect with respect to the off-campus department(s) for appraisal of emergencies and referral when appropriate. PART 485—CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS E. Part 485 is amended as follows: 1. The authority citation for Part 485 continues to read as follows: Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 1396hh). 2. In § 485.645, the introductory text of paragraph
(d)is republished and paragraph (d)(6) is revised, to read as follows. § 485.645 Special requirements for CAH providers of long-term care services (“swing-beds”).
(d)*SNF services.* The CAH is substantially in compliance with following SNF requirements contained in subpart B of part 483 of this chapter.
(6)Comprehensive assessment, comprehensive care plan, and discharge planning (§ 483.20(b), (k), and
(l)of this chapter, except that the CAH is not required to use the resident assessment instrument
(RAI)specified by the State that is required under § 483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in § 413.343(b) of this chapter). PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL F. Part 489 is amended as follows: 1. The authority citation for part 489 continues to read as follows: Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 1395hh). 2. Section 489.24 is amended by— A. Revising paragraph (a). B. Republishing the introductory text of paragraph
(b)and revising the definitions of “Comes to the emergency department” and “Hospital with an emergency department”. C. Adding definitions of “Dedicated emergency department”, “Hospital property”, and “Patient” in alphabetical order under paragraph (b). D. Under the definition of “Emergency medical condition” under paragraph (b), redesignating paragraphs (i), (i)(A), (i)(B), (i)(C), (ii), (ii)(A), and (ii)(B) as paragraphs (1), (1)(i), (1)(ii), (1)(iii), (2), (2)(i), and (2)(ii), respectively. E. Under the definition of “Participating hospital” under paragraph (b), redesignating paragraphs
(i)and
(ii)as paragraphs
(1)and (2), respectively. F. Under the definitions of “Stabilized” and “To stabilize” under paragraph (b), “paragraph (i)” is removed and “paragraph (1)” is added in its place; and “paragraph (ii)” is removed and “paragraph (2)” is added in its place. G. Removing paragraph (i); and redesignating paragraph
(c)through
(h)as paragraphs
(d)through (i), respectively. H. Adding a new paragraph (c). I. Revising newly redesignated paragraph (d). J. Adding a new paragraph (j). K. Making the following cross-reference changes: i. In redesignated paragraph (e)(1)(i), “paragraph (d)(2)” is removed and “paragraph (e)(2)” is added in its place. ii. In redesignated paragraph (e)(1)(ii)(C), “paragraph (d)(1)(ii)(B)” is removed and “paragraph (e)(1)(ii)(B)” is added in its place. iii. In redesignated paragraph (e)(2)(iii), “paragraph (d)(1)(ii)” is removed and “paragraph (e)(1)(ii)” is added in its place. iv. In redesignated paragraph (e)(2)(iii), “paragraph (f)” is removed and “paragraph (g)” is added in its place. v. In redesignated paragraph (e)(3), “paragraph (d)(1)(ii)(C)” is removed and “paragraph (e)(1)(ii)(C) is added in its place. vi. In redesignated paragraph (g), “paragraph
(a)through (e)” is removed and “paragraphs
(a)through (f)” is added in its place. vii. In redesignated paragraph (h)(1), “paragraph (g)(3)” is removed and “paragraph (h)(3)” is added in its place; and “paragraph (g)(2)(iv) and (v)” is removed and “paragraphs (h)(2)(iv) and (v)” is added in its place. viii. In redesignated paragraph (h)(2) introductory text, “paragraph (g)(1)” is removed and “paragraph (h)(1)” is added in its place. ix. In redesignated paragraph (h)(2)(iii)(B), “paragraph (g)(2)(iii)(A)” is removed and “paragraph (h)(2)(iii)(A)” is added in its place. x. In redesignated paragraph (h)(2)(vi), “paragraph (g)(2)(v)” is removed and “paragraph (h)(2)(v)” is added in its place. xi. In redesignated paragraph (h)(4), “paragraph (g)” is removed and “paragraph (h)” is added in its place; and “paragraph (g)(2)(v)” is removed and “paragraph (h)(2)(v)” is added in its place. The additions and revisions read as follows: § 489.24 Special responsibilities of Medicare hospitals in emergency cases.
(a)*Application.* In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph
(b)of this section, the hospital must—
(1)Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) determined qualified by hospital bylaws or rules and regulations and who meet the requirements of § 482.55 of this chapter concerning emergency services personnel and direction; and
(2)If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph
(d)of this section, or an appropriate transfer as defined in paragraph
(e)of this section.
(b)*Definitions.* As used in this subpart— *Comes to the emergency department* means, with respect to an individual who is not a patient, the individual—
(1)Has presented at a hospital's dedicated emergency department, as defined in this section, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition;
(2)Has presented on hospital property, as defined in this section, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf (except for certain outpatients as specified in paragraph (d)(3) of this section). In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment;
(3)Is in an ambulance owned and operated by the hospital for presentation for examination and treatment for a medical condition at a hospital's dedicated emergency department, even if the ambulance is not on hospital grounds. This provision does not apply if the ambulance is operating under communitywide EMS protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the nearest hospital. In this latter case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property; or
(4)Is in a nonhospital-owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital's dedicated emergency department. An individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital's emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. In the latter circumstance, the hospital may deny access if it is in “diversionary status,” that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital's instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department. *Dedicated emergency department* means a specially equipped and staffed area of the hospital that is used a significant portion of the time for the initial evaluation and treatment of outpatients for emergency medical conditions, as defined in this section, and that is located—
(1)On the main hospital campus; or
(2)Off the main hospital campus and is treated by Medicare under § 413.65(b) of this chapter as a department of the hospital. *Hospital property* means the entire main hospital campus as defined in § 413.65(b) of this chapter, including the parking lot, sidewalk, and driveway, but excluding other areas or structures that are located within 250 yards of the hospital's main building but are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately under Medicare, or restaurants, shops, or other nonmedical facilities. *Hospital with an emergency department* means a hospital that offers services for emergency medical conditions (as defined in this paragraph (b)) within its capability to do so, including a hospital that offers these services at locations other than its main hospital campus. *Patient,* for purposes of this section, means an individual who is either an outpatient as defined in § 410.2 of this chapter, or is receiving inpatient hospital services as defined in § 409.10(b) of this chapter.
(c)*Use of dedicated emergency department for nonemergency services.* If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.
(d)*Necessary stabilizing treatment for emergency medical conditions.—*
(1)*General.* If any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(i)Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition; or
(ii)For transfer of the individual to another medical facility in accordance with paragraph
(e)of this section.
(2)*Application to inpatients—admitted emergency patients.*
(i)When an individual has been screened under paragraph
(a)of this section and found to have an emergency medical condition, and the individual has not been stabilized as defined in paragraph
(b)of this section, the provisions of this section would apply, even if the hospital admits the patient as an inpatient. Admitting an individual whose emergency medical condition has not been stabilized does not relieve the hospital of further responsibility to the individual under this section.
(ii)If a hospital admits an individual with an unstable emergency medical condition for stabilizing treatment, as an inpatient, stabilizes that individual's emergency medical condition, and this period of stability is documented by relevant clinical data in the individual's medical record, the hospital has satisfied its special responsibilities under this section with respect to that individual. If the patient is stable for a transfer of the type usually undertaken with respect to patients having the same medical conditions, the hospital's special responsibilities under this section are satisfied, even if no transfer occurs and the individual remains at the hospital as an inpatient for followup care. If, after stabilization, the individual who was admitted as an inpatient again has an apparent decline of his or her medical condition, either as a result of the injury or illness that created the emergency for which he or she initially came to the dedicated emergency department or as a result of another injury or illness, the hospital must comply with the conditions of participation for hospitals under part 482 of this chapter but has no further responsibility under this section with respect to the individual.
(iii)A hospital has no responsibility under this section with respect to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. If such an inpatient has an abrupt deterioration of his or her medical condition after admission, the hospital must comply with the conditions of participation for hospitals under part 482 of this chapter and is not required to comply with the special responsibilities of this section.
(3)*Refusal to consent to treatment.* A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual's behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual's behalf) refuses to consent to the examination and treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both.
(4)*Delay in examination or treatment.*
(i)A participating hospital may not delay providing an appropriate medical screening examination required under paragraph
(a)of this section or further medical examination and treatment required under paragraphs (d)(1) and (d)(2) of this section in order to inquire about the individual's method of payment or insurance status.
(ii)A participating hospital may not seek, or direct a patient to seek, authorization from the individual's insurance company for screening or stabilization services to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph
(a)of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraphs (d)(1) and (d)(2) of this section.
(iii)An emergency physician is not precluded from contacting the patient's physician at any time to seek advice regarding the patient's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph
(a)or paragraphs (d)(1) and (d)(2) of this section.
(5)*Refusal to consent to transfer.* A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph
(e)of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual's behalf) refuses to consent to the transfer. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual's refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual.
(6)*Hospital responsibility for communication with Medicare+Choice organizations after stabilization of an emergency medical condition.* When an enrollee of a Medicare+Choice organization who is treated for an emergency medical condition is stabilized and needs further hospital care, the hospital must promptly contact the Medicare+Choice organization to obtain preapproval of the further hospital care, consistent with the provisions of § 422.113 of this chapter.
(j)*Availability of on-call physicians.* Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients. Physicians, including specialists and subspecialists, are not required to be on call at all times. The hospital must have written policies and procedures in place 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. (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance) Dated: April 24, 2002. Thomas A. Scully, Administrator, Centers for Medicare & Medicaid Services. Dated: April 26, 2002. Tommy G. Thompson, Secretary. [ **Editorial Note:** The following Addendum and appendixes will not appear in the Code of Federal Regulations.] Addendum—Proposed Schedule of Standardized Amounts Effective with Discharges Occurring On or After October 1, 2002 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2002 I. Summary and Background In this Addendum, we are setting forth the proposed amounts and factors for determining prospective payment rates for Medicare hospital inpatient operating costs and Medicare hospital inpatient capital-related costs. We are also setting forth proposed rate-of-increase percentages for updating the target amounts for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system. For discharges occurring on or after October 1, 2002, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the acute care hospital inpatient prospective payment system will be based on 100 percent of the Federal national rate. 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 75 percent of the updated hospital-specific rate based on FY 1996 costs per discharge, plus the greater of 25 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal DRG payment rate. Section 213 of Public Law 106-554 amended section 1886(b)(3) of the Act to allow all SCHs to rebase their hospital-specific rate based on their 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 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. For hospitals in Puerto Rico, the payment per discharge is based on the sum of 50 percent of a Puerto Rico rate and 50 percent of a Federal national rate. ( *See* section II.D.3. of this Addendum for a complete description.) As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2003. The changes, to be applied prospectively effective with discharges occurring on or after October 1, 2002, would affect the calculation of the Federal rates. In section III. of this Addendum, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2003. Section IV. of this Addendum sets forth our proposed changes for determining the rate-of-increase limits for hospitals excluded from the prospective payment system for FY 2003. The tables to which we refer in the preamble to this final rule are presented at the end of this Addendum in section V. II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2003 The basic methodology for determining prospective payment rates for hospital inpatient operating costs is set forth at § 412.63. The basic methodology for determining the prospective payment rates for hospital inpatient operating costs for hospitals located in Puerto Rico is set forth at §§ 412.210 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 and 1C of section V. of this Addendum reflect— • Updates of 2.75 percent for all areas (that is, the market basket percentage increase of 3.3 percent minus 0.55 percentage points); • An adjustment to ensure the proposed DRG recalibration and wage index update and changes are budget neutral, as provided for under sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act, by applying new budget neutrality adjustment factors to the large urban and other standardized amounts; • 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 2002 budget neutrality factor and applying a revised factor; • An adjustment to apply the new outlier offset by removing the FY 2002 outlier offsets and applying a new offset; and • An adjustment in the Puerto Rico standardized amounts to reflect the application of a Puerto Rico-specific wage index. A. Calculation of Adjusted Standardized Amounts 1. Standardization of Base-Year Costs or Target Amounts Section 1886(d)(2)(A) of the Act required the establishment of base-year cost data containing allowable operating costs per discharge of inpatient hospital services for each hospital. The preamble to the September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data were established in the initial development of standardized amounts for the acute care hospital inpatient prospective payment system. Section 1886(d)(9)(B)(i) of the Act required us to determine the Medicare target amounts for each hospital located in Puerto Rico for its cost reporting period beginning in FY 1987. The September 1, 1987 final rule (52 FR 33043, 33066) contains a detailed explanation of how the target amounts were determined and how they are used in computing the Puerto Rico rates. The standardized amounts are based on per discharge averages of adjusted hospital costs from a base period or, for Puerto Rico, adjusted target amounts from a base period, updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. 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. Under sections 1886(d)(2)(H) and (d)(3)(E) of the Act, in making payments under the acute care hospital inpatient prospective payment system, the Secretary estimates from time to time the proportion of costs that are wages and wage-related costs. Since October 1, 1997, when the market basket was last revised, we have considered 71.1 percent of costs to be labor-related for purposes of the acute care hospital inpatient prospective payment system. As discussed in section IV. of the preamble to this proposed rule, we are proposing to revise the labor share of the standardized amount (the proportion adjusted by the wage index) to be 72.5 percent. The average labor share in Puerto Rico is 71.3 percent. We are proposing to revise the discharge-weighted national standardized amount for Puerto Rico to reflect the proportion of discharges in large urban and other areas from the FY 2001 MedPAR file. 2. Computing Large Urban and Other Area Averages Sections 1886(d)(2)(D) and (d)(3) of the Act require the Secretary to compute two average standardized amounts for discharges occurring in a fiscal year: one for hospitals located in large urban areas and one for hospitals located in other areas. In addition, under sections 1886(d)(9)(B)(iii) and (d)(9)(C)(i) of the Act, the average standardized amount per discharge must be determined for hospitals located in large urban and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a blend of 50 percent of the applicable Puerto Rico standardized amount and 50 percent of a national standardized payment amount. Section 1886(d)(2)(D) of the Act defines “urban area” as those areas within a Metropolitan Statistical Area (MSA). A “large urban area” is defined as an urban area with a population of more than 1 million. In addition, section 4009(i) of Public Law 100-203 provides that a New England County Metropolitan Area (NECMA) with a population of more than 970,000 is classified as a large urban area. As required by section 1886(d)(2)(D) of the Act, population size is determined by the Secretary based on the latest population data published by the Bureau of the Census. Urban areas that do not meet the definition of a “large urban area” are referred to as “other urban areas.” Areas that are not included in MSAs are considered “rural areas” under section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals located in large urban areas will be based on the large urban standardized amount. Payment for discharges from hospitals located in other urban and rural areas will be based on the other standardized amount. Based on the latest available population estimates published by the Bureau of the Census, 63 areas meet the criteria to be defined as large urban areas for FY 2003. These areas are identified in Table 4A. 3. Updating the Average Standardized Amounts Under section 1886(d)(3)(A) of the Act, we update the average standardized amounts each year. In accordance with section 1886(d)(3)(A)(iv) of the Act, we are proposing to update the large urban areas' and the other areas' average standardized amounts for FY 2003 using the applicable percentage increases specified in section 1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XVIII) of the Act specifies that the update factor for the standardized amounts for FY 2003 is equal to the market basket percentage increase minus 0.55 percentage points for hospitals in all areas. 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 2003 is 3.3 percent. Thus, for FY 2003, the update to the average standardized amounts equals 2.75 percent for hospitals in all areas. As in the past, we are adjusting the FY 2002 standardized amounts to remove the effects of the FY 2002 geographic reclassifications and outlier payments before applying the FY 2003 updates. That is, we are increasing the standardized amounts to restore the reductions that were made for the effects of geographic reclassification and outliers. We then apply the new offsets to the standardized amounts for outliers and geographic reclassifications for FY 2003. Although the update factors for FY 2003 are set by law, we are required by section 1886(e)(3) of the Act to report to the Congress our initial recommendation of update factors for FY 2003 for both prospective payment hospitals and hospitals excluded from the prospective payment system. For general information purposes, we have included the report to Congress as Appendix B to this proposed rule. Our proposed recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth as Appendix C to this proposed rule. 4. Other Adjustments to the Average Standardized Amounts a. Recalibration of DRG Weights and Updated Wage Index—Budget Neutrality Adjustment Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II. of the preamble, we normalized the recalibrated DRG weights by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight prior to recalibration. However, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years, we are proposing to make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. Section 1886(d)(3)(E) of the Act requires us to update the hospital wage index on an annual basis beginning October 1, 1993. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. We note, however, that section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State. This provision is required by section 4410(b) of Public Law 105-33 to be budget neutral. To comply with the requirement of section 1886(d)(4)(C)(iii) of the Act that DRG reclassification and recalibration of the relative weights be budget neutral, and the requirement in section 1886(d)(3)(E) of the Act that the updated wage index be budget neutral, we used FY 2001 discharge data to simulate payments and compared aggregate payments using the FY 2002 relative weights and wage index to aggregate payments using the proposed FY 2003 relative weights and wage index. The same methodology was used for the FY 2002 budget neutrality adjustment. Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 1.001026. We also adjust the Puerto Rico-specific standardized amounts for the effect of DRG reclassification and recalibration. We computed a budget neutrality adjustment factor for Puerto Rico-specific standardized amounts equal to 1.002689. These budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 2002 budget neutrality adjustments. We do not remove the prior budget neutrality adjustment because estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition. In addition, we are proposing to apply these same adjustment factors to the hospital-specific rates that are effective for cost reporting periods beginning on or after October 1, 2002. (See the discussion in the September 4, 1990 final rule (55 FR 36073).) 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 Medicare Geographic Classification Review Board (MGCRB). Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the standardized amount or the wage index, or both. 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 acute care hospital inpatient prospective payment system 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. To calculate this budget neutrality factor, we used FY 2001 discharge data to simulate payments, and compared total prospective payments (including IME and DSH payments) prior to any reclassifications to total prospective payments after reclassifications. Based on these simulations, we are applying a proposed adjustment factor of 0.990536 to ensure that the effects of reclassification are budget neutral. The adjustment factor is applied to the standardized amounts after removing the effects of the FY 2002 budget neutrality adjustment factor. We note that the proposed FY 2003 adjustment reflects wage index and standardized amount reclassifications approved by the MGCRB or the Administrator as of February 28, 2002, and the effects of section 304 of Public Law 106-554 to extend wage index reclassifications for 3 years. The effects of any additional reclassification changes that occur as a result of appeals and reviews of the MGCRB decisions for FY 2003 or from a hospital's request for the withdrawal of a reclassification request for FY 2003 will be reflected in the final budget neutrality adjustment required under section 1886(d)(8)(D) of the Act and published in the final rule for FY 2003. c. Outliers Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for “outlier” cases, cases involving extraordinarily high costs (cost outliers). To qualify for outlier payments, a case must have costs above a threshold amount. To determine whether the costs of a case exceed the threshold, a hospital's cost-to-charge ratio is applied to the total covered charges for the case to convert the charges to costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the costs above the threshold. Under section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year must be 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 both the large urban and other area national standardized amounts by the same 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 large urban and other standardized amounts applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. i. FY 2003 outlier thresholds. For FY 2002, the threshold was equal to the prospective payment rate for the DRG plus any IME and DSH payments plus $21,025. The marginal cost factor for cost outliers (the percent of costs paid after costs for the case exceed the threshold) was 80 percent. For FY 2003, we are proposing to establish a fixed loss cost outlier threshold equal to the prospective payment rate for the DRG plus any IME and DSH payments, and any add-on payments for new technology, plus $33,450. This single threshold would be applicable to qualify for both operating and capital outlier payments. We are proposing to maintain the marginal cost factor for cost outliers at 80 percent. To calculate the proposed FY 2003 outlier thresholds, we simulated payments by applying proposed FY 2003 rates and policies to the December 2001 update of the FY 2001 MedPAR file and the December 2001 update of the Provider-Specific File. Therefore, it is necessary to inflate the charges on the MedPAR claims by 2 years. Previously, inflation factors have been calculated by measuring the percent change in costs using the two most recent available cost report files. For example, the FY 2002 threshold was determined using the rate of cost increase measured using costs from hospitals' FY 1998 and FY 1999 cost reports. However, at the time of this proposed rule, the FY 2000 cost reports are not available to produce an updated cost inflation factor due to processing delays associated with implementing the hospital outpatient prospective payment system. Rather than use the rate of cost increase from hospitals' FY 1998 and FY 1999 cost reports to project the rate of increase from FY 2001 to FY 2003, we are proposing to use a 3-year moving average of the rate of change in prior years to estimate the annual rates of increase from FY 2001 to FY 2003. The calculation is shown in the table below. For example, the rate of change in cost per case from 1998 to 1999 was 1.0242 percent. This rate of change is then subtracted by the rate of change from 1997 to 1998 (1.0237) to calculate a difference in change of 0.005. A 3-year average of the annual rates of change was then computed based on the difference in the percent changes from the 3 most recent prior years. The difference in change for 1997 to 1998 is then averaged with the differences for 1996 to 1997, and for 1995 to 1996, to calculate a 3-year average of 0.0180. To project percent changes in costs for FY 2000 through FY 2003, the average of the differences in the percent changes for the 3 most recent years (0.0180) was added to the percent change in cost per case for the previous year (1.0242) to estimate the percent change in costs between fiscal years. This proposed methodology resulted in an estimated change of 1.066 (6.6 percent increase) for FY 2001 to FY 2002 and 1.079 (7.9 percent increase) for FY 2002 to FY 2003. Cost reports begin in FY Cost/case Rate of change in cost per case Difference in change 3-year moving average of differences in change 1995 5818.50 1996 5644.52 0.9701 1997 5666.03 1.0038 0.0337 1998 5800.34 1.0237 0.0199 1999 5940.85 1.0242 0.0005 2000 1.0423 0.0180 0.0180 2001 1.0551 0.0128 0.0128 2002 1.0655 0.0105 0.0105 2003 1.0793 0.0138 0.0138 Based on this proposed methodology, we are proposing a 2-year cost inflation factor of 15.0 percent to inflate FY 2001 charges to FY 2003, determined by multiplying the annual projected inflation factors for FYs 2002 and 2003 of 1.0655 and 1.0793. Using FY 2001 cases now available, our analysis indicates that this 3-year moving average methodology would have resulted in FY 2002 outlier payments very close to 5.1 percent of total operating DRG payments and outlier payments (the current projection of FY 2002 outlier payments is 6.8 percent of total DRG and outlier payments—see discussion below). We intend to update our analysis of FY 2002 outlier payments using actual FY 2002 claims available through March 2002 prior to publishing the final rule by August 1. We want to emphasize that we are making this proposal due to the unavailability of the FY 2000 cost reports. If the proposed methodology is ultimately adopted in the final rule for FY 2003, this would not necessarily mean that we would apply the same methodology in future fiscal years when updated cost report information becomes available. ii. Other changes concerning outliers. In accordance with section 1886(d)(5)(A)(iv) of the Act, we calculated outlier thresholds so that outlier payments are projected to equal 5.1 percent of total operating DRG payments plus outlier payments. In accordance with section 1886(d)(3)(B), we reduced the proposed FY 2003 standardized amounts by the same percentage to account for the projected proportion of payments paid to outliers. As stated in the September 1, 1993 final rule (58 FR 46348), we establish outlier thresholds that are applicable to both hospital inpatient operating costs and hospital inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a higher percentage of outlier payments for capital-related costs than for operating costs. We project that the proposed thresholds for FY 2003 would result in outlier payments equal to 5.1 percent of operating DRG payments and 5.4 percent of capital payments based on the Federal rate. The proposed outlier adjustment factors to be applied to the standardized amounts for FY 2003 are as follows: Operating standardized amounts Capital Federal rate National 0.949004 0.945957 Puerto Rico 0.982910 0.980994 We apply the outlier adjustment factors after removing the effects of the FY 2002 outlier adjustment factors on the standardized amounts. To determine whether a case qualifies for outlier payments, we apply hospital-specific cost-to-charge ratios to the total covered charges for the case. Operating and capital costs for the case are calculated separately by applying separate operating and capital cost-to-charge ratios, then these costs are combined to compare with the fixed-loss outlier threshold. For those hospitals for which the fiscal intermediary computes operating cost-to-charge ratios lower than 0.200 or greater than 1.262, or capital cost-to-charge ratios lower than 0.012 or greater than 0.167, statewide average ratios would be used to calculate costs to determine whether a hospital qualifies for outlier payments. 1 Table 8A in section V. of this Addendum contains the proposed statewide average operating cost-to-charge ratios for urban hospitals and for rural hospitals for which the fiscal intermediary is unable to compute a hospital-specific cost-to-charge ratio within the above range. These statewide average ratios would replace the ratios published in the August 1, 2001 final rule (66 FR 40083). Table 8B contains comparable statewide average capital cost-to-charge ratios. We note that the cost-to-charge ratios in Tables 8A and 8B would be used during FY 2003 when hospital-specific cost-to-charge ratios based on the latest settled cost report are either not available or are outside the three standard deviations range. 1 This range represents 3.0 standard deviations (plus or minus) from the mean of the log distribution of cost-to-charge ratios for all hospitals. iii. FY 2001 and FY 2002 outlier payments. In the August 1, 2001 final rule (66 FR 39942), we stated that, based on available data, we estimated that actual FY 2001 outlier payments would be approximately 6.2 percent of actual total DRG payments. This was computed based on simulations using the March 2001 update of the Provider-Specific File and the March 2001 update of the FY 2000 MedPAR file (discharge data for FY 2000 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2001 bills but instead reflected the application of FY 2001 rates and policies to available FY 2000 bills. Our current estimate, using available FY 2001 bills, is that actual outlier payments for FY 2001 were approximately 7.6 percent of actual total DRG payments. Thus, the data indicate that, for FY 2001, the percentage of actual outlier payments relative to actual total payments is higher than we projected before FY 2001 (and thus exceeds the percentage by which we reduced the standardized amounts for FY 2001). Nevertheless, consistent with the policy and statutory interpretation we have maintained since the inception of the acute care hospital inpatient prospective payment system, we do not plan to recoup money and make retroactive adjustments to outlier payments for FY 2001. We note that the MedPAR file for FY 2001 discharges continues to be updated, and we will update our estimate of actual FY 2001 outlier payments as a percentage of total payments in the final rule. We currently estimate that actual outlier payments for FY 2002 will be approximately 6.8 percent of actual total DRG payments, 1.7 percentage points higher than the 5.1 percent we projected in setting outlier policies for FY 2002. This estimate is based on simulations using the December 2001 update of the Provider-Specific File and the December 2001 update of the FY 2001 MedPAR file (discharge data for FY 2001 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2002 by applying FY 2002 rates and policies to available FY 2001 bills. 5. FY 2003 Standardized Amounts The adjusted standardized amounts are divided into labor and nonlabor portions. Table 1A contains the two national standardized amounts that we are proposing to be applicable to all hospitals, except hospitals in Puerto Rico. As described in section II.A.1. of this Addendum, we are proposing to revise the labor share of the national standardized amount from 71.1 percent to 72.5 percent. Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount and the national other standardized amount (as set forth in Table 1A). The labor and nonlabor portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C. This table also includes the Puerto Rico standardized amounts. The labor share applied to the Puerto Rico standardized amount is 71.3 percent. B. Adjustments for Area Wage Levels and Cost of Living Tables 1A and 1C, as set forth in this Addendum, contain the labor-related and nonlabor-related shares that are proposed to be used to calculate the prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico. This section addresses two types of adjustments to the standardized amounts that are made in determining the proposed prospective payment rates as described in this Addendum. 1. Adjustment for Area Wage Levels Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the national and Puerto Rico prospective payment rates, respectively, to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of this preamble, we discuss the data and methodology for the proposed FY 2003 wage index. The proposed wage index is set forth in Tables 4A, 4B, 4C, and 4F of this Addendum. In section IV. of this preamble we discuss our proposed revised estimate of the labor-related portion of the standardized amounts. 2. Adjustment for Cost-of-Living in Alaska and Hawaii Section 1886(d)(5)(H) of the Act authorizes an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher labor-related costs for these two States are taken into account in the adjustment for area wages described above. For FY 2003, we are proposing to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor portion of the standardized amounts by the appropriate adjustment factor contained in the table below. If the Office of Personnel Management releases revised cost-of-living adjustment factors before July 1, 2002, we will publish them in the final rule and use them in determining FY 2003 payments. Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals Alaska—All areas 1.25 Hawaii: County of Honolulu 1.25 County of Hawaii 1.165 County of Kauai 1.2325 County of Maui 1.2375 County of Kalawao 1.2375 (The above factors are based on data obtained from the U.S. Office of Personnel Management.) C. DRG Relative Weights As discussed in section II. of the preamble, we have developed a classification system for all hospital discharges, assigning them into DRGs, and have developed relative weights for each DRG that reflect the resource utilization of cases in each DRG relative to Medicare cases in other DRGs. Table 5 of section V. of this Addendum contains the relative weights that we are proposing to use for discharges occurring in FY 2003. These factors have been recalibrated as explained in section II. of the preamble. D. Calculation of Prospective Payment Rates for FY 2003 General Formula for Calculation of Prospective Payment Rates for FY 2003 The operating prospective payment rate for all hospitals paid under the acute-care, short-term inpatient prospective payment system located outside of Puerto Rico, except SCHs and MDHs, equals the Federal rate based on the amounts in Table 1A. For FY 2003, the prospective payment rate for SCHs equals whichever of the following rates yields the greatest aggregate payment: the Federal rate, the updated hospital-specific rate based on FY 1982 cost per discharge, the updated hospital-specific rate based on FY 1987 cost per discharge, or, if qualified, 75 percent of the updated hospital-specific rate based on FY 1996 cost per discharge, plus the greater of 25 percent of the updated FY 1982 or FY 1987 hospital-specific rate, or 25 percent of the Federal rate. Section 1886(b)(3) of the Act, as amended, allows all SCHs to rebase their hospital-specific rate based on their FY 1996 cost per discharge. The prospective payment rate for MDHs equals 100 percent of the Federal rate, or, if the greater of the updated FY 1982 hospital-specific rate or the updated FY 1987 hospital-specific rate is higher than the Federal rate, 100 percent of the Federal rate plus 50 percent of the difference between the applicable hospital-specific rate and the Federal rate. The proposed prospective payment rate for Puerto Rico equals 50 percent of the Puerto Rico rate plus 50 percent of the national rate from Table 1C. 1. Federal Rate For discharges occurring on or after October 1, 2002 and before October 1, 2003, except for SCHs, MDHs, and hospitals in Puerto Rico, payment under the acute-care inpatient prospective payment system is based exclusively on the Federal national rate. The payment amount is determined as follows: Step 1—Select the appropriate national standardized amount considering the location of the hospital (large urban or other) (see Table 1A in section V. of this Addendum). Step 2—Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified (see Tables 4A, 4B, and 4C of section V. of this Addendum). Step 3—For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the appropriate cost-of-living adjustment factor. Step 4—Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if appropriate, under Step 3). Step 5—Multiply the final amount from Step 4 by the relative weight corresponding to the appropriate DRG (see Table 5 of section V. of this Addendum). 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, for FY 2003, 75 percent of the updated hospital-specific rate based on FY 1996 costs per discharge, plus the greater of 25 percent of the updated FY 1982 or FY 1987 hospital-specific rate or 25 percent of the Federal DRG payment rate. Section 1886(d)(5)(G) of the Act provides that MDHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate or the Federal rate plus 50 percent of the difference between the Federal rate and the greater of the updated hospital-specific rate based on FY 1982 and FY 1987 cost per discharge. Hospital-specific rates have been determined for each of these hospitals based on either the FY 1982 cost per discharge, the FY 1987 cost per discharge or, for SCHs, the FY 1996 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the September 1, 1983 interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the September 4, 1990 final rule (55 FR 35994); and the August 1, 2000 final rule (65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor (that is, by 1.001026) as discussed in section II.A.4.a. of this Addendum. The resulting rate is used in determining the payment rate an SCH or MDH would be paid for its discharges beginning on or after October 1, 2002. b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2003 We are proposing to increase the hospital-specific rates by 2.75 percent (the hospital market basket percentage increase minus 0.55 percentage points) for SCHs and MDHs for FY 2003. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs equal the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2003, is the market basket rate of increase minus 0.55 percentage points. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2003, is the market basket rate of increase minus 0.55 percentage points. 3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2002 and Before October 1, 2003 a. Puerto Rico Rate The Puerto Rico prospective payment rate is determined as follows: Step 1—Select the appropriate adjusted average standardized amount considering the large urban or other designation of the hospital (see Table 1C of section V. of the Addendum). Step 2—Multiply the labor-related portion of the standardized amount by the appropriate Puerto Rico-specific wage index (see Table 4F of section VI. of the Addendum). Step 3—Add the amount from Step 2 and the nonlabor-related portion of the standardized amount. Step 4—Multiply the result in Step 3 by 50 percent. Step 5—Multiply the amount from Step 4 by the appropriate DRG relative weight (see Table 5 of section V. of the Addendum). b. National Rate The national prospective payment rate is determined as follows: Step 1—Multiply the labor-related portion of the national average standardized amount (see Table 1C of section V. of the Addendum) by the appropriate national wage index (see Tables 4A and 4B of section VI. of the Addendum). Step 2—Add the amount from Step 1 and the nonlabor-related portion of the national average standardized amount. Step 3—Multiply the result in Step 2 by 50 percent. Step 4—Multiply the amount from Step 3 by the appropriate DRG relative weight (see Table 5 of section V. of the Addendum). 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. III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2003 The prospective payment system 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 and during a 10-year transition period extending through FY 2001, acute care hospital inpatient capital-related costs were paid on the basis of an increasing proportion of the capital prospective payment system Federal rate and a decreasing proportion of a hospital's historical costs for capital. The basic methodology for determining Federal capital prospective rates is set forth in regulations at §§ 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2003, which will be effective for discharges occurring on or after October 1, 2002. 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 § 412.324(b) and under proposed § 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the prospective payment system 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 standard Federal rate, as provided in § 412.308(c)(1), to account for capital input price increases and other factors. Also, § 412.308(c)(2) provides that the Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the Federal rate to total capital payments under the Federal rate. In addition, § 412.308(c)(3) requires that the Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under § 412.348. Furthermore, § 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral. For FYs 1992 through 1995, § 412.352 required that the Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the rate that was made in FY 1994, and § 412.308(b)(3) describes the 0.28 percent reduction to the rate made in FY 1996 as a result of the revised policy of paying for transfers. In the FY 1998 final rule with comment period (62 FR 45966), we implemented section 4402 of Public Law 105-33, which requires that, for discharges occurring on or after October 1, 1997, and before October 1, 2002, the unadjusted standard Federal rate is reduced by 17.78 percent. As we explained in section VI.D. of the preamble of this proposed rule, a small part of that reduction will be restored effective October 1, 2002. To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs, that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors. As we explained in the August 1, 2001 final rule (66 FR 39911), beginning in FY 2003 an adjustment for regular exceptions 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)). Since payments are no longer being made under the regular exceptions policy in FY 2003, we are no longer using the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the August 1, 2001 final rule (66 FR 40099). In accordance with section 1886(d)(9)(A) of the Act, under the prospective payment system for acute care hospital inpatient operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended 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. However, effective October 1, 1997, as a result of section 4406 of Public Law 105-33, operating payments to hospitals in Puerto Rico are 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 on or after October 1, 1997, we compute capital payments to hospitals in Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and 50 percent of the Federal rate. Section 412.374 provides for the use of this blended payment system for payments to Puerto Rico hospitals under the prospective payment system for acute care hospital inpatient capital-related costs. Accordingly, for capital-related costs, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital. A. Determination of Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update In the August 1, 2001 final rule (66 FR 39947), we established a Federal rate of $390.74 for FY 2002. As a result of the changes we are proposing to the factors used to establish the Federal rate in this addendum, the proposed FY 2003 Federal rate is $408.90. In the discussion that follows, we explain the factors that were used to determine the proposed FY 2003 Federal rate. In particular, we explain why the FY 2003 Federal rate has increased 4.6 percent compared to the FY 2002 Federal rate (published in the August 1, 2001 final rule (66 FR 39947)). We also estimate aggregate capital payments will increase by 5.72 percent during this same period. This increase is primarily due to the increase in the number of hospital admissions and the increase in case-mix. This increase in capital payments is slightly more than last year (4.27 percent) mostly due to the restoration of the 2.1 percent reduction to the capital Federal rate (see section VI.D. of the preamble of this proposed rule). Total payments to hospitals under the prospective payment system are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1 percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital prospective payment system are estimated to increase in FY 2003 compared to FY 2002. 1. Standard Federal Rate Update a. Description of the Update Framework Under § 412.308(c)(1), the 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 other factors. The update framework consists of a CIPI and several 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 2003 under that framework is 1.1 percent. This update factor is based on a projected 0.7 percent increase in the CIPI, a 1.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a −-0.3 percent adjustment for the FY 2001 DRG reclassification and recalibration, and a forecast error correction of −0.3 percent. We explain the basis for the FY 2003 CIPI projection in section III.C. of this Addendum. Below we describe the policy adjustments that have been applied. The case-mix index is the measure of the average DRG weight for cases paid under the acute care hospital inpatient prospective payment system. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments. The case-mix index can change for any of several reasons: • The average resource use of Medicare patients changes (“real” case-mix change); • Changes in hospital coding of patient records result in higher weight DRG assignments (“coding effects”); and • The annual DRG reclassification and recalibration changes may not be budget neutral (“reclassification effect”). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. In the update framework for the prospective payment system for operating costs, we adjust the update upwards to allow for real case-mix change, but remove the effects of coding changes on the case-mix index. We also remove the effect on total payments of prior changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than patient severity. (For example, we adjusted for the effects of the FY 2001 DRG reclassification and recalibration as part of our FY 2003 update recommendation.) We have adopted this case-mix index adjustment in the capital update framework as well. For FY 2003, we are projecting a 1.0 percent total increase in the case-mix index. We estimate that real case-mix increase will equal 1.0 percent in FY 2003. Therefore, the net adjustment for case-mix change in FY 2003 is 0.0 percentage points. We estimate that FY 2001 DRG reclassification and recalibration will result in a 0.3 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 making a −0.3 percent adjustment for DRG reclassification and recalibration in the update recommendation for FY 2003. The capital update framework contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of the forecast error. A forecast error of −0.3 percentage points was calculated for the FY 2001 update. That is, current historical data indicate that the forecasted FY 2001 CIPI used in calculating the FY 2001 update factor (0.9 percent) overstated the actual realized price increases (0.6 percent) by 0.3 percentage points. This over-prediction was due to prices from municipal bond yields declining faster than originally expected. Therefore, we are making a −0.3 percent adjustment for forecast error in the update for FY 2003. Under the capital prospective payment system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data as in the framework for the operating prospective payment system. 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, changes in within-DRG severity, and expected modification of practice patterns to remove cost-ineffective 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 proposed intensity factor makes it a total intensity factor, that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the revised operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one-half of the estimated annual increase in intensity to allow for within-DRG severity increases and the adoption of quality-enhancing technology. For FY 2003, we have developed a Medicare-specific intensity measure based on a 5-year average, using FY 1997 through 2001 data. In determining case-mix constant intensity, we found that observed case-mix increase was 0.3 percent in FY 1997, −0.4 percent in FY 1998, −0.3 percent in FY 1999, −0.7 in FY 2000, and −0.3 percent in FY 2001. Past studies of case-mix change by the RAND Corporation (“Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988” by G. M. Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC (1991)) suggest that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.4 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. Following that study, we consider up to 1.4 percent of observed case-mix change as real for FY 1997 through FY 2001. Since we did not find an increase in case-mix outside of the range of 1.0 to 1.4 percent, we believe that all of the observed case-mix increase for FYs 1997 through 2001 is real. Therefore, there was no need to employ the upper bound of 1.0 and 1.4 supported by the RAND study as we have done in the past since we did not find an increase in case-mix that was in excess of our estimate of real case-mix increase. 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. We estimate that case-mix constant intensity increased by an average of 1.0 percent during FYs 1997 through 2001, for a cumulative increase of 5.2 percent, given estimates of real case-mix of 0.3 percent for FY 1997, −0.4 percent for FY 1998, −0.3 percent for FY 1998, −0.7 percent for FY 2000, and −0.3 percent for FY 2001. Since we estimate that intensity has increased during that period, we are recommending a 1.0 percent intensity adjustment for FY 2003. Above we described the basis of the components used to develop the proposed 1.1 percent capital update factor for FY 2003 as shown in Table 1 below. Table 1.—CMS's Proposed FY 2003 Update Factor to the Capital Federal Rate— Capital Input Price Index 0.7 Intensity: 1.0 Case-Mix Adjustment Factors: Projected Case-Mix Change −1.0 Real Across DRG Change 1.0 Subtotal 0.0 Effect of FY 2001 Reclassification and Recalibration −0.3 Forecast Error Correction −0.3 Total Proposed Update 1.1 b. Comparison of CMS and MedPAC Update Recommendations In the past, MedPAC has included an update recommendation for capital prospective payment system payments in a Report to Congress. In its March 2001 report, MedPAC presented a combined operating and capital update for hospital inpatient prospective payment systems for FY 2002. Currently, section 1886(b)(3)(B)(i)(XVIII) of the Act sets forth the FY 2003 percentage increase in prospective payment system operating cost standardized amounts. The prospective payment system capital update is set at the discretion of the Secretary under the framework outlined in § 412.308(c)(1). In its March 2002 Report to Congress, MedPAC did not make an update recommendation for capital prospective payment system payments. MedPAC states that, with the two updates (operating and capital) remaining separate, it focused on the operating update since it involves more money (92 percent of hospital's Medicare costs) and it commands the most attention in Congress (page 65). 2. Outlier Payment Adjustment Factor Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of capital-related outlier payments to total inpatient capital-related prospective payment system 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 August 1, 2001 final rule, we estimated that outlier payments for capital in FY 2002 would equal 5.76 percent of inpatient capital-related payments based on the Federal rate (66 FR 39948). Accordingly, we applied an outlier adjustment factor of 0.9424 to the Federal rate. Based on the thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that outlier payments for capital will equal 5.40 percent of inpatient capital-related payments based on the Federal rate in FY 2003. Therefore, we are proposing an outlier adjustment factor of 0.9460 to the Federal rate. Thus, the projected percentage of capital outlier payments to total capital standard payments for FY 2003 is lower than the percentage for FY 2002. The outlier reduction factors are not built permanently into the rates; that is, they are not applied cumulatively in determining the Federal rate. Therefore, the net proposed change in the outlier adjustment to the Federal rate for FY 2003 is 1.0038 (0.9460/0.9424). The outlier adjustment increases the proposed FY 2003 Federal rate by 0.38 percent compared with the FY 2002 outlier adjustment. 3. Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the Geographic Adjustment Factor Section 412.308(c)(4)(ii) requires that the Federal rate be adjusted so that aggregate payments for the fiscal year based on the Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the geographic adjustment factor
(GAF)are projected to equal aggregate payments that would have been made on the basis of the Federal rate without such changes. Since we implemented a separate geographic adjustment factor for Puerto Rico, we apply separate budget neutrality adjustments for the national geographic adjustment factor and the Puerto Rico geographic adjustment factor. 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 since the geographic adjustment factor for Puerto Rico was implemented in FY 1998. In the past, we used the actuarial capital cost model (described in Appendix B of the August 1, 2001 final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the 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 exceptions payment adjustment factor. As we explain below in section III.A.4. of this Addendum, beginning in FY 2003 an adjustment for regular exceptions is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions adjustment factor for special exception payments. To determine the proposed factors for FY 2003, we compared (separately for the national rate and the Puerto Rico rate) estimated aggregate Federal rate payments based on the FY 2002 DRG relative weights and the FY 2002 GAF to estimated aggregate Federal rate payments based on the FY 2003 relative weights and the FY 2003 GAF. For FY 2002, the budget neutrality adjustment factors were 0.9927 for the national rate and 0.9916 for the Puerto Rico rate (see the August 1, 2001 final rule (66 FR 40101)). In making the comparison, we set the regular and special exceptions reduction factors to 1.00. To achieve budget neutrality for the changes in the national GAF, we propose to apply an incremental budget neutrality adjustment of 0.9990 for FY 2003 to the previous cumulative FY 2002 adjustment of (0.9927), yielding a proposed cumulative adjustment of 0.9917 through FY 2003. For the Puerto Rico GAF, we propose to apply an incremental budget neutrality adjustment of 1.0080 for FY 2003 to the previous cumulative FY 2002 adjustment (0.9916), yielding a proposed cumulative adjustment of 0.9996 through FY 2003. We then compared estimated aggregate Federal rate payments based on the FY 2002 DRG relative weights and the FY 2002 GAF to estimated aggregate Federal rate payments based on the proposed FY 2003 DRG relative weights and the FY 2003 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 1.0034 nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for changes in the GAF through FY 2003 are 0.9951 nationally and 1.0030 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year: Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors Fiscal year National Incremental adjustment Geographic adjustment factor DRG reclassifications and recalibration Combined Cumulative Puerto Rico Incremental adjustment Geographic adjustment factor DRG reclassifications and recalibration Combined Cumulative 1992 1.00000 1993 0.99800 0.99800 1994 1.00531 1.00330 1995 0.99980 1.00310 1996 0.99940 1.00250 1997 0.99873 1.00123 1998 0.99892 1.00015 1.00000 1999 0.99944 1.00335 1.00279 1.00294 0.99898 1.00335 1.00233 1.00233 2000 0.99857 0.99991 0.99848 1.00142 0.99910 0.99991 0.99901 1.00134 2001 1 0.99846 1.00019 0.99865 0.99933 1.00365 1.00009 1.00374 1.00508 2001 2 3 0.99771 3 1.00009 3 0.99780 0.99922 3 1.00365 3 1.00009 3 1.00374 1.00508 2002 4 0.99666 4 0.99668 4 0.99335 0.99268 4 0.98991 4 0.99668 4 0.99662 0.99164 2003 5 0.99902 5 1.00342 5 1.00244 5 0.99510 5 1.00804 5 1.00342 5 1.01149 5 1.00303 1 Factors effective for the first half of FY 2001 (October 2000 through March 2001). 2 Factors effective for the second half of FY 2001 (April 2001 through September 2001). 3 Incremental factors are applied to FY 2000 cumulative factors. 4 Incremental factors are applied to the cumulative factors for the first half of FY 2001. 5 Proposed factors for FY 2003. The methodology used to determine the proposed recalibration and geographic (DRG/GAF) budget neutrality adjustment factor for FY 2003 is similar to that used in establishing budget neutrality adjustments under the prospective payment system for operating costs. One difference is that, under the operating prospective payment system, 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 prospective payment system, there is a single DRG/GAF budget neutrality adjustment factor (the national rate and the Puerto Rico rate are determined separately) for changes in the GAF (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients, indirect medical education payments, or the large urban add-on payments. For FY 2002, we calculated a GAF/DRG budget neutrality factor of 0.9934. For FY 2003, we are proposing a GAF/DRG budget neutrality factor of 1.0024. The GAF/DRG budget neutrality factors are built permanently into the rates; that is, they are applied cumulatively in determining the Federal rate. This follows from the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The proposed incremental change in the adjustment from FY 2002 to FY 2003 is 1.0024. The proposed cumulative change in the rate due to this adjustment is 0.9951 (the product of the incremental factors for FY 1993, FY 1994, FY 1995, FY 1996, FY 1997, FY 1998, FY 1999, FY 2000, FY 2001, FY 2002, and the proposed incremental factor for FY 2003: 0.9980 × 1.0053 × 0.9998 × 0.9994 × 0.9987 × 0.9989 × 1.0028 × 0.9985 × 0.9979 × 0.9934 × 1.0024 = 0.9951). This proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the GAF of FY 2003 geographic reclassification decisions made by the MGCRB compared to FY 2002 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors or in the large urban add-on. 4. Exceptions Payment Adjustment Factor Section 412.308(c)(3) requires that the standard capital 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 prospective payment system payments. In estimating the proportion of regular exceptions payments to total capital prospective payment system payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the August 1, 2001 final rule (66 FR 40099)) to determine the exception adjustment factor, which was applied to both the Federal and hospital-specific rates. An adjustment for regular exceptions is no longer necessary in determining the proposed FY 2003 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 August 1, 2001 final rule (66 FR 39949), in FY 2003 and later, no payments will be made under the regular exceptions provision. However, in accordance with § 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under § 412.348(g). We describe our methodology for determining the special exceptions adjustment used in establishing the FY 2003 proposed 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 exception payments if it meets
(1)a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at § 412.348(g)(4);
(2)an age of assets test as described at § 412.348(g)(3); and
(3)a project size requirement as described at § 412.348(g)(5). As we explained in the August 1, 2001 final rule (66 FR 39912 through 39914), in order to determine the estimated proportion of special exceptions payments to total capital payments, we attempted to identify the universe of eligible hospitals that may potentially qualify for special exception payments. First, we identified hospitals that met the eligibility requirements at § 412.348(g)(1). Then we determined each hospital's average fixed asset age in the earliest available cost report starting in FY 1992 and later. For each of those hospitals, we calculated the average fixed asset age by dividing the accumulated depreciation by the current year's depreciation. In accordance with § 412.348(g)(3), a hospital must have an average age of buildings and fixed assets above the 75th percentile of all hospitals in the first year of the capital prospective payment system. In the September 1, 1994 final rule (59 FR 45385), we stated that, based on the June 1994 update of the cost report files in HCRIS, the 75th percentile for buildings and fixed assets for FY 1992 was 16.4 years. However, we noted that we would make a final determination of that value on the basis of more complete cost report information at a later date. In the August 29, 1997 final rule (62 FR 46012), based on the December 1996 update of HCRIS and the removal of outliers, we finalized the 75th percentile for buildings and fixed assets for FY 1992 as 15.4 years. Thus, we eliminated any hospitals from the potential universe of hospitals that may qualify for special exception payments if its average age of fixed assets did not exceed 15.4 years. For the hospitals remaining in the potential universe, we estimated project-size by using the fixed capital acquisitions shown on Worksheet A7 from the following HCRIS cost reports updated through December 2001. PPS year Cost reports periods beginning in * * * IX FY 1992 X FY 1993 XI FY 1994 XII FY 1995 XIII FY 1996 XIV FY 1997 XV FY 1998 XVI FY 1999 Because the project phase-in may overlap 2 cost reporting years, we added together the fixed acquisitions from sequential pairs of cost reports to determine project size. Under § 412.348(g)(5), the hospital's project cost must be at least $200 million or 100 percent of its operating cost during the first 12-month cost reporting period beginning on or after October 1, 1991. We calculated the operating costs from the earliest available cost report starting in FY 1992 and later by subtracting inpatient capital costs from inpatient costs (for all payers). We did not subtract the direct medical education costs as those costs are not available on every update of the HCRIS minimum data set. If the hospital met the project size requirement, we assumed that it also met the project need requirements at § 412.348(g)(2) and the excess capacity test for urban hospitals at § 412.348(g)(4). Because we estimate that so few hospitals will qualify for special exceptions, projecting costs, payments, and margins would result in high statistical variance. Consequently, we decided to model the effects of special exceptions using historical data based on hospitals' actual cost experiences. If we determined that a hospital may qualify for special exceptions, we modeled special exceptions payments from the project start date through the last available cost report (FY 1999). For purposes of modeling we used the cost and payment data on the cost reports from HCRIS assuming that special exceptions would begin at the start of the qualifying project. In other words, when modeling costs and payment data, we ignored any regular exception payments that these hospitals may otherwise have received as if there had not been regular exceptions during the transition period. In projecting an eligible hospital's special exception payment, we applied the 70-percent minimum payment level, the cumulative comparison of current year capital prospective payment system payments and costs, and the cumulative operating margin offset (excluding 75 percent of operating DSH payments). Our modeling of special exception payments for FY 2003 produced the following results: Cost report Number of hospitals eligible for special exceptions Special exceptions as a fraction of capital payments to all hospitals PPS IX PPS X PPS XI 2 PPS XII 6 0.0002 PPS XIII 8 0.0001 PPS XIV 16 0.0003 PPS XV 20 0.0011 PPS XVI 28 0.0019 We note that hospitals still have two more cost reporting periods (PPS XVII and PPS XVIII) to complete their projects in order to be eligible for special exceptions, and therefore, we estimate that about 30 additional hospitals could qualify for special exceptions. Thus, we project that special exception payments as a fraction of capital payments to all hospitals could be approximately 0.0040. Because special exceptions are budget neutral, we propose to offset the proposed Federal capital rate by 0.40 percent for special exceptions for FY 2003. Therefore, the proposed exceptions adjustment factor for special exception payments would equal 0.9960 (1 − 0.0040) to account for special exception payments in FY 2003. We will revise this projection of the special exception adjustment factor in the final rule based on the latest available data. For FY 2002, we estimated that total (regular and special) exceptions payments would equal 0.71 percent of aggregate payments based on the Federal rate. Therefore, we applied an exceptions reduction factor of 0.9929 (1−0.0071) in determining the Federal rate. As we stated above, we estimate that exceptions payments for FY 2003 will equal 0.40 percent of aggregate payments based on the Federal rate. Therefore, we are proposing an exceptions payment reduction factor of 0.9960 (1−0.0040) to the Federal rate for FY 2003. The proposed exceptions reduction factor for FY 2003 is 0.31 percent higher than the factor for FY 2002 published in the August 1, 2001 final rule. This increase is primarily due to the expiration of the regular exceptions provision and the narrowly defined nature of the special exceptions policy. The exceptions reduction factors are not built permanently into the rates; that is, the factors are not applied cumulatively in determining the Federal rate. Therefore, the proposed net change in the exceptions adjustment to the FY 2003 Federal rate is 0.9960/0.9929, or 1.0031. 5. Special Adjustment To Restore the 2.1 Percent Reduction to the Standard Federal Capital Prospective Payment System Payment Rate As we explained in section VI.D. of the preamble of this proposed rule, section 1886(g)(1)(A) of the Act, as amended by section 4402 of Public Law 105-33, requires the Secretary to reduce the unadjusted standard Federal capital prospective payment system payment rate by 2.1 percent for discharges on or after October 1, 1997, and through September 30, 2002. Therefore, under the statute the additional 2.1 percent reduction no longer applies to discharges occurring after September 30, 2002. Accordingly, we are proposing to revise § 412.308(b) to restore the 2.1 percent reduction to the unadjusted standard Federal capital prospective payment system payment rate for discharges occurring on or after October 1, 2002 to the level that it would have been without the reduction. As we state in section VI.D. of the preamble of this proposed rule and in the August 29, 1997 final rule (62 FR 46012), we applied a factor of 0.8222 in FY 1998 to account for both the reduction equal to the FY 1995 budget neutrality factor (0.1568) and the 2.1 percent reduction (0.021) provided for under section 4402 of Public Law 105-33. In order to determine the adjustment factor needed to restore the 2.1 percent reduction, we would divide the amount of the adjustment without the 2.1 percent reduction (1− 0.1568 = 0.8432) by the amount of the adjustment with the 2.1 percent reduction (0.8222). Therefore, we are proposing to apply a factor of 1.02554 (0.8432/0.8222) to the unadjusted FY 2002 standard Federal capital prospective payment system payment rate to restore the 2.1 percent reduction for discharges occurring on or after October 1, 2002. 6. Standard Capital Federal Rate for FY 2003 For FY 2002, the capital Federal rate was $390.74. For FY 2003, we are proposing a capital Federal rate of $408.90. The proposed Federal rate for FY 2003 was calculated as follows: • The proposed FY 2003 update factor is 1.0110; that is, the update is 1.10 percent. • The proposed FY 2003 budget neutrality adjustment factor that is applied to the standard Federal payment rate for changes in the DRG relative weights and in the GAF is 1.0024. • The proposed FY 2003 outlier adjustment factor is 0.9460. • The proposed FY 2003 exceptions payments adjustment factor is 0.9960. • The proposed special adjustment factor for FY 2003 to restore the 2.1 percent reduction to the standard Federal rate is 1.0255. Since the 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 proposing to make no additional adjustments in the standard Federal rate for these factors, other than the budget neutrality factor for changes in the DRG relative weights and the GAF. We are providing a chart that shows how each of the proposed factors and adjustments for FY 2003 affected the computation of the proposed FY 2003 Federal rate in comparison to the FY 2002 Federal rate. The proposed FY 2003 update factor has the effect of increasing the Federal rate by 1.10 percent compared to the FY 2002 Federal rate, while the proposed geographic and DRG budget neutrality factor has the effect of increasing the Federal rate by 0.24 percent. The proposed FY 2003 outlier adjustment factor has the effect of increasing the Federal rate by 0.38 percent compared to the FY 2002 Federal rate. The proposed FY 2003 exceptions reduction factor has the effect of increasing the Federal rate by 0.31 percent compared to the exceptions reduction for FY 2002. The proposed special adjustment factor for FY 2003 to restore the 2.1 percent reduction to the standard Federal rate has the effect of increasing the Federal rate by 2.55 percent compared to the FY 2002 Federal rate. The combined effect of all the proposed changes is to increase the Federal rate by 4.65 percent compared to the FY 2002 Federal rate. Comparison of Factors and Adjustments: FY 2002 Federal Rate and Proposed FY 2003 Federal Rate FY 2002 Proposed FY 2003 Change Percent change Update factor 1 1.0130 1.0110 1.0110 1.10 GAF/DRG Adjustment Factor 1 0.9934 1.0024 1.0024 0.24 Outlier Adjustment Factor 2 0.9424 0.9460 1.0038 0.38 Exceptions Adjustment Factor 2 0.9929 0.9960 1.0031 0.31 Special Adjustment 3 N/A 1.0255 1.0255 2.55 Federal Rate $390.74 $408.90 1.0465 4.65 1 The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for example, the incremental change from FY 2002 to FY 2003 resulting from the application of the 1.0024 GAF/DRG budget neutrality factor for FY 2003 is 1.0024. 2 The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates; that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net change resulting from the application of the FY 2003 outlier reduction factor is 0.9460/0.9424, or 1.0038. 3 Section 1886(g)(1)(A) of the Act requires, for discharges on or after October 1, 1997, and through September 30, 2002, the Secretary to reduce the unadjusted standard Federal capital prospective payment system payment rate by 2.1 percent. Thus, the 2.1 percent reduction no longer applies to discharges occurring after September 30, 2002, and we are proposing to restore the 2.1 percent reduction by applying a factor of 1.0255 (see section VI.D. of the preamble of this proposed rule). 7. Special Rate for Puerto Rico Hospitals As explained at the beginning of section II.D. of this Addendum, hospitals in Puerto Rico are paid based on 50 percent of the Puerto Rico rate and 50 percent of the Federal rate. The Puerto Rico rate is derived from the costs of Puerto Rico hospitals only, while the Federal rate is derived from the costs of all acute care hospitals participating in the prospective payment system (including Puerto Rico). To adjust hospitals' capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended rate. The GAF is calculated using the operating prospective payment system wage index and varies, depending on the MSA or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital-blended rate and the national wage index to determine the GAF for the national part of the blended 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 in section III.A.4. of this Addendum, for Puerto Rico the proposed GAF budget neutrality factor is 1.0080, while the proposed DRG adjustment is 1.0034, for a proposed combined cumulative adjustment of 1.0115. In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the rate (50 percent) is multiplied by the Puerto Rico-specific GAF for the MSA in which the hospital is located, and the national portion of the rate (50 percent) is multiplied by the national GAF for the MSA 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 rate as a result of Public Law 105-33. For FY 2002, before application of the GAF, the special rate for Puerto Rico hospitals was $187.73. With the changes we are proposing to the factors used to determine the rate, the proposed FY 2003 special rate for Puerto Rico is $199.70. B. Calculation of Inpatient Capital-Related Prospective Payments for FY 2003 With the end of the capital prospective payment system transition period in FY 2001, all hospitals (except “new” hospitals under § 412.324(b) and under proposed § 412.304(c)(2)) are paid based on 100 percent of the Federal rate in FY 2003. The applicable Federal rate was determined by making adjustments as follows: • For outliers, by dividing the 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 2003, the standard Federal rate is adjusted as follows: (Standard Federal Rate) × (DRG weight) ×
(GAF)× (Large Urban Add-on, if applicable) × (COLA adjustment for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted Federal rate. Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The outlier thresholds for FY 2003 are in section II.A.4.c. of this Addendum. For FY 2003, 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 $33,450. An eligible hospital may also qualify for a special exception payment under § 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets
(1)a project need requirement described at § 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at § 412.348(g)(4); and
(2)a project size requirement as described at § 412.348(g)(5). Eligible hospitals include sole community hospitals, 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 prospective payment system 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 prospective payment system; 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 prospective payment system for their first 2 years of operation and are 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 hospital under the appropriate transition methodology. If the hold-harmless methodology was applicable, the hold-harmless payment for assets in use during the base period would extend for 8 years, even if the hold-harmless payments extend beyond the normal transition period. As discussed in section VI.B. of the preamble of this proposed rule, we are proposing under § 412.304(c)(2) to pay new hospitals 85 percent of their reasonable costs during the first 2 years of operation. Effective with the third year of operation through the remainder of the transition period, we would pay the hospital based on 100 percent of the capital Federal (that is, the same methodology used to pay all other hospitals subject to capital prospective payment system). C. Capital Input Price Index 1. Background Like the operating input price index, the capital input price index
(CIPI)is a fixed-weight price index that measures the price changes associated with 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 1992 in the August 30, 1996 final rule (61 FR 46196). In this proposed rule, we are proposing to revise and rebase the CIPI to a FY 1997 base year to reflect the more recent structure of capital costs. For further details on the proposed rebasing and revision of the CIPI, see section IV.B. of this proposed rule. 2. Forecast of the CIPI for Federal Fiscal Year 2003 We are forecasting the proposed CIPI to increase 0.7 percent for FY 2003. This reflects a projected 1.3 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 2.7 percent increase in other capital expense prices in FY 2003, partially offset by a 2.2 percent decline in vintage-weighted interest rates in FY 2003. The weighted average of these three factors produces the 0.7 percent increase for the CIPI as a whole. IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages The inpatient operating costs of hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system are subject to rate-of-increase limits established under the authority of section 1886(b) of the Act, which is implemented in regulations at § 413.40. Under these limits, a hospital-specific target amount (expressed in terms of the inpatient operating cost per discharge) is set for each hospital, based on the hospital's own historical cost experience trended forward by the applicable rate-of-increase percentages (update factors). Under existing § 413.40(c)(4)(iii)(B), for cost reporting periods beginning and during FYs 1998 and through 2002, in the case of a psychiatric hospital or hospital unit, a rehabilitation hospital or hospital unit, or a long-term care hospital, the target amount may not exceed the updated figure for the 75th percentile of target amounts adjusted to take into account the differences between average wage-related costs in the area of the hospital and the national average of such costs within the same class of hospitals for hospitals and hospital units in the same class (psychiatric, rehabilitation, and long-term care) for cost reporting periods ending during FY 1996. The target amount is multiplied by the number of Medicare discharges in a hospital's cost reporting period, yielding the ceiling on aggregate Medicare inpatient operating costs for the cost reporting period. Each hospital-specific target amount is adjusted annually, at the beginning of each hospital's cost reporting period, by an applicable update factor. Under existing §§ 413.40(c)(4)(ii) and (d)(1)(i) and (ii), effective for cost reporting periods beginning during FY 2003, payments to existing excluded hospitals and hospital units will no longer be subject to a 75th percentile cap. These excluded hospitals and hospital units will be paid based on their aggregate Medicare inpatient operating costs, which may not exceed their ceiling. The ceiling on a hospital's or hospital unit's aggregate Medicare inpatient operating costs would be computed using the hospital's or hospital unit's target amount from the previous cost reporting period updated using the rate-of-increase percentage specified in § 413.40(c)(3)(viii) and multiplied by the total number of Medicare discharges. Section 1886(b)(3)(B) of the Act, as implemented in regulations at § 413.40(c)(3)(viii), provides that, for cost reporting periods beginning on or after October 1, 2002, the update factor for a hospital or hospital unit is the percentage increase projected by the hospital market basket index. The most recent proposed projected forecast of the market basket percentage increase for FY 2003 for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system is 3.4 percent. This proposed percentage change is made by CMS” Office of the Actuary and reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient hospital care. Therefore, we are proposing that the update to a hospital's target amount for its cost reporting period beginning in FY 2003 would be 3.4 percent. As discussed in section VII. of the preamble of this proposed rule, we are proposing to make an adjustment to the updated cap on the target amounts per discharge for each class of new excluded hospitals and hospital units for cost reporting periods beginning during FY 2003, using the prospective payment system wage index without taking into account the reclassifications under sections 1886(d)(8)(B) and (d)(10) of the Act. For a new provider, the labor-related share of the target amount is multiplied by the appropriate geographic area wage index, without regard to prospective payment system reclassifications, and added to the nonlabor-related share in order to determine the per case limit on payment under the statutory payment methodology for new providers. Regulations at § 413.40(f)(2)(ii) specify the payment methodology for new hospitals and hospital units, effective October 1, 1997. For cost reporting periods beginning in FY 2003, the proposed caps are as follows: Class of excluded hospital or unit FY 2003 proposed labor-related share FY 2003 proposed nonlabor-related share Psychiatric $7,047 $2,801 Long-Term Care 17,269 6,866 Effective for cost reporting periods beginning on or after October 1, 2002, this payment limitation is no longer applicable to new rehabilitation hospitals and units since they will be paid under the inpatient rehabilitation facility prospective payment system. Regulations at § 413.40(d) specify the formulas for determining bonus and relief payments for excluded hospitals and specify established criteria for an additional bonus payment for continuous improvement. V. Tables This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. For purposes of this proposed rule, and to avoid confusion, we have retained the designations of Tables 1 through 5 that were first used in the September 1, 1983 initial prospective payment final rule (48 FR 39844). Tables 1A, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 9, and 10 are presented below. The tables presented below are as follows: Table 1A—National Adjusted Operating Standardized Amounts, Labor/Nonlabor Table 1C—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D—Capital Standard Federal Payment Rate Table 2—Hospital Average Hourly Wage for Federal Fiscal Years 2001 (1997 Wage Data), 2002 (1998 Wage Data), and 2003 (1999 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages Table 3A—3-Year Average Hourly Wage for Urban Areas Table 3B—3-Year Average Hourly Wage for Rural Areas Table 4A—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Urban Areas Table 4B—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Rural Areas Table 4C—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Hospitals That Are Reclassified Table 4F—Puerto Rico Wage Index and Capital Geographic Adjustment Factor
(GAF)Table 4G—Pre-Reclassified Wage Index for Urban Areas Table 4H—Pre-Reclassified Wage Index for Rural Areas Table 5—List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, 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 Table 6H—Deletions to the CC Exclusions List Table 7A—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2001 MedPAR Update 12/01 GROUPER V19.0 Table 7B—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2001 MedPAR Update 12/01 GROUPER V20.0 Table 8A—Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) March 2002 Table 8B—Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) March 2002 Table 9—Hospital Reclassifications and Redesignations by Individual Hospital—FY 2003 Table 10—Mean and Standard Deviations by Diagnosis-Related Groups (DRGs)—FY 2003 Table 1A.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor Large urban areas Labor-related Nonlabor-related Other areas Labor-related Nonlabor-related $3,099.62 $1,175.71 $3,050.55 $1,157.10 Table 1C.—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Large Urban Areas Labor Nonlabor Other Areas Labor Nonlabor National $3,073.03 $1,165.63 $3,073.03 $1,165.63 Puerto Rico 1,475.56 593.94 1,452.19 584.54 Table 1D.—Capital Standard Federal Payment Rate Rate National $408.90 Puerto Rico $199.70 —————————— * Denotes wage data not available for the provider for that year. ** Based on the sum of the salaries and hours computed for Federal FYs 2001, 2002, and 2003. Table 2.—Hospital Average Hourly Wage for Federal Fiscal Years 2001 (1997 Wage Data), 2002 (1998 Wage Data) and 2003 (1999 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages Provider No. Average hourly wage FY 2001 Average hourly wage FY 2002 Average hourly wage FY 2003 Average hourly** wage (3 yrs) 010001 16.4088 17.4467 17.7070 17.1977 010004 17.9732 19.0010 20.1613 19.0027 010005 17.5985 18.6554 21.5442 19.2074 010006 16.7480 17.6115 18.6118 17.6922 010007 15.4798 15.6788 16.0781 15.7477 010008 14.7443 17.4728 19.0182 17.0908 010009 18.7731 18.4979 19.7272 18.9866 010010 16.4468 16.4664 17.7348 16.9045 010011 20.7972 22.4292 24.7067 22.5297 010012 17.7171 15.8686 20.3948 17.8168 010015 15.4510 19.1178 19.8205 18.1040 010016 17.2473 20.2198 20.4139 19.2448 010018 17.6449 18.9388 19.5519 18.7214 010019 16.3493 17.0856 17.4615 16.9602 010021 16.2919 15.1241 * 15.7091 010022 18.5879 17.6435 22.2036 19.2378 010023 16.1025 16.3209 18.4567 16.9929 010024 16.2900 15.9034 17.0372 16.4149 010025 15.1356 15.1548 16.9733 15.7569 010027 11.7900 16.8595 16.5157 14.5941 010029 17.6461 18.3605 19.1001 18.3671 010031 18.7835 18.6402 19.2612 18.9043 010032 12.5995 15.3590 16.3967 14.8530 010033 20.3923 21.2986 21.8375 21.1715 010034 15.0959 15.3639 14.9379 15.1325 010035 20.1853 15.9439 20.8498 18.7765 010036 17.8140 17.7166 18.1325 17.8864 010038 18.2671 19.6098 19.6887 19.2225 010039 20.1045 20.3406 21.1309 20.5522 010040 18.9376 20.0983 20.4032 19.7634 010043 30.7489 18.6640 18.1128 21.1242 010044 22.0091 24.0265 23.4575 23.1128 010045 15.2200 17.0417 18.7569 16.8822 010046 17.3970 18.9737 18.8741 18.4218 010047 13.3521 15.4190 13.4130 14.0833 010049 14.7590 15.5246 16.3349 15.5762 010050 18.5163 17.9830 20.3028 18.9035 010051 11.9275 11.8108 12.3280 12.0151 010052 16.5486 18.0653 19.8289 18.3581 010053 14.6267 15.5649 15.4156 15.2353 010054 18.5103 19.4955 20.9656 19.7134 010055 18.9526 18.8590 19.4959 19.1060 010056 19.2175 19.6577 20.5645 19.7867 010058 16.1702 16.9715 16.1265 16.4288 010059 19.1286 18.8020 19.1270 19.0199 010061 14.9547 14.5003 18.5320 15.9823 010062 14.7732 12.3259 * 13.4892 010064 20.4139 19.5256 20.6628 20.1862 010065 16.4049 16.8752 18.8957 17.4231 010066 15.4317 13.1559 14.8904 14.4355 010068 12.0525 18.6925 23.4322 17.0157 010069 13.8636 14.7211 15.4497 14.6885 010072 14.9526 16.2339 16.5652 15.9117 010073 13.8601 14.1273 13.5594 13.8482 010078 17.9202 18.1363 18.5127 18.1930 010079 16.4421 17.0648 16.8045 16.7705 010081 18.9474 17.2996 * 18.1637 010083 16.8933 18.0312 18.4282 17.8382 010084 18.4965 18.7769 19.8773 19.0316 010085 18.4744 19.9023 21.3593 19.9065 010086 16.6694 16.5711 16.8886 16.7103 010087 19.0033 18.0567 18.6860 18.6208 010089 16.8042 17.7800 19.5697 18.0246 010090 18.3866 18.9445 19.5635 18.9671 010091 13.9405 17.0799 17.1775 15.9756 010092 16.9900 17.8144 18.5703 17.8203 010095 12.4525 12.2597 13.7865 12.8381 010097 13.0413 12.7286 14.2675 13.3206 010098 15.9165 14.0300 15.5763 15.1201 010099 15.9874 15.5619 15.9232 15.8146 010100 17.2011 17.9430 18.3755 17.8826 010101 15.3859 14.4625 18.7988 16.0267 010102 13.7933 13.8136 15.7777 14.4205 010103 17.9358 17.7242 22.2456 19.1327 010104 17.7126 16.8457 22.0038 18.6396 010108 17.9017 19.4617 19.1596 18.8606 010109 15.3107 14.6752 15.9627 15.2873 010110 15.6317 15.8283 15.5817 15.6824 010112 15.1401 16.8271 15.6041 15.8270 010113 16.9683 16.8936 18.2706 17.3693 010114 15.2454 17.0760 19.0678 17.1007 010115 14.6268 14.2261 15.3510 14.7053 010118 18.8477 17.0834 17.4620 17.7157 010119 18.8024 19.3942 19.4672 19.3127 010120 17.2336 18.2567 18.9975 18.1726 010121 14.6444 14.5262 15.2345 14.7784 010123 16.7344 19.2140 * 17.9083 010124 16.2846 16.7465 * 16.5122 010125 15.5304 16.0136 16.5117 16.0174 010126 19.5710 19.1065 19.5933 19.4288 010127 19.5190 18.2786 * 18.9233 010128 14.5056 14.4322 15.1184 14.6873 010129 14.7286 16.1733 16.7609 15.8741 010130 16.6809 19.5573 17.4614 17.7942 010131 17.8260 20.1883 19.0492 18.9966 010134 18.8835 19.9856 18.5179 19.1797 010137 12.1217 20.5828 21.3573 17.6481 010138 12.8675 14.5254 14.1369 13.8739 010139 19.0001 20.4331 20.5708 19.9541 010143 16.7911 17.6212 18.8903 17.7663 010144 17.1320 18.2040 18.7743 18.0281 010145 20.8434 20.5895 20.8110 20.7460 010146 18.5198 19.1415 18.3666 18.6687 010148 12.2214 15.8349 16.6251 14.5873 010149 18.6333 18.0156 19.0199 18.5806 010150 17.8951 18.9359 19.4819 18.7907 010152 17.8306 18.7677 19.8695 18.8444 010155 9.0300 15.0689 13.6136 11.6435 010157 * * 18.0689 18.0689 010158 17.3227 18.3957 18.8358 18.2136 010159 * * 20.4419 20.4419 020001 28.1747 28.0394 28.6292 28.2864 020002 24.5815 25.1987 28.2759 25.9928 020004 30.5667 25.4679 26.5088 27.6844 020005 30.2920 29.2378 35.0860 31.4575 020006 31.2404 28.1417 33.0843 30.7594 020007 27.8319 32.3852 27.7269 28.9902 020008 29.4146 30.8691 31.8715 30.7301 020009 20.1930 18.4660 18.5594 19.0476 020010 23.6727 22.7559 23.7275 23.3859 020011 30.4727 28.0658 27.5062 28.6155 020012 24.8543 25.5320 26.7586 25.6982 020013 23.8847 28.1557 29.5646 26.9336 020014 27.3823 24.5875 * 25.9860 020017 26.8319 28.0572 28.8752 27.9519 020024 24.0872 25.3205 25.5933 25.0276 020025 21.7557 20.2583 29.4375 23.2312 030001 20.3673 21.7869 22.8996 21.6709 030002 21.5977 21.8375 23.1450 22.2070 030003 23.4833 22.6804 23.9849 23.3723 030004 14.0711 15.5478 13.8452 14.3965 030006 18.2668 20.0273 20.5019 19.5831 030007 19.6708 21.5169 22.2473 21.1843 030008 22.2758 22.2190 * 22.2524 030009 18.1794 18.7557 19.1258 18.6629 030010 19.0907 19.5123 19.8496 19.4665 030011 19.2973 19.4310 19.8141 19.5088 030012 18.9918 20.6585 21.1099 20.2847 030013 20.7458 20.0535 19.9517 20.2223 030014 19.9315 19.7966 20.0568 19.9241 030016 19.3967 19.4785 22.2526 20.4395 030017 22.8765 21.7938 23.1702 22.6064 030018 20.2032 20.8980 21.8067 20.9825 030019 21.7005 21.2540 22.0341 21.6682 030022 19.2966 19.5794 22.3351 20.3379 030023 23.6697 24.1678 25.4626 24.5066 030024 22.2541 23.6009 23.5218 23.1550 030025 12.7254 11.9894 20.2690 14.6291 030027 15.7554 17.6555 18.5500 17.3221 030030 20.8303 21.6932 23.1280 21.8856 030033 20.0044 20.2820 20.3034 20.1983 030034 16.8241 20.8689 19.5578 19.0205 030035 19.2781 20.0226 20.5339 19.9127 030036 20.7567 21.6371 22.2690 21.5890 030037 22.8266 23.7615 23.7325 23.4266 030038 22.6776 22.9822 23.4477 23.0337 030040 18.5456 19.7636 19.3706 19.2127 030041 15.8921 18.8717 18.4750 17.5529 030043 20.9341 20.5598 18.7843 19.9580 030044 16.8649 17.6575 18.6781 17.7554 030047 22.6401 21.4412 22.7385 22.2630 030049 19.0881 19.3580 19.7315 19.3525 030054 15.3338 15.0657 15.7973 15.4130 030055 16.3613 20.2991 20.8373 19.1429 030059 24.0465 22.6279 27.3929 24.5505 030060 19.2461 18.6313 19.5021 19.1145 030061 18.9063 19.9047 21.1013 19.9959 030062 17.6738 18.7172 19.2670 18.6035 030064 19.5673 20.3837 21.6435 20.5204 030065 20.5130 20.7838 22.2846 21.2496 030067 14.4446 17.2778 17.6414 16.3935 030068 17.3614 17.7208 18.9718 18.0528 030069 19.0961 21.0936 23.4902 21.1503 030080 20.5144 20.6581 21.2079 20.8105 030083 23.3355 23.5229 23.2965 23.3842 030085 21.0954 20.8690 21.4417 21.1505 030086 19.5436 * * 19.5436 030087 21.4084 21.9465 23.1339 22.1276 030088 19.8682 20.5340 21.4201 20.6453 030089 20.4019 20.9516 22.0850 21.2122 030092 20.6986 21.8308 19.4627 20.4899 030093 19.7262 20.4314 21.7195 20.6797 030094 21.6218 22.8123 21.8049 22.0984 030095 13.7293 13.7664 20.5222 15.2252 030099 16.1541 18.2263 19.8092 18.2768 030100 * 23.7609 23.5868 23.6643 030101 * 19.2547 21.1029 20.2450 030102 * 18.2413 21.5405 19.8425 030103 * * 15.0859 15.0859 030104 * * 32.8668 32.8668 040001 15.1624 16.9178 16.3882 16.1463 040002 13.0592 15.1107 16.1353 14.6990 040003 14.2089 15.5740 15.5186 15.0890 040004 17.8476 17.9034 19.0105 18.2433 040005 13.2597 11.1318 16.5465 13.4890 040007 21.9583 18.6998 * 20.1466 040008 15.3040 14.7985 20.2121 16.6104 040010 18.6023 19.4913 19.8251 19.3459 040011 14.5319 16.0995 17.1337 15.8295 040014 17.6340 18.1434 19.3996 18.3693 040015 16.5891 15.5207 17.4003 16.5312 040016 19.0295 20.2321 19.8087 19.7068 040017 13.5098 15.4736 16.5602 15.1870 040018 17.6027 18.7463 18.8203 18.3807 040019 22.6769 23.4163 21.0465 22.2688 040020 16.4827 18.9844 17.6056 17.6157 040021 17.6398 19.6835 21.3321 19.4636 040022 17.0397 20.8281 19.2393 18.9742 040024 14.4541 17.6607 15.0590 15.6850 040025 11.5079 13.4705 14.8071 13.1413 040026 19.5563 19.7924 21.0143 20.1201 040027 16.0975 17.4431 17.7161 17.1113 040028 14.6584 13.9946 15.2850 14.6612 040029 17.8787 21.1370 22.5094 20.5216 040030 13.5428 11.2402 16.5488 13.3388 040032 13.7030 13.2872 13.8013 13.5932 040035 12.8300 10.9569 11.0611 11.5521 040036 18.9757 20.2012 21.1066 20.1370 040037 14.6559 14.0941 15.4984 14.7015 040039 14.3576 14.7177 14.8433 14.6458 040040 18.0895 19.1984 19.6704 18.9937 040041 15.9896 16.4624 17.7783 16.7177 040042 15.2142 15.2057 16.6875 15.6976 040044 12.6275 13.3501 17.1869 14.3743 040045 14.9429 16.2469 16.6648 15.9379 040047 16.8654 17.5336 18.6295 17.6726 040050 13.3818 14.0036 14.2087 13.8730 040051 15.8627 16.6039 18.0487 16.8084 040053 16.3610 15.0219 14.1508 15.1659 040054 15.3219 14.2577 16.5217 15.3669 040055 17.1269 18.0414 16.6283 17.2760 040058 17.6766 16.4278 19.3124 17.6534 040060 12.8148 17.9805 15.4220 15.0376 040062 18.2048 17.8902 19.4255 18.5267 040064 10.7255 11.5029 13.3479 11.7813 040066 18.3377 19.7144 18.7831 18.9326 040067 14.6014 14.4741 15.0081 14.6924 040069 17.5052 17.0026 18.9754 17.8560 040070 16.9027 16.9700 18.6066 17.5468 040071 16.9610 17.6144 18.0874 17.5370 040072 16.0895 17.4960 21.3094 18.1882 040074 18.3224 18.7542 20.8465 19.2921 040075 13.3623 14.0975 14.6681 14.0257 040076 19.0732 20.5840 21.8010 20.4612 040077 12.9211 13.9114 14.7230 13.8164 040078 18.7600 18.5821 * 18.6754 040080 19.2461 19.3707 22.8153 20.3838 040081 11.3169 11.1332 12.4796 11.6373 040082 16.2152 15.1331 16.4840 15.9329 040084 17.2613 17.7295 18.3410 17.7584 040085 16.8957 16.5216 14.1782 15.7843 040088 17.9636 17.1624 18.2831 17.7943 040090 17.8282 19.0824 16.6619 17.8476 040091 19.8700 20.1378 20.2904 20.1018 040093 12.3537 13.9741 14.7132 13.5635 040100 14.7587 15.6833 16.9558 15.9133 040105 15.3319 14.3896 14.8936 14.8814 040106 15.6545 18.1341 19.0936 17.8001 040107 18.8120 17.8628 20.6852 19.1446 040109 14.6266 16.6278 16.2496 15.8538 040114 18.8743 21.1231 21.3826 20.4184 040116 20.2716 * * 20.2716 040118 19.3720 18.2123 19.6248 19.0444 040119 15.5338 16.9407 18.5876 17.0324 040124 19.1349 19.2889 * 19.2100 040126 12.5368 11.6517 16.3391 13.4177 040132 17.5179 10.3875 * 13.5846 040134 18.0787 19.0185 22.1291 19.8434 040135 22.6761 23.0084 * 22.8797 040136 * * 21.4139 21.4139 050002 37.8295 36.9630 30.2629 34.5243 050006 19.5594 18.2061 22.4890 20.0298 050007 30.7126 30.8676 31.6270 31.0595 050008 26.2458 26.3682 28.2021 26.8667 050009 26.8159 28.4734 28.3021 27.8816 050013 23.2201 28.0569 27.2552 25.9477 050014 22.8478 23.6745 25.1664 23.9039 050015 26.2481 27.7731 28.2204 27.4404 050016 20.5566 21.2045 22.7014 21.5040 050017 23.9625 25.6178 25.7403 25.1023 050018 15.4721 15.2903 16.4211 15.7749 050021 25.8966 * * 25.8966 050022 24.0318 24.5254 26.2574 24.9836 050024 21.3989 22.4274 21.5230 21.7688 050025 23.3896 24.8245 26.0161 24.7262 050026 27.8736 23.1904 23.4651 24.6800 050028 16.4671 17.6138 17.9421 17.3234 050029 25.1259 24.6839 26.6783 25.4673 050030 20.9812 21.5621 21.8639 21.4881 050032 25.2010 24.3598 24.4176 24.6502 050033 24.9328 32.0179 31.1768 29.1633 050036 21.2420 21.8239 24.1361 22.4423 050038 28.6528 29.9698 32.1757 30.1303 050039 22.7117 22.8288 23.8122 23.1279 050040 32.1287 30.2607 30.1153 30.8697 050042 24.8067 24.5260 25.4903 24.9502 050043 32.9958 33.8255 38.8988 35.0749 050045 19.8831 21.1474 21.0356 20.7131 050046 25.3185 25.2005 25.3067 25.2745 050047 29.9255 29.9580 31.6959 30.5375 050051 17.8945 18.7809 17.9266 18.1624 050054 20.7212 22.0982 19.2395 20.6257 050055 29.3984 29.2730 32.0923 30.2190 050056 27.4321 23.8396 24.7994 25.2478 050057 21.1554 20.7420 21.7403 21.2220 050058 23.1641 23.3009 24.8366 23.7800 050060 20.7747 20.5450 21.9971 21.2660 050061 23.5454 24.5488 23.9906 24.0316 050063 24.8851 25.7593 25.5798 25.3924 050065 24.0420 24.6290 27.6677 25.3130 050066 16.5725 16.1649 26.3920 18.5257 050067 23.1966 25.8857 22.1250 23.5170 050068 20.6851 19.3615 19.2325 19.8460 050069 25.9420 24.6153 25.8560 25.4593 050070 32.5166 34.0721 36.4136 34.4086 050071 33.1850 34.4367 36.4834 34.7318 050072 33.2858 39.7321 36.1146 36.2550 050073 33.3922 32.8555 36.1054 34.1118 050075 33.9095 33.7160 37.8104 35.1272 050076 27.7797 33.9752 37.0415 32.6495 050077 24.1019 24.1404 25.3481 24.5518 050078 23.0736 24.3150 22.6776 23.3158 050079 33.2432 30.0167 36.5455 33.0896 050082 22.1009 23.7617 23.7718 23.2042 050084 23.5866 25.4517 25.1155 24.6796 050088 20.8406 24.9641 25.2282 23.4877 050089 20.9117 22.8450 23.4120 22.3589 050090 23.4097 24.6070 25.4545 24.4799 050091 25.2792 23.7713 * 24.5189 050092 16.7969 17.1211 17.1883 17.0299 050093 25.2130 25.6647 27.1820 26.0418 050095 33.6718 30.4847 29.2226 31.0314 050096 20.0487 22.7394 22.5034 21.6293 050097 16.7054 22.5991 24.2548 20.5747 050099 24.8091 25.3722 26.2363 25.4947 050100 29.8758 25.2031 23.9877 26.2195 050101 31.0264 31.8957 32.7594 31.9069 050102 22.2937 24.0014 22.6741 22.9916 050103 24.7932 25.4133 23.5946 24.5653 050104 25.5797 26.9726 25.4575 26.0072 050107 21.2690 22.2019 22.2746 21.9397 050108 23.5564 25.1758 25.6983 24.8127 050110 20.1870 19.9589 21.3399 20.4921 050111 21.5487 20.7897 21.0813 21.1480 050112 25.3015 26.8182 28.3676 26.8364 050113 28.8420 28.5224 32.3967 30.0407 050114 24.7286 26.6757 27.6486 26.3583 050115 21.3291 23.0182 24.3748 22.9340 050116 25.2130 24.9196 27.0331 25.6442 050117 23.3612 22.2123 23.0697 22.8657 050118 23.7698 23.7129 24.9094 24.1342 050121 19.5252 18.7272 18.8430 19.0230 050122 26.3172 26.9546 26.9193 26.7318 050124 22.7736 24.5069 23.9379 23.7017 050125 29.6147 32.0230 33.3290 31.6254 050126 23.9247 24.6752 26.9718 25.2082 050127 22.1937 20.9027 20.5928 21.0815 050128 25.7240 26.6132 26.2519 26.1998 050129 26.5030 24.0108 23.2118 24.4255 050131 31.0732 32.5462 33.0980 32.2202 050132 24.0834 24.0173 24.1583 24.0881 050133 24.9746 23.2093 23.9479 23.9946 050135 23.2361 24.7157 23.2750 23.7026 050136 24.7921 24.7280 28.0754 25.7753 050137 32.6507 32.9192 33.7489 33.1070 050138 37.3286 38.1584 40.8912 38.7884 050139 32.9351 31.4984 35.1492 33.0424 050140 34.1499 32.7609 36.7096 34.4570 050144 27.8751 27.4069 * 27.6480 050145 32.3857 34.5185 37.5003 34.7881 050148 21.9211 20.0971 21.1622 21.0247 050149 24.6078 26.8674 25.8880 25.7652 050150 24.9073 24.6596 25.9494 25.1761 050152 34.0766 33.3305 33.1217 33.4979 050153 30.5714 32.3389 32.1256 31.7026 050155 21.0257 25.3354 23.2118 23.0854 050158 27.5623 28.6071 28.9764 28.3557 050159 23.2912 22.5313 26.6139 23.7086 050167 21.9128 21.8796 21.9596 21.9174 050168 23.3511 25.1937 27.1971 25.2088 050169 22.3888 24.8407 24.7737 23.9439 050170 23.9574 24.3654 27.9459 25.2622 050172 20.1841 19.6120 22.0400 20.6111 050173 24.5545 24.8694 * 24.7049 050174 30.2140 30.2775 31.6888 30.7398 050175 27.2806 24.7548 26.0146 25.8419 050177 21.7943 21.1396 22.5039 21.8034 050179 21.7175 23.8868 22.8941 22.7755 050180 31.8947 33.3257 34.0900 33.1860 050183 20.3638 * * 20.3638 050186 22.4155 23.6288 25.0791 23.7560 050188 28.0918 28.2364 30.6007 29.0015 050189 22.8687 27.4071 28.3295 26.4046 050191 20.8321 25.3516 29.2992 25.0950 050192 18.6701 14.1996 19.0400 17.0362 050193 22.6316 24.9444 25.5294 24.3542 050194 29.7371 29.5678 28.5389 29.2648 050195 35.5621 36.9068 39.1617 37.2637 050196 18.5180 18.2411 19.4304 18.7370 050197 35.7449 32.4030 34.6750 34.1639 050204 23.6105 22.7099 23.0192 23.1063 050205 23.6831 24.1691 24.1275 23.9917 050207 21.6214 22.9941 23.4210 22.6876 050211 31.6084 31.7280 33.2481 32.1766 050213 21.4806 21.4951 * 21.4880 050214 21.7335 24.0276 21.1480 22.2422 050215 29.8563 35.0459 31.6895 32.1029 050217 19.6010 20.2042 21.3026 20.3986 050219 21.7444 21.2458 21.7637 21.5978 050222 27.4809 23.3563 23.0670 24.3640 050224 23.5316 23.5101 24.8431 23.9839 050225 23.3480 21.6820 22.0981 22.3835 050226 27.7315 24.4443 26.1959 26.0496 050228 34.0711 34.2596 36.0632 34.7751 050230 27.7357 26.6291 26.7963 27.0820 050231 26.1508 26.7321 26.8977 26.6061 050232 24.3072 24.5245 25.8640 24.8981 050234 25.7035 24.6126 25.0104 25.0823 050235 25.2527 27.0922 26.0323 26.1239 050236 26.9803 25.9458 27.7406 26.8805 050238 24.2922 24.5823 25.1796 24.6748 050239 22.6625 23.2711 24.9463 23.6289 050240 26.3657 26.7620 * 26.5501 050241 26.3740 29.8345 * 27.9992 050242 31.1576 32.0829 32.9875 32.0689 050243 28.9635 26.4627 26.0256 27.1221 050245 23.8124 23.2716 27.5920 24.8781 050248 26.2015 27.6457 28.4413 27.4692 050251 21.6574 23.6360 27.9531 24.2057 050253 16.0701 16.7540 21.0399 17.6028 050254 19.3126 20.1176 22.3414 20.6227 050256 23.6887 23.4835 25.1104 24.1533 050257 15.2306 17.2596 15.6379 16.0441 050260 23.2421 27.4234 30.1623 26.5840 050261 20.0552 20.1040 19.4649 19.8596 050262 28.8785 29.5550 30.8866 29.7520 050264 32.1312 36.0331 32.8689 33.6109 050267 26.2264 26.0401 27.8393 26.6370 050270 24.0439 25.3757 26.4092 25.2781 050272 22.4247 23.0587 23.3443 22.9405 050274 20.0422 * * 20.0422 050276 29.8624 33.3302 34.0633 32.3736 050277 20.0520 26.0822 23.6065 23.0165 050278 24.7787 23.9289 24.9699 24.5628 050279 20.8444 21.8949 22.2776 21.6332 050280 25.2149 25.6651 26.3392 25.7541 050281 19.6888 24.2251 25.2699 22.9927 050282 28.8261 25.4428 26.4698 26.9213 050283 29.7734 31.7669 32.3270 31.3481 050286 16.5708 19.4241 20.6191 18.4349 050289 34.1393 30.4750 32.2125 32.1522 050290 28.6231 29.6796 31.5000 29.9312 050291 30.2748 29.4029 30.9334 30.2109 050292 21.6243 20.8410 21.4357 21.2903 050293 22.2963 24.1875 * 23.1602 050295 21.2892 21.7883 24.5917 22.5802 050296 27.2948 28.3906 30.0984 28.6215 050298 24.4477 23.2006 22.4000 23.3022 050299 26.4543 25.5035 24.6751 25.5099 050300 23.5116 25.9228 26.0298 25.2222 050301 22.5201 21.1403 24.7987 22.7770 050305 34.5185 36.7908 36.6981 36.0318 050307 17.2147 * * 17.2147 050308 29.3803 28.9284 28.5759 28.9478 050309 23.7884 25.3515 25.5221 24.8819 050312 26.7617 26.0015 26.0172 26.2525 050313 21.7577 25.6827 28.9126 25.5297 050315 24.7086 22.7359 25.8372 24.4689 050317 21.6937 * * 21.6937 050320 30.4101 32.4809 31.6571 31.4911 050324 26.6049 25.3694 26.8313 26.2820 050325 24.4862 23.6327 22.6353 23.5919 050327 23.9484 25.6450 * 24.7970 050329 19.7455 21.6984 24.2134 21.8073 050331 22.2536 25.0230 25.2110 24.0855 050333 19.4589 19.1449 14.1808 17.2305 050334 34.2330 34.2557 34.3956 34.2968 050335 23.0258 22.9926 22.9335 22.9822 050336 20.7979 21.3402 18.9187 20.3375 050342 20.1841 20.8255 22.4356 21.1404 050343 17.2085 * * 17.2085 050348 23.8779 25.1085 29.3364 26.0263 050349 14.9754 15.0667 15.4536 15.1663 050350 24.8340 26.4161 27.2368 26.1456 050351 25.4791 24.8121 25.2436 25.1768 050352 26.1380 26.4262 27.7489 26.7934 050353 23.0564 23.2699 24.1009 23.4992 050355 17.2778 21.0969 * 18.6280 050357 22.6545 24.5345 24.3540 23.9188 050359 17.7907 21.7548 19.6236 19.5994 050360 31.3526 31.7583 33.3592 32.1693 050366 23.7528 19.6823 22.0442 21.7233 050367 28.2805 30.7328 31.7487 30.2799 050369 27.0548 26.2234 26.6627 26.6233 050373 26.9776 27.8275 29.9749 28.1900 050376 26.5840 28.0990 28.4026 27.6603 050377 17.1764 17.0012 * 17.1127 050378 25.9810 26.9101 27.8389 26.9067 050379 15.2022 18.4278 * 16.6705 050380 31.4343 31.9578 31.5137 31.6362 050382 26.1398 25.9244 26.3968 26.1598 050385 24.6083 * 27.1692 25.6464 050388 19.1512 22.0122 17.6762 19.5684 050390 25.0426 24.2700 25.8556 25.0345 050391 18.9266 20.0615 19.0832 19.3414 050392 21.6729 22.9430 24.9003 23.1073 050393 25.6964 24.1981 25.4028 25.0965 050394 23.0604 23.1526 23.1641 23.1275 050396 24.0636 25.3729 25.7580 25.0612 050397 20.2601 20.6397 23.3212 21.1533 050401 20.7473 18.4593 * 19.5658 050404 17.3396 15.9839 16.4845 16.6030 050406 17.3016 17.8596 21.5282 18.7226 050407 29.9642 30.8346 32.0753 30.9310 050410 17.6769 19.8508 17.1718 18.1805 050411 34.8899 33.1943 33.1718 33.7076 050414 24.2060 25.9723 24.4936 24.8800 050417 21.5739 23.3005 23.3862 22.7800 050419 23.7584 23.4936 25.1449 24.1188 050420 22.3166 23.5438 26.4201 24.1207 050423 17.3771 21.3552 24.8113 20.9574 050424 22.8350 24.0727 25.9378 24.3139 050425 32.8364 35.3712 33.7276 33.9997 050426 25.2453 29.0120 27.4428 27.1541 050427 20.1674 16.4330 * 17.9553 050430 23.8788 21.2275 25.2322 23.4217 050432 24.4133 24.5630 26.0686 25.0170 050433 17.4643 18.9021 17.7980 18.0325 050434 19.7591 * 24.0017 21.7788 050435 25.6676 23.3426 22.2458 23.7166 050436 14.8121 * * 14.8121 050438 25.0138 23.2583 25.3763 24.5467 050440 23.5167 22.5400 25.4767 23.8254 050441 28.9804 31.8774 33.4696 31.2892 050443 19.9020 17.2875 16.8897 17.9266 050444 21.4533 22.4530 22.6469 22.1781 050446 20.4908 22.3422 20.3611 21.0344 050447 17.9751 18.9851 24.4339 20.7186 050448 19.7046 21.7718 22.6612 21.3755 050449 23.8001 23.4614 * 23.6286 050454 28.7432 30.0792 30.3063 29.7856 050455 20.1643 19.8577 20.5575 20.1952 050456 20.1254 18.1585 17.5846 18.4965 050457 34.4949 32.1910 33.5750 33.4045 050464 25.3292 25.7710 25.8092 25.6421 050468 23.3050 22.2926 22.9771 22.8607 050469 23.8759 24.5205 * 24.1896 050470 16.0292 16.0805 15.7765 15.9567 050471 25.6172 27.1597 29.4705 27.3360 050476 22.4754 24.0253 25.9458 24.2592 050477 27.9595 27.5819 30.8781 28.6932 050478 24.5401 26.3306 28.1829 26.3141 050481 28.9722 27.7973 28.5320 28.4396 050482 18.1217 16.0114 21.6091 18.2297 050483 22.7182 * * 22.7182 050485 24.1983 24.6906 23.9507 24.2714 050488 34.6939 31.7481 33.8291 33.4344 050491 26.8703 27.4600 27.7412 27.3548 050492 19.5457 20.5030 23.4977 21.2468 050494 29.2621 29.1296 30.2875 29.5621 050496 32.5168 34.9704 32.7474 33.3456 050497 13.8110 15.4115 * 14.5264 050498 24.9677 26.1716 27.6099 26.2387 050502 22.3788 25.3701 27.2724 24.9510 050503 24.4069 23.3745 25.7668 24.5458 050506 25.0845 25.0333 27.1555 25.7636 050510 33.3774 33.7481 36.2548 34.4910 050512 35.3581 34.4368 36.0785 35.2923 050515 35.3419 33.7321 37.3440 35.4231 050516 24.7992 26.1969 25.1778 25.3919 050517 20.9550 22.0985 23.6067 22.1150 050522 35.3784 36.2127 37.0295 36.1638 050523 27.0544 31.2522 32.1272 30.1439 050526 23.8099 26.4014 27.9306 26.0042 050528 19.0611 18.9155 21.1741 19.7510 050531 22.7308 21.3948 * 22.0804 050534 24.0700 24.0001 24.4038 24.1576 050535 25.4215 26.8511 27.7626 26.6201 050537 22.2256 24.0354 26.2342 24.2063 050539 20.7129 23.3846 23.6244 22.6500 050541 34.4573 36.6149 37.0551 36.1147 050542 16.0892 17.7737 21.8129 18.4625 050543 22.3994 21.6795 22.4134 22.1708 050545 26.3304 31.7280 33.6302 29.6054 050546 26.1949 38.8087 39.4266 31.5013 050547 26.8305 37.7681 37.7633 31.6990 050548 28.8083 29.8516 30.3336 29.5564 050549 27.2765 28.9615 30.0948 28.8364 050550 24.8048 25.6588 * 25.2235 050551 25.4652 24.8084 25.9619 25.4069 050552 21.5216 20.3239 20.6068 20.8970 050557 21.1243 22.2562 23.8340 22.4197 050559 23.5759 24.7866 26.3799 24.8811 050561 34.5791 33.4423 34.2065 34.0632 050564 23.5922 24.2091 * 23.9025 050565 23.7829 20.8349 * 22.1110 050566 17.4423 22.3448 21.7712 20.6000 050567 24.6454 25.0787 26.2588 25.3566 050568 19.5816 20.5376 21.9313 20.7038 050569 26.5479 27.3429 27.3294 27.0680 050570 25.2294 25.8619 26.8965 26.0357 050571 26.2039 24.0154 24.6237 24.9296 050573 24.9644 25.6589 25.9380 25.5333 050575 19.5611 20.7090 27.8579 22.3375 050577 25.1549 23.5487 25.2861 24.6231 050578 28.5379 28.9009 32.0554 29.7756 050579 30.4952 29.9348 32.0245 30.8151 050580 25.9004 24.6962 22.7522 24.4365 050581 23.8584 24.9807 26.0580 24.9311 050583 24.3987 25.8800 26.2664 25.5050 050584 21.2366 19.5805 24.5294 21.6929 050585 25.9426 24.2824 26.4446 25.5528 050586 23.4079 23.1850 * 23.3000 050588 25.3094 24.5472 27.0506 25.7065 050589 24.8698 23.8880 23.7918 24.1317 050590 22.4480 24.4797 25.7756 24.1986 050591 23.9412 25.0209 26.7662 25.1993 050592 21.1745 22.1174 23.8267 22.4222 050594 27.1584 27.7002 28.7415 27.8366 050597 22.8523 23.3280 23.1209 23.0979 050598 24.3597 23.9202 25.1622 24.5206 050599 29.1221 26.0892 26.3782 27.1542 050601 31.8670 29.7417 29.7734 30.4482 050603 23.3390 21.7031 24.9032 23.2638 050604 34.0461 35.4034 36.4669 35.3805 050608 18.0947 18.1664 20.7987 18.9517 050609 34.9935 33.5028 34.8949 34.4263 050613 23.3835 30.2413 34.9980 28.8691 050615 23.8815 27.5682 25.8698 25.6901 050616 22.7437 24.9843 25.0016 24.2299 050618 21.6509 21.4895 22.3548 21.8584 050623 29.1806 27.5832 28.6475 28.4545 050624 22.7148 26.4659 22.4030 23.6850 050625 26.4849 27.5816 28.1438 27.4404 050630 23.9159 24.2120 25.1453 24.4580 050633 23.1918 25.4283 27.8165 25.4720 050636 21.2618 23.5257 25.0214 23.2191 050638 18.2859 18.2159 15.6375 17.1599 050641 21.8315 17.1258 17.9379 18.6266 050644 22.3456 22.1489 * 22.2474 050661 19.6780 * * 19.6780 050662 26.9606 35.0989 38.9592 31.5421 050663 30.6591 24.9110 22.7770 25.2271 050667 24.9979 27.5045 26.9236 26.1684 050668 42.0974 61.7751 57.8627 51.0207 050670 20.0152 24.6101 24.1626 22.6855 050674 34.7380 32.4807 33.7845 33.5929 050675 15.6794 * * 15.6794 050676 18.6672 20.2087 16.3948 18.3663 050677 35.6503 33.6070 34.0936 34.4139 050678 26.8741 22.7756 25.2143 24.8560 050680 28.0584 31.4839 31.9166 30.4823 050682 26.2882 17.3566 19.8107 20.5443 050684 22.3398 23.3697 24.2792 23.3071 050685 31.1725 35.1307 30.4194 32.1391 050686 35.2631 33.4420 34.8278 34.4753 050688 30.6635 31.0648 34.9936 32.8691 050689 30.7295 30.9399 34.0571 31.9763 050690 32.8204 34.8112 36.7516 34.8707 050693 26.8265 25.5662 29.1213 27.1699 050694 23.2293 23.5572 25.1964 23.9614 050695 21.1377 24.4301 26.2838 24.0169 050696 28.0015 28.3291 29.6685 28.6563 050697 21.1566 18.2338 24.1116 21.0055 050698 * * 24.9559 24.9559 050699 25.7843 17.5296 23.4611 21.9391 050701 22.6959 24.3055 26.4901 24.3588 050704 22.8716 22.7618 25.6565 23.8031 050707 26.2732 27.8958 28.2637 27.6356 050708 22.7821 24.8647 24.5606 24.0910 050709 21.9598 19.4977 21.8770 21.0737 050710 26.9060 27.5828 30.5918 28.4895 050713 17.7259 16.8538 18.2822 17.6031 050714 28.9314 30.1925 30.3290 29.7818 050717 25.9534 28.7973 31.5021 28.6924 050718 17.6062 18.0940 22.5989 19.6750 050719 25.5508 23.0833 * 23.8495 050720 * 25.8677 * 25.8677 050723 * * 32.0291 32.0291 060001 21.3659 21.1819 20.6781 21.0801 060003 19.8023 20.4682 21.9043 20.7102 060004 22.8750 21.4496 22.9265 22.4496 060006 19.3651 20.0213 21.0003 20.1579 060007 17.4682 18.2977 19.3071 18.3452 060008 18.0333 18.4590 18.7097 18.3997 060009 21.4312 22.7164 23.9272 22.7121 060010 24.0872 23.6827 24.7332 24.1778 060011 23.4366 22.3458 22.2058 22.6927 060012 20.1442 19.4932 21.2980 20.3114 060013 22.7346 19.1256 23.5248 21.7755 060014 24.2459 24.3210 25.7689 24.7914 060015 20.9773 23.2469 23.6015 22.5801 060016 16.4707 20.2408 20.2361 18.8056 060018 20.3183 21.5083 21.8478 21.1863 060020 18.3099 18.8985 19.4966 18.9093 060022 21.0558 21.0830 22.6052 21.6192 060023 19.2373 21.5475 22.6480 21.1568 060024 21.9955 22.9185 23.5154 22.8418 060027 20.9846 22.0713 21.7571 21.6190 060028 23.2065 23.1792 24.2985 23.5665 060029 20.8585 18.2938 19.8498 19.6763 060030 20.5002 20.3452 18.0264 19.6163 060031 21.1649 22.5067 23.3995 22.3074 060032 23.4162 22.8123 24.2216 23.4772 060033 15.9085 16.0760 17.8514 16.5805 060034 22.4791 23.2816 23.4859 23.0898 060036 15.0698 18.5988 18.6521 17.3368 060037 15.5611 15.4513 15.7495 15.5902 060038 14.0791 14.3249 16.6525 15.2260 060041 14.8934 19.1263 19.0282 17.3424 060042 19.1892 20.8597 19.3967 19.6496 060043 13.6717 13.4443 15.4073 14.1048 060044 19.7039 20.8673 21.3102 20.6215 060046 19.4567 22.2699 22.6819 21.4974 060047 15.8770 17.1534 17.9173 16.9143 060049 21.7797 23.0613 25.9592 23.6523 060050 18.2238 19.0832 * 18.6522 060052 13.4210 14.8729 16.0543 14.6462 060053 15.9806 18.0232 19.4746 17.7396 060054 22.8985 20.4160 19.7753 20.9273 060056 18.2831 18.1263 21.9586 19.5606 060057 26.4046 25.4185 24.6599 25.4808 060058 15.4856 13.8539 16.4504 15.2822 060060 15.6469 15.6018 19.4418 16.7387 060062 17.2991 16.8640 17.1032 17.1033 060064 21.2207 22.7797 * 22.0259 060065 21.6305 24.5572 23.7809 23.3223 060066 16.3485 17.2537 17.5556 16.9855 060070 17.3184 18.8960 19.2220 18.4993 060071 17.5987 17.4068 17.6452 17.5489 060073 15.7860 17.0846 18.4971 17.0767 060075 24.1550 23.8724 25.0552 24.3665 060076 24.8732 20.3265 22.9203 22.6621 060085 13.6277 14.3409 10.9724 12.8943 060088 25.2786 13.7174 18.1570 17.7609 060090 22.2974 16.3760 16.5321 18.2600 060096 21.9623 20.8937 21.9951 21.6204 060100 23.5986 23.9305 24.1341 23.8807 060103 24.8151 23.5083 24.4962 24.2301 060104 22.2295 21.1820 24.4248 22.5603 060107 14.2698 21.9221 * 16.3130 060108 * * 19.1327 19.1327 060109 * * 27.3180 27.3180 070001 26.0878 26.3596 27.7441 26.7515 070002 26.2801 26.1768 26.6881 26.3761 070003 25.6949 27.5200 28.1721 27.1059 070004 22.4871 24.2567 25.4310 24.0188 070005 26.6483 26.9151 27.6733 27.0706 070006 27.5674 28.6413 33.6291 30.1330 070007 26.9505 26.3313 28.0875 27.1381 070008 23.0227 24.2971 25.1362 24.0979 070009 24.6201 24.1871 24.9408 24.5838 070010 26.2354 29.2194 28.3168 27.8716 070011 23.3638 23.0883 24.8206 23.7802 070012 23.0321 28.8067 * 25.4962 070015 23.8240 28.1204 29.2693 27.0233 070016 24.9148 24.4633 28.4833 25.9349 070017 26.2923 26.0424 27.5515 26.5441 070018 28.0689 30.6864 32.6301 30.4394 070019 25.7283 24.9249 26.2348 25.6326 070020 23.9987 25.9964 26.6203 25.5573 070021 25.2978 26.3043 29.4596 26.9916 070022 26.5691 26.9111 26.9907 26.8202 070024 25.2983 24.8948 26.2173 25.4902 070025 25.1315 25.4345 27.3592 25.9673 070027 23.6412 26.8450 25.8163 25.4005 070028 24.6788 25.7492 26.7286 25.7052 070029 22.0080 23.9682 23.8427 23.2454 070030 28.9117 22.1578 * 25.8929 070031 23.4419 24.1198 25.6347 24.3735 070033 30.4214 31.4736 32.8256 31.5451 070034 28.9200 29.4916 30.0480 29.4611 070035 23.0869 24.1423 24.1838 23.7950 070036 28.8400 29.9470 31.2961 29.9831 070038 * * 26.3126 26.3126 070039 22.9032 22.3356 * 22.7640 080001 25.4836 24.8833 26.8887 25.7287 080002 19.6011 20.1965 20.9385 20.3062 080003 22.1856 23.1275 24.8200 23.2380 080004 21.9391 22.9706 21.7344 22.1849 080006 20.0792 22.6671 20.8203 21.1329 080007 19.6213 21.3746 21.1211 20.7477 090001 21.7526 21.5751 23.0365 22.1027 090002 19.4191 21.5726 20.6550 20.5048 090003 22.1090 23.1268 26.6720 23.7360 090004 24.3367 25.5054 25.9717 25.2072 090005 23.8620 26.3074 26.6217 25.5545 090006 20.8675 22.0957 22.6250 21.8452 090007 22.1973 29.2840 26.7809 26.4132 090008 20.2166 25.2708 * 22.7566 090010 24.1287 23.6616 25.9373 24.5182 090011 27.4781 26.6349 28.0948 27.4100 100001 19.5796 20.2157 21.9071 20.5375 100002 20.7136 21.0222 21.5772 21.1199 100004 14.6283 15.4149 16.1638 15.4361 100006 20.1133 21.2293 20.9190 20.7854 100007 21.7242 22.1590 22.5317 22.1527 100008 20.4980 20.8381 21.6416 21.0118 100009 22.6419 22.1741 21.3298 22.0295 100010 21.9078 23.0637 23.9582 22.9492 100012 19.6177 20.4659 21.7527 20.6367 100014 19.8023 19.5770 21.7358 20.3525 100015 18.4779 18.0654 18.9383 18.4860 100017 19.0608 19.8655 20.0861 19.6893 100018 21.0332 21.6388 22.5429 21.7594 100019 22.6152 23.5462 28.2362 24.8745 100020 21.3848 20.7816 21.7421 21.3134 100022 26.4094 26.5695 27.4235 26.7855 100023 19.9739 19.1787 20.2034 19.7906 100024 21.8791 22.1332 22.9872 22.3458 100025 18.7774 19.4529 20.1360 19.4381 100026 20.5641 20.9461 21.3742 20.9788 100027 19.1481 14.7916 20.5889 17.6926 100028 19.3757 19.3371 19.7475 19.4900 100029 20.8745 20.8950 22.2553 21.3244 100030 22.8204 20.5952 20.4996 21.1231 100032 19.8127 19.7451 20.6543 20.0503 100034 17.8743 19.5282 20.1214 19.1092 100035 20.1540 23.8117 21.2830 21.7761 100038 23.3578 24.5864 24.9548 24.3305 100039 21.5297 21.7861 23.3111 22.2259 100040 19.0449 18.6321 18.7546 18.8065 100043 18.7993 18.8206 20.7414 19.4322 100044 21.4764 22.7236 22.4824 22.2380 100045 20.9216 21.0228 22.8096 21.6136 100046 21.6207 21.3028 23.8909 22.2917 100047 20.0114 20.6068 21.4971 20.7134 100048 15.0584 15.7790 17.3663 16.1388 100049 18.8535 19.1025 20.9490 19.6376 100050 17.2377 17.9039 17.8960 17.6845 100051 23.1273 17.9453 19.3264 19.7334 100052 17.9537 18.1780 17.9957 18.0416 100053 20.1724 19.6800 21.6634 20.4905 100054 23.5491 21.1518 20.8078 21.8397 100055 18.0547 18.8760 19.1324 18.6804 100056 25.7863 21.8506 23.1737 23.6729 100057 19.9712 19.5319 22.3406 20.5479 100060 23.2561 23.5997 * 23.4313 100061 22.1133 22.9176 24.4704 23.1202 100062 19.4370 21.4424 21.9054 21.0072 100063 19.2629 18.4642 19.0908 18.9473 100067 18.0877 18.4851 18.5405 18.3328 100068 19.9305 19.8308 19.9648 19.9094 100069 16.8271 17.3666 18.5789 17.6344 100070 18.7408 20.0381 20.9592 19.7991 100071 17.5451 17.7234 20.7461 18.6293 100072 21.0225 20.5968 22.0317 21.2423 100073 21.1898 22.2812 22.2425 21.9197 100075 18.3688 19.4480 20.4664 19.4104 100076 17.8733 17.8612 18.4815 18.0825 100077 22.3438 19.0640 16.8641 17.3061 100078 18.4499 19.2891 14.4191 17.3311 100080 22.1966 22.7153 21.3374 22.0479 100081 14.8313 15.4253 16.5149 15.5681 100082 18.8998 * * 18.8998 100084 22.3674 22.7009 24.5682 23.2945 100085 22.1231 * * 22.1231 100086 21.6997 23.3718 24.3067 23.1462 100087 23.6090 23.6562 21.2831 22.8681 100088 20.3693 20.5566 20.0598 20.3349 100090 19.1479 19.7695 21.0431 20.0438 100092 17.9216 20.1760 20.5186 19.5588 100093 16.5128 16.8422 18.7153 17.3704 100098 19.2427 20.8315 21.1723 20.4066 100099 15.7823 15.7591 16.5624 16.0147 100102 18.9701 19.7673 19.0195 19.2464 100103 17.2364 18.7844 20.6957 18.8771 100105 21.6604 21.8268 22.7793 22.1049 100106 17.2527 17.4958 21.4342 18.9189 100107 20.1281 20.0719 21.7553 20.6632 100108 19.9593 20.1125 18.4127 19.5107 100109 20.8440 20.8370 20.5973 20.7560 100110 20.8995 20.1853 22.2354 21.1342 100112 25.2570 15.2128 16.2109 17.7240 100113 23.2020 21.3489 22.7264 22.3351 100114 21.6262 22.8178 22.5326 22.3196 100117 20.7624 20.6962 21.3007 20.9256 100118 22.8702 20.7323 21.4486 21.6456 100121 * 18.5842 18.8073 18.6952 100122 19.8783 19.2643 24.9765 21.2147 100124 17.0713 20.4022 * 18.7024 100125 18.9535 19.6097 20.3232 19.6414 100126 19.5413 19.3103 21.4349 20.0428 100127 19.9860 19.2122 20.4778 19.8925 100128 20.1536 22.8826 23.5835 22.0798 100129 19.1936 * * 19.1936 100130 18.6751 20.0947 21.0023 19.9341 100131 23.4373 23.1622 24.1745 23.6099 100132 18.1167 18.7863 19.0747 18.6426 100134 15.1764 15.9733 16.9302 15.9832 100135 18.8253 19.1865 19.7675 19.2758 100137 18.6955 19.5562 20.9015 19.8112 100138 17.1373 14.9539 14.9760 15.5324 100139 15.6514 15.2532 15.7378 15.5541 100140 17.1389 19.0584 20.1703 18.8122 100142 19.6815 18.4113 17.7250 18.5714 100144 12.2877 * * 12.2877 100146 18.1267 21.3359 21.9435 20.4800 100147 14.6616 15.2348 17.1566 15.6835 100150 21.2807 21.5057 25.4269 22.5635 100151 21.6087 23.8489 26.6143 24.0945 100154 20.0015 20.4068 21.6715 20.7094 100156 19.4980 18.4779 20.0348 19.3485 100157 22.6744 22.6195 24.2188 23.1792 100159 10.2793 10.7818 15.0633 11.7916 100160 20.5581 23.3121 22.6942 22.2030 100161 22.2994 22.3053 22.6534 22.4189 100162 20.1411 20.3110 20.4188 20.2955 100165 19.0388 22.6622 * 21.0526 100166 20.0250 21.2309 22.2379 21.1128 100167 23.4075 23.2969 25.6873 24.1145 100168 20.1994 20.3167 23.0121 21.2144 100169 20.9506 20.3017 21.6397 20.9720 100170 18.5088 19.3005 21.2469 19.5894 100172 14.3446 14.8826 15.7827 14.9994 100173 18.5662 17.1337 18.3828 18.0289 100174 26.1826 21.9807 * 24.0224 100175 18.1692 20.5442 21.2532 20.0936 100176 22.8604 24.3089 24.6595 23.9677 100177 24.4296 24.4284 26.4489 25.1965 100179 22.3015 23.0849 23.9633 23.1372 100180 20.2130 21.5388 22.6895 21.4521 100181 23.0800 18.9510 17.9048 19.7877 100183 24.6121 23.0654 22.2063 23.2470 100187 20.2533 20.8535 21.4988 20.8818 100189 21.3147 26.5962 27.1295 24.9742 100191 19.9879 21.0647 21.7024 20.8988 100199 21.7193 * * 21.7193 100200 22.4579 23.8729 24.8878 23.7939 100204 20.8995 20.2193 20.8626 20.6601 100206 19.5710 20.1171 20.3436 20.0192 100208 21.2117 20.7029 20.4678 20.8077 100209 22.4577 23.3903 22.5915 22.8006 100210 21.3575 21.8545 23.0431 22.0260 100211 20.6427 20.7516 21.6367 21.0021 100212 21.1187 21.1263 * 21.1225 100213 20.6558 21.1818 21.9371 21.2709 100217 20.5909 22.7335 22.7116 21.9737 100220 21.2796 21.8246 22.3283 21.7592 100221 17.3965 21.2321 23.2263 20.3743 100223 20.6302 20.2233 21.3859 20.7713 100224 20.0251 21.8628 21.9515 21.2530 100225 20.6802 21.5059 22.4619 21.5424 100226 20.6858 21.8808 22.4084 21.7019 100228 21.3168 20.8810 23.4697 21.8662 100229 19.6908 18.2350 19.7259 19.2271 100230 20.5051 22.5650 23.4169 22.2637 100231 17.9226 18.7526 21.1128 19.1318 100232 19.3491 19.8002 19.9125 19.6887 100234 20.9104 21.6360 23.4761 21.9136 100235 17.1622 * * 17.1622 100236 20.3766 20.6942 21.5316 20.8545 100237 22.0865 23.2408 23.2712 22.8481 100238 19.6367 20.8252 22.8488 21.0709 100239 21.3193 19.4481 23.0048 21.1692 100240 20.4340 21.0606 21.3495 20.9700 100241 14.7224 17.1063 14.1059 15.3322 100242 17.9260 18.6938 18.9062 18.5149 100243 21.2644 20.8041 22.4644 21.5426 100244 18.6227 20.5352 21.2521 20.2154 100246 19.6376 21.9247 23.5171 21.5681 100248 20.7007 21.2988 21.8086 21.2951 100249 19.2808 18.1397 18.4932 18.6366 100252 17.7778 19.8079 22.0976 19.8858 100253 21.3232 22.4778 22.6517 22.1811 100254 19.6598 19.5523 19.5050 19.5721 100255 25.2119 21.0284 20.7228 22.1421 100256 20.9356 21.2786 22.0528 21.4173 100258 21.3501 20.0300 22.0790 21.1494 100259 20.3815 21.1160 21.4991 21.0228 100260 21.0506 24.9183 21.1292 22.2409 100262 20.0433 21.0927 22.7137 21.2022 100264 19.1556 19.9491 21.5104 20.1857 100265 18.8301 18.2291 20.2365 19.1431 100266 18.2993 19.3623 20.2821 19.3534 100267 20.1141 21.7430 21.7446 21.2105 100268 23.9249 24.0538 23.6367 23.8643 100269 21.6724 22.5114 26.0271 23.4143 100270 15.1462 16.7148 20.8217 17.5380 100271 20.4824 20.8695 21.9823 21.1576 100275 20.9188 21.4904 23.2088 21.8580 100276 22.3646 24.1022 24.8251 23.8061 100277 16.6255 19.7241 14.9157 16.6327 100279 22.9095 22.5879 21.1094 22.2253 100280 17.3676 18.1972 19.0157 18.2076 100281 22.4392 23.0142 23.4729 23.0255 100282 19.1978 18.4884 20.9256 19.5516 100284 * 18.9448 18.4204 18.6867 110001 19.1971 20.1150 22.3072 20.5112 110002 17.1406 19.5158 20.2149 18.9927 110003 18.1168 17.1450 18.2792 17.8514 110004 19.5591 19.7733 20.6096 19.9776 110005 17.7348 22.4568 21.8105 20.9768 110006 20.7820 21.0601 21.9525 21.2769 110007 21.9505 25.2523 26.3143 24.5085 110008 22.0081 18.5265 19.9606 20.1468 110009 16.3069 17.4306 16.6452 16.8052 110010 23.3213 23.9104 25.1930 24.1454 110011 18.6144 18.9823 20.4028 19.3209 110013 16.2811 18.9160 16.7833 17.3444 110014 16.0658 18.1787 18.4463 17.4976 110015 21.2146 20.9926 21.2600 21.1563 110016 22.5321 14.2398 14.7571 16.4041 110017 13.1960 22.2537 21.2970 19.1377 110018 19.6064 22.1480 22.3933 21.3958 110020 18.3147 19.4617 20.9687 19.5535 110023 21.1994 22.0546 * 21.6186 110024 20.7297 20.7345 21.3945 20.9529 110025 19.5749 20.4232 20.2493 20.0573 110026 17.2977 16.2484 16.6320 16.7325 110027 16.0642 14.7081 19.8976 16.6619 110028 20.1547 29.1670 28.1695 25.3235 110029 20.2906 21.2150 21.3492 20.9560 110030 18.8105 19.6412 20.4656 19.6568 110031 19.9482 20.0553 20.9219 20.3082 110032 15.7349 18.2014 19.2685 17.6324 110033 22.1879 25.6335 23.1939 23.6010 110034 19.6055 19.5554 23.0724 20.6505 110035 19.3795 22.7950 21.8646 21.4160 110036 22.2498 24.9234 25.1127 24.0254 110038 17.7060 17.7396 18.4508 17.9715 110039 20.6011 20.4998 18.9817 19.9578 110040 17.0743 16.8083 17.7798 17.2164 110041 18.8035 20.2755 20.1398 19.7378 110042 24.0153 25.2331 25.0535 24.7832 110043 20.1016 20.6150 21.2714 20.6367 110044 16.3624 17.2087 17.5905 17.0642 110045 20.2498 21.3049 20.6934 20.7294 110046 19.7377 21.4905 22.8820 21.3991 110048 16.3148 15.6113 18.8751 16.8775 110049 16.1817 16.8639 17.1396 16.7155 110050 20.7619 19.2291 18.9048 19.6044 110051 17.0070 17.2292 17.2050 17.1503 110054 * 20.0549 20.5698 20.3256 110056 15.6202 17.7959 16.0362 16.5039 110059 16.6678 16.7990 17.8076 17.0958 110061 15.0367 16.3557 17.4601 16.2796 110062 18.8019 17.0053 17.9421 17.8940 110063 16.9612 18.5071 18.0256 17.8146 110064 18.9515 19.1203 18.8578 18.9772 110065 15.6771 16.3546 16.9829 16.3529 110066 21.0207 22.4189 23.4554 22.2503 110069 19.3109 20.9575 21.1513 20.4832 110070 21.0227 17.3438 19.6361 19.3058 110071 14.5984 18.8321 21.5042 17.7757 110072 12.7877 12.7625 13.6626 13.0734 110073 15.4261 16.4658 17.9372 16.5696 110074 21.3945 22.3769 24.4924 22.7969 110075 18.5199 20.1757 20.1604 19.6679 110076 21.2867 21.9798 23.6127 22.2999 110078 22.3718 24.0893 25.9119 24.1213 110079 21.0593 22.1070 22.3641 21.8325 110080 18.4768 19.1839 19.4635 19.0419 110082 23.8768 24.3140 22.7015 23.5986 110083 23.1219 23.1463 22.2609 22.8147 110086 18.2815 16.6374 19.0164 17.9653 110087 21.7773 22.7069 24.0994 22.9041 110089 18.5587 19.3855 19.0453 18.9917 110091 19.5114 21.5328 23.7110 21.5509 110092 17.3479 16.9725 15.9178 16.7054 110093 * 16.9827 * 16.9827 110094 14.5641 16.9503 16.8890 16.0918 110095 16.4670 17.1195 17.4302 17.0118 110096 16.8541 17.4157 18.0418 17.4444 110097 15.5811 17.4558 17.8454 16.7969 110098 16.3532 16.0597 16.7800 16.4135 110100 18.6978 19.0764 18.6822 18.8175 110101 10.8187 18.8491 13.8787 13.5799 110103 13.6842 21.1837 21.5683 17.7316 110104 15.7781 15.9431 16.6322 16.1150 110105 16.8909 16.7775 18.1306 17.2936 110107 19.3609 19.3897 21.0863 19.9482 110108 19.7938 25.2161 20.1140 21.3451 110109 15.9359 16.4031 16.5977 16.3157 110111 18.5108 18.3951 18.4274 18.4433 110112 19.0619 19.8986 18.9574 19.2821 110113 16.8179 15.9532 16.0942 16.2556 110114 14.6888 16.4812 16.8297 16.0087 110115 43.9427 22.5049 26.5759 28.7027 110118 20.5368 19.7509 17.5714 19.1118 110120 15.2589 17.7452 18.4738 17.1958 110121 16.2711 19.3643 18.8744 18.1723 110122 21.1385 21.1469 20.4922 20.9166 110124 17.5732 18.3366 19.4093 18.3953 110125 19.1311 18.0090 19.4207 18.8387 110127 14.6143 20.3765 16.1107 17.0392 110128 18.1845 18.0835 19.5450 18.6049 110129 18.9388 19.0001 20.8935 19.6183 110130 16.0580 14.6011 16.6915 15.7591 110132 16.0419 16.3943 17.1820 16.5355 110134 12.5723 19.8639 19.0305 17.6901 110135 17.4380 17.3504 15.6668 16.7018 110136 18.0639 16.9629 20.7827 18.4333 110140 17.8870 17.7915 * 17.8447 110141 13.2501 14.4935 13.2710 13.6692 110142 14.6144 13.9525 14.1203 14.2070 110143 20.1603 22.5926 22.4254 21.8082 110144 16.8685 17.5112 17.5678 17.2876 110146 16.1316 17.1835 17.5940 17.0117 110149 17.7535 32.1975 25.2525 24.0956 110150 20.2644 21.2909 22.4899 21.3508 110152 15.3996 15.1324 16.3837 15.6496 110153 19.2744 20.5068 20.6972 20.1497 110154 14.9636 17.3761 16.5286 16.2471 110155 15.5306 16.5146 16.4756 16.1555 110156 14.7477 16.3876 16.0759 15.7007 110161 21.7153 22.2861 24.5776 22.9656 110163 20.4202 18.6637 20.0673 19.6918 110164 20.2074 21.2160 22.5865 21.3587 110165 21.2577 20.8030 22.5604 21.5831 110166 20.5882 20.5049 22.3657 21.1057 110168 20.6646 21.8058 22.2537 21.6267 110169 20.6385 22.6648 23.3750 21.9474 110171 23.7893 25.5296 24.5313 24.5760 110172 23.3730 23.6803 24.7005 23.9332 110174 13.7339 14.6199 * 14.1346 110177 20.7187 21.2796 22.7831 21.6138 110178 18.8306 * * 18.8306 110179 22.7841 22.0767 24.3673 23.0370 110181 14.0941 12.9798 13.9591 13.6986 110183 23.3826 22.5148 24.2899 23.3905 110184 22.1970 22.1920 22.2761 22.2235 110185 16.7246 17.7925 17.3330 17.2705 110186 17.4287 18.3178 19.7172 18.4775 110187 20.1154 19.8419 22.8248 20.9454 110188 24.8376 23.7032 21.9945 23.3633 110189 22.2715 20.8786 19.3335 20.7205 110190 18.5728 18.3649 20.7292 19.1518 110191 20.2033 21.4033 21.3404 21.0040 110192 21.4951 21.0486 22.9684 21.8761 110193 20.6380 20.7867 22.1392 21.1880 110194 15.1480 14.8115 15.8129 15.2645 110195 13.9135 12.7261 10.9444 12.3540 110198 24.1999 24.8646 24.8275 24.6410 110200 18.1862 17.7744 17.9631 17.9701 110201 20.4699 20.9497 21.9313 21.1039 110203 26.8148 22.7453 24.2062 24.5686 110204 19.7317 30.7342 35.3699 24.8432 110205 21.1435 21.3617 20.1405 20.8862 110207 12.9727 14.7154 14.6045 14.1130 110208 15.1742 15.6161 15.0350 15.2676 110209 17.9190 18.6404 20.0629 18.7585 110211 20.9372 26.9151 20.1024 22.3126 110212 11.8545 14.3790 15.8420 13.8932 110213 14.3651 * * 14.3651 110215 20.1928 18.1539 21.0263 19.7770 110216 * 27.1878 * 27.1878 120001 27.9213 29.0427 29.4126 28.7754 120002 25.0744 25.2021 23.5667 24.5781 120003 25.9059 23.9115 24.6238 24.8142 120004 23.9208 24.8632 26.1398 24.8838 120005 23.3975 24.1662 22.3213 23.2601 120006 25.0895 25.8943 26.0904 25.6667 120007 22.7200 22.8772 22.7179 22.7718 120009 17.4693 16.4485 16.7630 16.8820 120010 25.1480 24.1923 24.9089 24.7414 120011 35.0582 37.2759 35.2051 35.8314 120012 23.1144 21.8507 22.0371 22.3824 120014 22.8866 24.1208 25.3557 24.0761 120015 32.9906 42.6465 * 37.0469 120016 27.9127 45.1899 43.5083 34.2774 120018 24.5031 31.1879 * 26.7466 120019 22.9341 25.5659 23.8535 24.0876 120021 23.4508 23.1839 * 23.3291 120022 21.7868 19.2614 17.3744 19.4456 120024 29.4808 32.2514 * 30.1443 120025 20.1065 50.6376 40.1332 25.3493 120026 26.0787 25.1314 25.7023 25.6323 120027 24.7255 24.4535 23.1434 24.0841 120028 27.5023 27.0897 27.5365 27.3898 130001 18.8471 17.6306 19.6328 18.7161 130002 16.6620 16.9867 18.5746 17.4270 130003 21.7313 22.3430 23.0994 22.4005 130005 20.7169 21.2386 22.6364 21.5043 130006 19.3392 20.4614 21.4640 20.4603 130007 20.8338 21.8107 22.0894 21.5806 130008 12.5506 13.6018 19.3392 14.7112 130009 19.1837 15.9701 16.8563 17.2592 130010 17.6795 17.5119 17.7826 17.6635 130011 20.5031 20.1147 22.1125 20.9248 130012 22.9813 24.9976 24.2451 24.1243 130013 17.4038 15.1129 22.6624 18.2887 130014 18.9769 19.2107 19.7560 19.3379 130015 15.7233 18.5913 16.4136 16.7965 130016 17.3942 19.0516 20.1220 18.8309 130017 17.1710 19.6875 19.9511 18.7336 130018 19.7368 19.8425 20.1934 19.9339 130019 18.6648 19.1711 19.5147 19.0953 130021 12.8588 15.6155 14.3089 14.2489 130022 16.5270 18.9127 19.7814 18.3410 130024 19.3634 19.0703 19.9934 19.4905 130025 17.5213 16.4627 17.5989 17.2009 130026 21.5934 21.8106 23.2093 22.2042 130027 21.4279 20.5344 19.0911 20.3739 130028 19.1093 20.9674 18.1205 19.2837 130029 18.4263 18.7694 22.9243 19.6491 130030 17.8440 17.5759 18.5827 17.9732 130031 16.2397 16.7766 20.4146 17.4242 130034 16.9873 18.9483 20.5802 18.9102 130035 19.3478 20.7770 16.9671 19.1314 130036 13.7933 13.6362 15.1590 14.2304 130037 18.8071 18.6856 19.2108 18.9127 130043 16.5102 16.7904 17.6920 16.9853 130044 17.8160 13.4513 16.7797 15.8094 130045 16.0990 19.0208 17.5152 17.4280 130048 16.0899 16.7900 * 16.4201 130049 20.3129 22.4440 22.0520 21.6192 130054 17.2729 17.7085 16.4675 17.1120 130056 14.6862 20.9476 28.8008 19.9051 130060 21.8662 22.7399 23.2512 22.6187 130061 15.4006 14.7394 * 15.1267 130062 16.5672 19.8157 19.8264 18.8380 130063 15.9441 18.8024 18.4797 18.1425 140001 16.3372 17.7990 17.7421 17.2408 140002 19.0248 19.9284 20.9959 19.9709 140003 21.2886 17.8595 18.0163 18.9220 140004 15.7042 17.4574 19.0486 17.4249 140005 11.6127 12.3002 12.4144 12.1009 140007 22.9799 23.8585 25.0105 23.9811 140008 21.6548 22.1111 24.2779 22.6707 140010 31.8207 28.5635 26.6836 28.8200 140011 17.8676 18.6164 18.4052 18.3022 140012 23.0653 21.4374 22.5885 22.3529 140013 18.3060 19.6722 20.3147 19.4284 140014 22.4737 21.4042 22.2944 22.0537 140015 16.6735 17.6805 20.3540 18.1726 140016 13.1278 14.4938 15.4454 14.3266 140018 22.3070 22.4132 23.4595 22.7307 140019 16.6548 16.4254 16.1180 16.3909 140024 16.8271 15.3782 16.1032 16.1040 140025 16.9462 18.5135 21.7775 18.9319 140026 16.6612 18.3220 19.7839 18.2263 140027 18.7553 19.2149 20.5980 19.5140 140029 22.8322 26.0833 28.0683 25.6669 140030 21.9475 23.1760 25.2828 23.5549 140031 19.5731 17.6067 16.9650 17.9987 140032 18.1058 19.0383 19.8033 18.9961 140033 24.1722 25.1639 22.8705 24.0049 140034 19.5278 19.8792 19.7711 19.7256 140035 15.2649 15.5040 17.4514 16.0631 140036 18.5771 19.1076 21.2366 19.6677 140037 13.0764 14.1083 14.3082 13.8255 140038 18.3035 18.4948 19.8197 18.8624 140040 19.9267 16.7450 18.0342 18.2044 140041 17.6582 18.5952 18.8042 18.3411 140042 15.4095 15.8892 16.1157 15.8051 140043 19.4683 20.1176 21.7356 20.4389 140045 15.5807 17.7799 17.4261 16.8835 140046 18.9763 18.6371 20.0859 19.2505 140047 17.1539 13.3610 16.6672 15.5612 140048 24.0913 23.9545 22.5870 23.5490 140049 28.4958 26.9483 27.0250 27.5281 140051 23.8264 24.0796 24.6964 24.2137 140052 19.6409 17.9571 21.0450 19.4727 140053 19.1892 19.9620 20.5244 19.8722 140054 22.1921 23.1576 23.9416 23.0858 140055 16.3404 14.3603 15.8756 15.4931 140058 17.4927 18.6861 19.1199 18.4367 140059 15.0195 * 18.2593 16.6820 140061 17.3012 18.2039 18.4264 17.9767 140062 28.0877 28.5304 28.6390 28.4255 140063 25.3641 29.1453 25.8203 26.5945 140064 19.1023 18.9379 19.6954 19.2477 140065 24.1128 25.3336 25.5939 25.0012 140066 17.3902 13.6491 15.4818 15.3710 140067 19.3267 19.5292 20.7511 19.8509 140068 19.9691 21.6188 21.6089 21.0342 140069 16.7544 17.3879 17.7785 17.3221 140070 22.9678 22.7153 25.2646 23.5870 140074 19.3504 21.6052 22.2604 20.9581 140075 21.6313 21.6434 21.0968 21.4950 140077 17.5305 17.3647 17.3236 17.4081 140079 23.3020 23.6928 22.7046 23.2149 140080 21.0739 22.1968 22.0682 21.7613 140081 16.2247 16.9808 18.1746 17.0842 140082 23.8960 29.7262 26.5960 26.4591 140083 19.3145 21.0330 18.0664 19.5127 140084 20.9709 22.3467 22.0706 21.7924 140086 18.3803 19.1613 19.1815 18.9175 140087 16.1009 17.1147 21.4593 18.0959 140088 25.2369 25.4176 26.5258 25.7146 140089 17.6366 18.3157 19.3230 18.4019 140090 26.4325 26.9364 28.0530 26.9854 140091 20.9018 21.9322 22.9565 21.9272 140093 18.2899 20.1528 20.7564 19.6330 140094 21.4709 21.9383 22.8892 22.0901 140095 24.0549 24.2859 23.8834 24.0755 140097 17.5081 21.1719 21.8418 20.1374 140100 21.3581 23.1399 23.8226 22.7460 140101 21.5473 21.4211 23.1418 22.0459 140102 17.1500 17.5729 18.6328 17.7567 140103 19.2783 18.1303 16.2009 17.8612 140105 22.6573 22.8944 23.8258 23.1227 140107 13.7533 11.8383 11.5827 12.2495 140108 25.4742 26.9971 27.9140 26.8421 140109 15.7465 14.5498 15.9178 15.3965 140110 19.1822 19.2888 20.9631 19.8004 140112 17.6856 17.6974 18.1119 17.8311 140113 19.0592 19.5584 * 19.3069 140114 21.1639 21.0976 22.9844 21.7634 140115 21.1926 21.0433 20.7660 21.0012 140116 23.1177 23.8993 27.8888 25.1841 140117 21.5671 21.4876 22.0889 21.7249 140118 23.5952 24.3260 25.3249 24.4123 140119 29.1419 27.9145 30.6468 29.2072 140120 18.0743 17.9716 18.5685 18.2090 140121 16.0397 16.6993 16.2607 16.3273 140122 24.6470 26.1270 26.7344 25.7959 140124 27.1906 27.9813 30.2658 28.3904 140125 17.6759 16.9516 17.8190 17.4826 140127 19.8973 20.0489 20.8397 20.2623 140128 19.4955 23.1327 23.5481 22.1101 140129 18.2639 20.2868 21.6252 19.9926 140130 22.2285 23.4298 26.0464 23.9518 140132 23.5475 23.3054 23.7046 23.5171 140133 21.4090 21.4166 20.1740 21.0117 140135 17.8100 17.3985 18.2479 17.8298 140137 16.8969 18.6330 19.2594 18.2334 140138 16.7420 17.1968 14.5771 16.0861 140139 14.0619 11.0397 * 12.4249 140140 17.8243 17.6845 18.8185 18.1076 140141 17.5204 19.1097 20.2606 18.9480 140143 19.1862 19.0810 19.9885 19.4222 140144 21.3245 22.2864 24.8854 22.7447 140145 17.5471 18.1788 19.4509 18.3977 140146 21.9573 19.9704 19.4272 20.3714 140147 16.1336 18.8049 17.1013 17.2344 140148 18.6598 18.7730 19.7630 19.0696 140150 27.3378 24.7976 28.1723 26.6696 140151 21.3896 20.0310 20.8820 20.7518 140152 24.6333 25.6011 27.9615 26.0086 140155 19.9738 20.2778 23.9957 21.3787 140158 22.7639 22.7988 23.7428 23.1140 140160 17.7691 17.7921 19.8825 18.5234 140161 20.0948 20.3799 21.2045 20.5610 140162 19.6464 20.3452 21.6901 20.5431 140164 18.7806 18.6589 19.8246 19.1100 140165 14.9156 14.7223 16.3700 15.3419 140166 17.5496 18.3833 18.9513 18.2817 140167 17.1479 17.6525 18.8532 17.9029 140168 16.6770 17.7453 18.2896 17.5820 140170 16.1621 16.4107 17.6901 16.7412 140171 14.1637 15.0237 15.2617 14.8002 140172 23.8431 23.6262 26.2314 24.4761 140173 15.1487 16.3924 16.0030 15.8459 140174 20.5339 35.9320 21.8272 23.9333 140176 23.2866 24.5338 26.2821 24.7364 140177 18.2648 15.0827 20.3142 17.5964 140179 21.1948 21.9859 22.6795 21.9485 140180 22.4548 22.7996 22.7508 22.6646 140181 20.8709 21.9864 22.6089 21.8164 140182 22.0170 28.9515 25.1352 24.9085 140184 17.8155 17.2401 17.9169 17.6582 140185 17.6514 18.2867 18.8573 18.2635 140186 22.7890 23.5034 20.7389 22.2767 140187 17.9201 18.3331 19.4049 18.5535 140188 15.2479 16.1907 * 15.6443 140189 21.0616 20.6627 21.1515 20.9599 140190 16.3366 17.5263 16.6673 16.8245 140191 25.8835 25.2628 27.4166 26.1852 140193 15.8022 17.4057 18.5651 17.2695 140197 18.6394 19.3774 19.9406 19.3426 140199 18.3507 18.0450 18.5409 18.3150 140200 21.5220 21.7680 22.5226 21.9573 140202 22.1939 23.7955 25.2777 23.7942 140203 19.9194 21.0848 24.8870 21.9324 140205 17.4751 20.0784 * 18.5139 140206 21.3295 22.5109 23.0603 22.2974 140207 21.9779 22.3905 25.4539 23.1447 140208 25.9900 26.2527 28.0890 26.7814 140209 18.1206 20.1557 20.2433 19.4720 140210 15.6899 14.8248 15.5345 15.3479 140211 21.8891 22.6265 22.8852 22.4887 140213 27.0645 24.9892 25.6839 25.9086 140215 15.9949 15.2893 18.5502 16.5949 140217 24.8229 25.7329 25.6584 25.3935 140218 14.9459 14.9851 17.4171 15.7345 140220 17.6370 17.8450 19.3915 18.3036 140223 24.9249 24.9017 26.2168 25.3383 140224 25.8668 32.8292 24.7882 27.5872 140228 19.6988 20.1688 21.2764 20.3895 140230 18.0918 18.2983 * 18.1984 140231 23.9176 24.5019 26.0439 24.9346 140233 19.4542 21.2333 23.5331 21.4436 140234 18.9945 * 19.7266 19.3554 140236 * 12.9253 * 12.9253 140239 18.8127 20.3745 20.9926 20.0958 140240 23.6860 24.6949 25.1418 24.5193 140242 24.5428 25.2317 26.1850 25.3655 140245 13.4839 14.2481 15.1320 14.2800 140246 13.4639 11.6267 15.0650 13.2908 140250 25.0876 23.6449 25.3410 24.6985 140251 21.4385 21.9435 23.3971 22.2702 140252 25.2246 25.0220 26.0869 25.4562 140253 18.5511 19.5858 18.4567 18.8447 140258 23.2973 25.3622 24.3731 24.3357 140271 15.5079 12.0079 16.0350 14.2915 140275 20.1699 23.8171 21.8908 21.8947 140276 26.6777 25.3134 26.1713 26.0267 140280 20.2360 18.8300 20.0763 19.6936 140281 24.0192 25.2719 26.5197 25.2957 140285 18.1181 18.5916 15.7435 17.3779 140286 20.3735 26.1290 24.0947 23.4832 140288 25.2327 24.4331 25.8717 25.1876 140289 17.1388 18.1747 15.9356 16.9462 140290 21.1784 22.8590 26.8449 23.6369 140291 25.0911 24.9537 26.8628 25.6578 140292 20.8560 21.9950 26.8610 23.2005 140294 17.7226 17.7301 19.4218 18.2830 140300 25.3662 27.8436 28.5457 27.2635 150001 22.8109 24.0620 22.1398 22.9956 150002 19.3401 20.7651 20.7353 20.3004 150003 19.7661 20.8636 22.3835 21.0177 150004 20.3685 21.2449 22.8060 21.4609 150005 20.6260 21.6806 22.5280 21.6427 150006 20.8158 20.6523 21.8435 21.1085 150007 20.1826 20.6635 21.2811 20.6934 150008 21.4545 21.8457 22.9042 22.0745 150009 18.7073 19.0030 19.4599 19.0578 150010 21.7125 20.5570 20.8213 21.0317 150011 18.3742 18.3275 19.8823 18.8436 150012 22.4751 22.1402 21.7903 22.1209 150013 17.0352 16.9327 17.5531 17.1857 150014 22.0143 21.5168 22.8402 22.1055 150015 22.5409 21.9037 24.2370 22.8616 150017 18.7664 19.5339 20.4814 19.6077 150018 20.4947 21.0496 23.0257 21.5245 150019 16.6327 17.8585 19.8341 18.0075 150020 15.1120 16.6600 15.9405 15.8686 150021 19.5096 21.5944 23.2077 21.4598 150022 19.1555 17.9222 18.7751 18.6044 150023 18.3598 19.3412 20.3015 19.3319 150024 18.4140 19.2295 19.8368 19.1528 150025 17.7007 20.2750 * 18.8948 150026 18.8417 22.4978 21.9448 21.0269 150027 17.3284 18.0335 19.4238 18.2383 150029 23.0546 23.2454 24.8939 23.7166 150030 17.9992 19.2406 20.5272 19.2757 150031 17.2429 18.3463 18.9672 18.2134 150033 21.8768 22.6741 23.0163 22.5338 150034 22.1317 23.1533 23.3718 22.8966 150035 20.4477 21.2374 22.3779 21.3734 150036 20.8692 21.4567 22.1464 21.5046 150037 21.7109 24.4611 22.3699 22.8076 150038 21.2193 22.0572 20.3454 21.1795 150039 18.4729 19.6215 16.0227 17.8696 150042 18.1632 20.2221 17.5614 18.5653 150043 19.0120 20.1741 20.5266 19.8572 150044 18.4381 19.1309 19.8951 19.1600 150045 16.8121 18.1670 21.3723 18.7127 150046 17.6342 18.2543 19.4146 18.4518 150047 19.7441 22.0145 21.9824 21.1814 150048 19.3329 19.1648 21.1441 19.9048 150049 17.0141 18.6451 21.6309 18.9803 150050 16.8354 17.7354 18.0411 17.5369 150051 19.0130 19.7257 20.6895 19.8190 150052 15.8590 17.3750 18.7783 17.3644 150053 19.1421 18.8632 17.8949 18.6402 150054 17.3825 18.3916 19.3424 18.3843 150056 22.4087 21.5774 23.0603 22.3391 150057 16.5882 16.9736 * 16.7800 150058 20.8178 22.1409 23.0273 22.0105 150059 21.2535 22.7360 22.9822 22.3129 150060 17.0743 18.6159 19.5011 18.4069 150061 17.3887 19.7968 19.4014 18.8242 150062 20.5415 20.8274 21.2608 20.9059 150063 22.0925 22.6525 24.8587 23.1574 150064 18.1400 20.3865 20.6232 19.7087 150065 19.8913 21.2153 21.4572 20.8676 150066 15.3373 19.5313 19.6845 18.2239 150067 18.2926 18.8862 19.8632 19.0434 150069 21.5310 23.3969 23.5510 22.9021 150070 17.9260 18.0827 18.9332 18.3136 150071 13.4760 13.5111 16.4179 14.3733 150072 16.2054 15.0765 18.5813 16.5238 150073 22.2968 * 19.7285 21.0407 150074 20.4175 20.2305 21.3821 20.6660 150075 15.5603 16.7532 17.1709 16.4680 150076 22.9382 22.6424 23.3724 22.9988 150078 19.2718 19.9668 20.2068 19.8183 150079 17.2436 18.2051 18.3668 17.9396 150082 17.5265 17.8381 19.6881 18.3251 150084 23.2506 24.3107 24.9054 24.1870 150086 18.9735 18.3838 19.7763 19.0552 150088 18.9869 20.3366 22.3055 20.5100 150089 23.8791 22.1725 21.0399 22.2998 150090 20.7726 21.0945 21.9803 21.2765 150091 20.4053 22.4640 26.2176 22.8558 150092 16.7434 16.9179 18.2592 17.3164 150094 16.5788 17.5244 16.7680 16.9454 150095 17.1324 19.2749 22.3214 19.5343 150096 23.2764 20.8204 * 21.9551 150097 19.3802 19.7751 21.0944 20.1363 150098 15.0943 15.2829 16.4763 15.6011 150099 22.4229 * * 22.4229 150100 18.4148 19.8066 18.7289 18.9950 150101 16.4604 20.6209 20.9635 19.3121 150102 19.7426 23.7180 20.8818 21.3162 150103 18.4781 18.7036 19.2881 18.8849 150104 17.6981 20.0765 21.3141 19.7260 150105 20.0431 22.4412 21.6975 21.3454 150106 16.1510 16.8714 18.7088 17.2750 150109 18.8077 19.9066 21.6285 20.0890 150110 18.6627 21.9336 * 20.0654 150111 18.4556 19.2355 24.0256 20.3967 150112 20.4109 20.5253 22.1939 21.0672 150113 20.3780 19.6603 20.5871 20.2207 150114 19.5183 17.9877 18.3097 18.6233 150115 17.4315 18.4844 18.1308 18.0117 150122 18.7139 17.7867 20.7540 19.0652 150123 14.1105 14.0508 16.2898 14.8865 150124 14.6245 15.9487 16.2104 15.6060 150125 20.6735 21.3311 22.0021 21.3476 150126 21.3697 20.6857 24.0000 22.0092 150127 17.1994 17.0052 17.7858 17.3321 150128 18.5100 19.5576 20.3880 19.4584 150129 24.7711 28.6211 29.9888 27.3320 150130 18.1971 18.4846 18.3852 18.3505 150132 20.1684 20.9443 21.2747 20.8045 150133 17.3966 18.4250 19.0871 18.2346 150134 19.2526 19.3632 20.2764 19.6091 150136 20.1245 21.8097 22.9091 21.6195 150145 16.6851 * * 16.6851 150146 * 19.0204 * 19.0204 160001 18.6035 19.0085 20.1699 19.2573 160002 15.9534 16.6003 17.6600 16.7287 160003 16.0862 16.2208 17.5429 16.6099 160005 17.6153 17.9405 19.3348 18.3156 160007 13.2101 15.1738 14.9137 14.4341 160008 15.9742 16.6193 16.7484 16.4416 160009 16.8391 17.9886 19.0664 17.9375 160012 16.4827 16.7112 17.9236 17.0145 160013 18.3996 18.6304 20.3023 19.1017 160014 15.9086 16.7146 18.7253 17.0747 160016 19.6322 19.9747 21.6050 20.4119 160018 14.5946 15.6141 16.0793 15.4308 160020 15.4712 15.5384 15.7960 15.6015 160021 16.5049 16.7617 16.7920 16.6812 160023 15.0665 15.0099 15.3854 15.1530 160024 19.7050 19.4764 20.5622 19.9066 160026 18.8379 19.5260 20.4567 19.6047 160027 16.3477 16.9417 18.2081 17.1431 160028 19.9595 21.0000 * 20.4650 160029 20.4678 21.3457 22.2106 21.3395 160030 19.9508 19.6182 21.6899 20.4018 160031 15.2448 16.1267 16.8957 16.0812 160032 17.3202 18.3168 19.2464 18.2782 160033 18.8673 18.8859 20.1916 19.3159 160034 15.0019 16.5957 17.3644 16.3397 160035 15.2211 16.3991 17.0165 16.0816 160036 17.8849 17.4558 20.2598 18.5977 160037 19.0532 19.5045 19.5067 19.3582 160039 17.4758 17.8647 19.1998 18.1868 160040 18.1949 18.0667 19.6339 18.6033 160041 16.7850 17.4435 18.7943 17.7638 160043 15.6909 14.8564 16.7841 15.7684 160044 16.7439 17.8323 19.5552 18.0882 160045 20.1236 20.0611 21.4757 20.5590 160046 14.5655 16.2737 16.8665 15.8592 160047 18.3593 19.0787 20.4259 19.2869 160048 14.6144 15.6856 17.2709 15.7797 160049 14.5457 15.5673 15.3233 15.1526 160050 17.4912 17.7878 21.1184 18.6885 160051 14.6400 16.4261 15.8213 15.6207 160052 18.0941 21.7647 22.1933 20.7461 160054 16.1753 16.1981 16.5258 16.3024 160055 14.7600 15.1674 17.6177 15.8187 160056 16.1575 17.0172 17.9534 17.0042 160057 18.1776 19.1378 19.6802 19.0270 160058 21.1159 22.1061 23.2042 22.1074 160060 16.0436 17.2825 17.7489 16.9862 160061 17.3215 17.0938 17.2064 17.2123 160062 17.8086 17.4388 18.8163 18.0222 160063 16.8834 16.3583 17.3771 16.8779 160064 20.5496 22.2131 25.1546 22.5347 160065 16.9373 17.1043 17.0609 17.0424 160066 17.1875 17.9971 19.3202 18.1697 160067 17.8514 16.7833 17.6602 17.4022 160068 17.9892 19.0572 20.5995 19.2056 160069 19.7280 19.1640 20.4556 19.7835 160070 16.7017 18.4588 17.7855 17.6458 160072 14.9536 14.4141 15.3384 14.9054 160073 11.8261 11.4997 15.5946 12.7126 160074 19.5092 17.9513 18.4624 18.6658 160075 19.4948 18.4613 20.7842 19.5335 160076 17.9381 17.8824 19.1590 18.2977 160077 12.8826 13.6658 15.0468 13.8624 160079 17.6187 18.6333 20.5010 18.9292 160080 18.6687 19.4925 19.6680 19.2860 160081 17.0052 17.4466 19.1442 17.8781 160082 19.6499 19.5322 20.6425 19.9343 160083 20.6189 19.7542 21.3221 20.5512 160085 18.0063 21.2557 19.1929 19.4359 160086 17.3271 17.5308 19.0477 17.9338 160088 20.2331 22.3655 23.8098 22.1152 160089 16.9538 17.3449 18.3526 17.5556 160090 17.1090 17.9614 18.4210 17.8146 160091 12.8516 14.2573 14.8904 13.9759 160092 15.5011 17.0633 17.9251 16.7839 160093 17.7457 18.5675 19.5732 18.6194 160094 18.7653 17.6094 18.7835 18.3744 160095 15.1895 15.2722 16.4927 15.6525 160097 15.9263 16.6790 17.7860 16.8002 160098 16.3135 16.8670 16.8997 16.6946 160099 13.9053 15.0880 16.0710 15.0169 160101 18.3705 18.9788 19.6314 18.9647 160102 18.8765 20.1161 14.4837 17.6011 160103 17.0973 18.2741 19.6168 18.2567 160104 18.8301 17.4829 21.0060 19.1043 160106 16.9639 17.3474 19.4385 17.8892 160107 18.0634 18.0097 18.8936 18.3269 160108 16.0529 16.7779 17.7577 16.8631 160109 16.5593 17.9873 18.2938 17.5854 160110 19.1420 20.6215 20.9346 20.2607 160111 14.1644 14.9965 15.1104 14.7432 160112 16.8332 17.2450 19.6950 17.9037 160113 14.7097 15.4834 14.9449 15.0474 160114 16.1423 16.5006 18.0532 16.8768 160115 15.8995 16.5654 16.9991 16.4863 160116 16.9534 16.6993 18.4261 17.3468 160117 17.9410 18.7615 19.9040 18.8566 160118 17.2523 19.4472 17.1480 17.8721 160120 10.5992 15.6789 15.0577 13.1432 160122 18.9252 18.1469 18.8469 18.6451 160124 18.0908 19.1600 19.9144 19.0634 160126 17.8142 19.4903 17.6813 18.2418 160129 16.7131 17.2112 18.0113 17.3098 160130 16.0528 15.6666 16.2628 15.9955 160131 15.4898 16.0424 16.5397 16.0265 160134 13.4743 15.3012 14.6396 14.4558 160135 18.2682 18.7711 18.3973 18.4829 160138 16.8699 17.1491 18.3957 17.4264 160140 18.4007 18.5630 19.6155 18.8655 160142 16.2875 18.1467 17.2792 17.2139 160143 16.6154 17.4497 18.1287 17.4014 160145 13.9152 16.9092 17.8887 16.1391 160146 16.6024 17.7010 19.0576 17.7319 160147 17.4880 19.4041 21.6062 19.3700 160151 16.8257 17.2177 18.3398 17.4331 160152 15.6170 15.9500 17.0750 16.1956 160153 20.2316 21.2085 22.7004 21.3705 170001 17.9304 17.9218 18.3934 18.0897 170004 15.0636 16.1442 17.2262 16.1274 170006 17.2192 17.5982 19.1802 18.0107 170008 14.9124 16.8412 17.7061 16.4380 170009 20.7795 23.1349 25.0155 23.0594 170010 18.7384 19.4584 19.5990 19.2633 170012 17.8719 18.4432 20.2281 18.8642 170013 18.6454 19.4667 20.1123 19.4285 170014 17.9349 18.4931 19.3973 18.6216 170015 16.5750 17.1302 17.2443 16.9768 170016 19.2130 20.0675 20.9301 20.0460 170017 17.7958 19.5994 19.7908 19.0428 170018 15.2984 15.3237 14.8794 15.1619 170019 15.2094 16.9362 17.3043 16.4640 170020 17.3400 18.1325 18.9345 18.1573 170022 18.5309 19.1888 20.3269 19.3395 170023 19.1351 19.2441 19.6533 19.3514 170024 13.6803 14.3604 15.0081 14.3388 170025 17.8667 18.7182 19.1720 18.5412 170026 15.0470 14.8974 16.6547 15.5216 170027 17.3604 17.8690 18.4466 17.8805 170030 14.6530 15.9282 12.9413 14.4010 170031 13.9601 14.2151 16.4660 14.7972 170032 15.6093 16.3449 15.2207 15.7224 170033 16.4059 19.1952 21.2104 18.9788 170034 15.8202 16.9586 17.8239 16.8326 170035 18.5885 17.0945 19.8334 18.5082 170038 14.7776 13.8582 15.2505 14.6401 170039 15.8635 17.0774 18.5780 17.1811 170040 21.6440 21.0617 23.1014 21.8449 170041 11.7566 12.4488 9.9263 11.2790 170044 15.3011 17.3254 * 16.3356 170045 14.0875 25.8331 20.5454 19.8078 170049 19.9415 20.7921 21.2917 20.7035 170051 15.0889 16.4851 16.9003 16.1546 170052 15.0108 15.2283 16.0948 15.4803 170053 16.5102 14.6133 14.3628 15.2080 170054 14.4353 14.6354 15.1330 14.7339 170055 16.9800 18.2607 18.1783 17.7932 170056 17.0442 18.3550 19.7369 18.3732 170057 13.0007 * * 13.0007 170058 18.6983 19.5415 20.1090 19.4664 170060 17.3482 18.9853 17.5290 17.8991 170061 15.6527 15.0258 15.2924 15.3392 170063 12.8082 14.1185 13.7611 13.4911 170066 15.5322 16.2891 16.8009 16.1505 170067 14.7492 14.9921 20.7945 16.7328 170068 15.1790 17.0022 19.2629 17.0101 170070 14.2445 14.0627 14.8348 14.3652 170072 12.6329 12.7709 * 12.7037 170073 17.5368 17.7056 17.7586 17.6632 170074 17.5537 17.3699 17.2800 17.4035 170075 12.4212 13.6816 14.4939 13.5832 170076 14.5866 14.6109 14.9392 14.7111 170077 13.5235 13.9104 14.1376 13.8508 170079 13.5261 11.5902 16.7227 13.6766 170080 12.6014 14.8293 13.6794 13.6471 170081 13.8077 14.6823 15.0840 14.5566 170082 12.8563 13.7462 14.8154 13.7610 170084 12.5410 13.0519 13.5927 13.0488 170085 15.4518 17.5422 21.8907 18.4877 170086 20.4068 19.7182 20.2892 20.1437 170088 13.4542 13.4860 * 13.4703 170089 18.8136 15.4860 20.2263 18.3293 170090 11.9147 10.9444 * 11.4573 170093 13.5490 14.0276 14.7803 14.0852 170094 20.1985 21.2035 21.2484 20.8944 170095 15.5463 15.3532 16.1078 15.6715 170097 16.4608 17.7540 18.6805 17.6242 170098 15.5259 16.6210 17.3480 16.4881 170099 13.6033 14.3370 16.5247 14.7568 170101 14.5629 18.0143 17.3381 16.4637 170102 13.6321 14.2447 14.4499 14.1084 170103 17.2844 17.9530 18.6172 17.9709 170104 20.6182 21.0049 21.9487 21.1996 170105 16.5408 16.7403 18.2788 17.1877 170106 18.5479 17.7467 * 18.0680 170109 17.2629 16.9782 18.3483 17.5682 170110 16.9823 18.5731 21.0637 18.8359 170112 14.3855 15.4049 15.8097 15.1873 170113 13.9038 14.6486 16.4938 15.0142 170114 14.4545 16.2645 13.8347 14.7519 170115 12.6997 12.9216 13.0253 12.8848 170116 16.8714 18.1830 19.4278 18.1442 170117 15.7875 16.8237 16.8301 16.4481 170119 15.1990 15.2708 15.1982 15.2222 170120 17.6748 17.4917 18.2061 17.7788 170122 20.0615 21.1769 21.4205 20.8657 170123 23.1697 23.6534 25.2071 23.9580 170124 11.1249 15.0596 16.3925 13.8286 170126 12.8096 13.5736 14.5527 13.6140 170128 14.8891 14.1676 17.6259 15.4144 170131 10.1000 * * 10.1000 170133 18.0243 18.8119 19.9778 18.9214 170134 14.1085 14.6799 15.1932 14.6538 170137 17.8290 19.3118 19.3344 18.8395 170139 14.1967 14.3001 14.8157 14.4193 170142 * 17.7134 18.9169 18.3246 170143 15.6509 16.0415 16.3258 16.0049 170144 19.0929 20.4392 20.7583 20.0727 170145 17.1837 19.0142 18.1398 18.1031 170146 20.9075 21.7919 25.4405 22.7798 170147 22.3017 17.6717 17.4968 19.0192 170148 16.9183 19.1942 24.4828 19.5145 170150 15.5651 15.9072 14.9718 15.4692 170151 13.8934 14.3668 14.5002 14.2317 170152 14.9139 15.6423 16.0930 15.5503 170160 13.7108 14.4732 17.0629 15.0179 170164 16.6542 17.4072 17.0791 17.0445 170166 27.5567 12.7507 16.5113 18.0323 170171 12.5200 13.1792 14.7051 13.3708 170175 19.0232 20.1907 19.9712 19.7266 170176 21.3400 23.5043 23.5743 22.8029 170180 16.6921 8.6352 * 11.8552 170182 22.2164 21.3454 21.9797 21.8339 170183 20.3505 19.5182 16.6577 18.5979 170185 * * 26.6814 26.6814 170186 * * 32.9088 32.9088 180001 17.9906 20.4885 20.8419 19.8481 180002 17.9669 17.5798 19.7742 18.4114 180004 17.2581 17.7149 18.0494 17.6734 180005 21.1390 22.4634 23.4941 22.1458 180006 11.4398 10.3400 11.2872 11.0389 180007 17.6776 17.9491 18.6823 18.0973 180009 21.4730 21.0608 21.7746 21.4458 180010 19.1100 19.6311 19.4210 19.3847 180011 17.1050 19.0526 22.6798 19.8513 180012 18.7223 19.0646 19.6614 19.1485 180013 18.2354 19.7418 19.9690 19.3345 180014 21.4856 21.3361 22.9674 21.8678 180016 19.8892 21.1458 19.7132 20.2640 180017 15.4140 15.6583 16.7649 15.9422 180018 17.1692 15.4892 17.2357 16.6084 180019 17.3970 17.8285 19.0883 18.1044 180020 17.7288 18.0111 19.3978 18.3483 180021 15.4580 17.0618 16.5376 16.3552 180023 15.8803 17.4717 19.0574 17.4610 180024 16.1731 16.5040 19.6313 17.2961 180025 14.1841 15.4180 17.1875 15.5888 180026 14.6804 15.0118 13.9959 14.5545 180027 16.4116 17.5286 19.6928 17.8399 180028 19.5276 15.7005 26.1723 19.5534 180029 17.7729 17.7248 20.0357 18.4826 180030 17.3430 17.9543 17.5043 17.5959 180031 13.9844 13.1848 17.1003 14.4541 180032 16.8318 17.2784 17.2362 17.1383 180033 17.7344 15.4131 17.0498 16.6984 180034 15.3369 16.3991 17.0349 16.2188 180035 20.1305 21.3666 22.6728 21.3628 180036 19.8398 20.1860 20.6951 20.2522 180037 19.9737 21.2184 21.0177 20.7450 180038 17.7626 18.5923 19.0457 18.4790 180040 19.5337 21.2229 22.1332 20.9525 180041 15.0785 16.3699 17.5950 16.3724 180042 16.7691 17.1519 15.5660 16.4438 180043 16.8027 14.6526 17.0419 16.0656 180044 18.5571 19.4984 21.1057 19.7654 180045 17.7130 20.8455 20.7850 19.9661 180046 19.2523 21.2080 20.8544 20.4279 180047 16.2304 18.6938 17.8625 17.5927 180048 18.3442 17.7816 18.3151 18.1431 180049 16.4319 16.5459 17.0422 16.6742 180050 17.8540 17.1493 19.4583 18.1528 180051 16.3960 17.5441 17.7358 17.2163 180053 15.9284 15.8994 17.3167 16.3733 180054 19.4858 20.0946 17.4354 19.0288 180055 15.2663 15.8422 16.6072 15.8890 180056 17.0056 17.5881 18.6075 17.7242 180058 15.9685 14.5355 14.7900 15.0323 180059 13.3955 14.7032 17.2542 14.9522 180063 13.1036 12.4448 14.7338 13.4418 180064 15.2424 15.5066 16.3894 15.6781 180065 12.0629 11.1934 11.0966 11.4164 180066 19.2981 19.8956 19.4875 19.5598 180067 20.6322 20.1712 20.2762 20.3589 180069 17.7911 16.2916 19.0443 17.6808 180070 13.1923 15.9362 15.4643 14.7849 180072 16.9021 17.2347 17.0576 17.0759 180078 21.1170 21.7116 22.2802 21.7169 180079 15.1636 15.9048 18.1683 16.3817 180080 16.4989 16.6428 17.5659 16.9072 180087 14.9167 15.6089 16.2378 15.5798 180088 22.0374 22.1774 22.8908 22.3519 180092 18.2405 18.3597 18.8964 18.5113 180093 17.0132 17.8492 17.6961 17.5099 180094 13.5490 13.6233 14.3306 13.8326 180095 13.8021 13.9050 15.4478 14.3114 180099 13.3631 13.2991 14.0464 13.5559 180101 18.4883 * 20.2958 19.4148 180102 17.9618 18.5240 16.6998 17.7006 180103 19.8965 20.3490 20.8866 20.3712 180104 18.9281 19.3922 20.3023 19.5481 180105 15.2394 16.6997 18.2976 16.6579 180106 14.3505 15.2895 15.5278 15.0462 180108 14.8187 14.4740 14.8720 14.7266 180115 16.7003 16.9096 18.0951 17.2235 180116 18.0392 18.6077 18.1923 18.2836 180117 17.7857 23.0192 20.7961 20.3977 180118 15.8597 16.9250 17.9017 16.8657 180120 16.1591 15.3115 16.4226 15.9318 180121 15.0983 20.0494 16.9570 17.2427 180122 18.5094 18.1930 18.7549 18.4922 180123 21.0613 21.1067 21.8227 21.3332 180124 17.4994 18.8487 19.7138 18.6761 180125 19.6416 14.9314 22.6161 18.1828 180126 12.9228 14.3551 14.8501 14.0804 180127 19.2581 17.6365 18.0498 18.2667 180128 17.6385 18.2817 18.7194 18.2299 180129 16.8378 22.3536 15.6637 17.9690 180130 19.8192 20.6450 21.9268 20.8000 180132 17.7744 19.5884 19.4233 18.9093 180133 21.6794 21.7800 23.2679 22.2101 180134 13.1935 14.5387 16.5901 14.7149 180136 17.3542 * * 17.3542 180138 19.3692 20.2102 19.8524 19.8199 180139 18.7198 20.5350 20.3816 19.9038 180140 16.8152 15.2719 14.6466 15.5892 180141 20.9820 23.8930 23.0957 22.5668 180142 * 20.751 * 20.7510 180143 * * 21.3197 21.3197 190001 17.6832 18.1514 18.8583 18.2414 190002 19.1924 19.8834 20.6057 19.8935 190003 19.7749 19.9121 19.5115 19.7281 190004 17.7710 18.3620 19.6755 18.6227 190005 17.2422 17.5161 18.6994 17.8286 190006 17.8036 17.5911 17.7333 17.7115 190007 13.8189 14.4720 15.8753 14.7770 190008 18.6664 19.2456 22.4797 20.0804 190009 15.3555 15.9731 16.0395 15.7936 190010 16.2805 16.5020 17.7616 16.8604 190011 15.9534 15.6351 15.7319 15.7701 190013 16.8181 15.5019 16.7770 16.3476 190014 17.0959 17.8015 18.6929 17.8513 190015 18.6266 18.9896 19.7673 19.1223 190017 16.2393 17.5381 19.8449 17.8836 190018 15.0668 11.1898 13.1355 13.0348 190019 18.5257 18.3788 18.6473 18.5189 190020 17.5256 17.6840 18.7252 17.9732 190025 18.6369 16.8686 18.1892 17.9111 190026 18.1622 18.5015 18.8895 18.5256 190027 17.0827 17.4761 18.3203 17.6149 190029 16.5239 19.1967 18.7344 18.0923 190034 16.8503 18.0754 19.2007 18.0146 190036 20.1780 20.0300 21.1870 20.4494 190037 17.6945 19.9878 14.1323 17.4581 190039 19.4713 19.0376 17.8217 18.7156 190040 21.4634 21.7376 23.0537 22.0787 190041 17.6646 17.9535 17.2344 17.5871 190043 15.5580 15.5618 15.5645 15.5614 190044 17.2892 17.4471 17.6788 17.4765 190045 21.6107 21.2853 22.0065 21.6574 190046 19.7964 20.4458 20.2414 20.1666 190048 16.6683 16.8136 16.6848 16.7218 190049 17.2280 17.7417 18.5902 17.8611 190050 16.1980 16.2854 16.9053 16.4718 190053 13.2159 13.0080 13.4768 13.2412 190054 19.1738 18.9059 17.7269 18.6351 190059 15.6942 15.8373 17.8651 16.5018 190060 14.7186 17.8443 19.9121 17.2297 190064 20.4482 18.2466 19.9873 19.5473 190065 20.9927 18.3091 18.3050 19.0764 190071 14.4827 16.4138 16.3822 15.7772 190077 15.7805 16.5536 16.8829 16.4072 190078 14.8826 16.9383 19.5879 16.9873 190079 17.7120 17.9403 18.1929 17.9449 190081 15.3198 14.9707 14.7919 15.0273 190083 18.8895 18.4951 16.2970 17.9487 190086 15.8694 16.5074 17.6237 16.6689 190088 20.5531 19.9362 20.4725 20.3095 190089 13.0503 15.0395 15.2055 14.4221 190090 16.6664 16.2351 19.8201 17.5803 190095 16.2287 17.3258 17.3637 16.9543 190098 20.4897 21.0847 22.5793 21.3421 190099 19.9018 19.0635 19.0545 19.3385 190102 20.0300 20.7870 21.0423 20.6389 190103 12.1389 14.4158 15.6415 14.0050 190106 18.5813 18.5908 19.9117 19.0267 190109 15.5767 15.8187 16.3641 15.9327 190110 15.8052 15.7313 15.2652 15.5956 190111 19.7514 20.6508 20.2253 20.2164 190112 21.0232 22.0741 24.2806 22.3499 190113 12.5777 * 19.0411 16.0667 190114 12.6366 13.9209 13.4402 13.3357 190115 20.2473 22.7583 23.7462 22.1782 190116 15.5481 17.3757 18.3223 17.0452 190118 14.7876 16.3776 17.8543 16.2736 190120 13.9591 17.2309 17.6708 16.2867 190122 15.4793 15.3742 16.7189 15.8764 190124 20.6222 20.1206 22.8245 21.2142 190125 20.4517 19.8298 20.1401 20.1511 190128 20.4688 20.8770 21.1465 20.8466 190130 15.1467 14.0379 14.5586 14.5812 190131 20.7565 18.8958 19.7483 19.8133 190133 13.5383 15.1393 15.7834 14.7342 190134 12.1749 12.4507 * 12.3182 190135 21.6875 21.3454 23.1434 22.0401 190136 12.4091 15.1662 15.6286 14.4513 190140 14.2256 14.6829 14.8738 14.5954 190142 15.4861 16.2280 19.0464 16.8845 190144 16.2068 18.4405 18.3513 17.6419 190145 15.2345 16.2505 16.4402 15.9754 190146 21.2825 21.9607 20.6776 21.3057 190147 14.4345 14.7202 15.2732 14.8106 190148 16.6337 15.5338 19.4518 17.1031 190149 17.5997 16.4722 16.5153 16.8165 190151 14.7333 15.5210 16.2783 15.5127 190152 22.2070 22.0319 22.7142 22.3160 190156 15.7478 16.0442 17.6573 16.4812 190158 20.4637 20.4078 21.6307 20.8104 190160 17.1003 18.4662 19.3139 18.3349 190161 15.5737 15.9280 15.7807 15.7581 190162 20.6143 20.1962 20.9645 20.5966 190164 15.1783 18.2379 19.0473 17.3930 190167 16.6681 17.7611 15.5795 16.5709 190170 14.1750 14.5222 16.2045 15.0173 190173 23.6398 23.0934 * 23.4298 190175 19.3625 20.4580 22.2470 20.7017 190176 24.0574 22.2316 21.7051 22.5987 190177 18.6715 19.7794 20.3679 19.5997 190178 11.0657 12.0372 * 11.5413 190182 20.2855 20.7102 23.1997 21.3232 190183 16.7671 16.0752 16.7402 16.5275 190184 17.2044 19.8436 18.6583 18.5582 190185 20.1444 20.5852 20.5454 20.4315 190186 18.7568 17.4078 16.7272 17.7093 190190 17.4642 15.8985 13.7951 15.8564 190191 20.4975 19.6911 19.7218 19.9785 190196 17.9225 18.6138 19.1961 18.6202 190197 19.5569 20.2082 20.5377 20.1371 190199 16.0637 15.3522 17.8288 16.5088 190200 22.0391 21.6852 22.3510 22.0311 190201 18.7079 19.7421 21.5656 20.0412 190202 * * 22.4701 22.4701 190203 21.7350 21.7931 23.0636 22.1708 190204 21.4624 20.5784 22.9134 21.6176 190205 19.6587 19.3737 18.8750 19.3122 190206 21.7012 21.3307 21.7867 21.6067 190207 20.5082 19.0216 20.7024 20.0851 190208 20.0065 16.9641 17.6834 18.1192 190218 19.7518 19.2992 20.7290 19.9128 190231 15.8287 17.7247 * 16.7208 190236 19.3395 21.1982 22.5796 21.1124 190238 * 20.6799 * 20.6799 190239 * 19.7601 * 19.7601 190240 * 14.3579 16.0112 15.2482 200001 18.0527 18.2513 19.9438 18.7634 200002 19.3629 22.3035 22.3272 21.3905 200003 16.9566 18.4141 18.8570 18.0991 200006 17.6586 21.0922 24.1167 20.8621 200007 18.7992 18.1681 19.4177 18.7699 200008 21.7489 21.5556 24.2833 22.5897 200009 22.2280 21.4763 23.2456 22.3157 200012 18.3484 19.1047 20.9187 19.4746 200013 18.0566 17.9378 20.2192 18.8221 200016 18.0866 17.1187 16.2939 17.1580 200017 17.2930 * * 17.2930 200018 18.5397 17.8675 20.6104 19.0069 200019 19.2348 19.9245 21.3003 20.1669 200020 22.4526 22.3355 24.8195 23.2627 200021 19.9133 20.7361 22.4038 21.0287 200023 16.1707 20.2063 * 18.0379 200024 19.4329 20.8336 21.2346 20.5158 200025 20.2259 20.4165 21.6002 20.7762 200026 18.1194 17.9021 21.4758 18.9050 200027 18.5659 19.4220 20.2146 19.4316 200028 19.5708 18.8763 19.9926 19.4914 200031 16.2217 16.1641 17.3915 16.5880 200032 18.9315 19.4613 20.8973 19.7659 200033 21.8634 22.4685 23.6538 22.6396 200034 20.1519 20.4941 21.3303 20.6756 200037 18.6713 20.3015 19.7768 19.6048 200038 23.3851 21.2632 22.9629 22.5227 200039 19.8589 20.1508 21.0884 20.3830 200040 19.5503 18.9580 19.5917 19.3665 200041 19.3563 18.8131 20.3761 19.5462 200043 16.7224 19.4295 19.8833 18.5621 200050 20.1214 20.2014 14.6387 17.8681 200051 22.1525 22.0712 * 22.1031 200052 17.2099 17.6271 19.9239 18.2260 200055 18.8422 18.5983 19.4998 18.9700 200062 17.2273 18.4279 18.4038 18.0038 200063 19.9331 21.2121 22.5278 21.2360 200066 17.0289 17.0570 18.7143 17.6294 210001 20.4841 18.6617 21.5280 20.1745 210002 19.9219 23.5132 21.1426 21.7024 210003 20.3446 26.0447 21.6625 22.4257 210004 24.2909 24.9760 * 24.6345 210005 21.4929 21.3829 23.8670 22.2506 210006 18.9436 19.3682 20.8607 19.7283 210007 23.1007 23.8840 23.4582 23.4837 210008 21.1768 21.2895 21.0767 21.1826 210009 20.5447 20.7479 20.8476 20.7179 210010 18.7197 19.5908 19.7917 19.3735 210011 21.4862 21.4043 20.0662 20.9726 210012 20.7203 21.3977 24.0745 21.9907 210013 19.7288 19.4505 23.1649 20.7921 210015 16.1912 18.7448 23.9651 19.4078 210016 23.8739 26.5193 * 25.1634 210017 18.8928 18.5079 18.2963 18.5724 210018 22.2135 22.8553 23.6442 22.8975 210019 19.3046 20.6025 21.5429 20.4724 210022 22.6389 24.5744 25.6728 24.3137 210023 23.1950 22.9989 24.4815 23.5799 210024 20.6011 24.4280 24.7858 23.2181 210025 19.5876 21.2769 21.4910 20.6428 210026 12.1348 13.8668 20.7986 14.8993 210027 17.6855 17.1060 16.2219 17.0429 210028 19.6408 19.4157 20.4027 19.8293 210029 21.2167 25.4939 24.7605 23.8903 210030 21.7403 20.9574 21.9547 21.5644 210031 16.2299 * * 16.2299 210032 17.7228 20.1955 20.0825 19.3625 210033 20.8053 23.7588 22.8303 22.4103 210034 15.7322 19.4144 22.6812 19.1023 210035 20.2731 20.8317 21.6662 20.9231 210037 18.3072 20.5528 19.2811 19.3731 210038 23.4971 24.9762 25.9701 24.7755 210039 19.9901 21.3559 23.3583 21.5884 210040 21.5014 23.4252 23.1960 22.7040 210043 19.6474 22.4000 22.9504 21.5561 210044 22.5781 23.0917 22.9540 22.8695 210045 11.6086 12.1467 13.5654 12.4021 210048 23.0537 24.6921 24.9381 24.2387 210049 19.0821 19.3022 21.1056 19.8459 210051 22.4335 23.6476 24.8949 23.6510 210054 22.3559 23.2730 25.1694 23.5831 210055 29.2539 26.5272 23.8025 26.3168 210056 19.2662 22.9593 23.8915 21.9932 210057 23.8289 26.0076 * 24.8719 210058 22.0753 16.3191 17.4250 18.5418 210059 22.6766 25.6052 * 23.8855 210060 * 26.5846 26.4566 26.5245 210061 17.2240 16.1931 20.8975 18.1853 220001 21.9369 22.9064 23.4091 22.7509 220002 24.1285 24.5840 25.3171 24.6486 220003 16.9246 17.9319 17.6069 17.4814 220006 22.3085 22.6337 23.5624 22.8309 220008 24.4691 22.0796 23.0806 23.1592 220010 21.8582 22.0067 23.8256 22.5598 220011 26.1827 29.5290 24.8039 26.6476 220012 32.0829 31.2303 30.4104 31.2159 220015 22.5773 23.1893 24.1348 23.2890 220016 23.3750 23.0951 24.5411 23.6644 220017 22.4605 25.1568 25.9000 24.3877 220019 19.5613 19.8551 19.9268 19.7870 220020 21.4152 22.4295 22.5375 22.1352 220023 16.1885 * * 16.1885 220024 21.5363 21.9316 23.8620 22.4506 220025 20.7882 22.8593 22.8936 22.1783 220028 22.8036 21.0630 24.0441 22.5673 220029 23.1509 25.6560 26.3117 25.0100 220030 18.5441 18.7429 19.3387 18.8705 220031 30.2430 29.3091 28.3832 29.0231 220033 20.0695 20.3609 22.3195 20.8616 220035 21.6396 23.1892 24.5685 23.0612 220036 24.6470 24.4091 24.9637 24.6635 220038 22.6518 22.3162 22.4302 22.4673 220041 23.4720 27.5034 28.6303 26.3941 220042 25.0779 26.0473 28.4675 26.3871 220046 22.7068 23.3149 23.8578 23.2791 220049 26.0025 27.2689 25.2174 26.1330 220050 22.0144 22.5265 23.3330 22.6222 220051 21.1033 21.7357 22.4826 21.7398 220052 23.7650 23.5225 24.4403 23.8995 220053 19.1280 * * 19.1280 220055 21.3743 * * 21.3743 220057 25.3902 25.8064 26.2945 25.8083 220058 19.9369 26.8345 21.6814 22.7654 220060 28.0843 28.0794 28.1888 28.1190 220062 20.4685 20.2254 16.0585 19.0019 220063 20.3951 20.8079 21.7336 21.0041 220064 22.3260 22.7497 23.8859 22.7342 220065 20.1364 20.1424 21.5556 20.6267 220066 20.7826 23.4477 24.5463 22.8901 220067 26.4443 27.5405 27.9807 27.2636 220070 19.7528 20.9128 21.0606 20.5677 220071 25.6184 27.4151 27.4906 26.8301 220073 25.6025 26.1328 27.4458 26.3872 220074 25.6390 24.3057 24.8908 24.8286 220075 22.8057 22.5329 24.5769 23.3112 220076 22.6668 23.2795 24.1224 23.3492 220077 25.2646 26.1545 27.1503 26.1736 220079 22.6256 22.0769 25.7305 22.9418 220080 21.5238 22.1971 22.9911 22.2508 220081 29.1726 29.6682 29.6399 29.4983 220082 21.6726 22.1453 22.9171 22.2513 220083 23.9156 22.5815 27.2605 24.4264 220084 23.6641 25.3761 25.8300 24.9680 220086 23.8705 26.7778 28.7276 26.2967 220088 22.9067 23.4258 25.0671 23.8081 220089 23.0965 25.4106 25.3521 24.5662 220090 22.0041 23.3049 25.0628 23.4549 220092 18.5239 24.7905 * 20.9405 220095 21.4831 21.7851 22.4924 21.9294 220098 21.5906 23.1547 24.7180 23.1447 220100 25.7077 27.5841 26.8001 26.6854 220101 25.9204 27.0711 27.9184 26.9502 220104 28.0021 28.7258 * 28.3658 220105 21.4129 21.9185 23.2210 22.2352 220106 25.6577 25.9277 28.1034 26.6044 220108 21.9115 23.4975 24.5939 23.3257 220110 28.7071 29.1648 30.2500 29.3820 220111 23.8066 24.7510 26.7336 25.0953 220116 26.1662 32.0049 28.4236 28.6928 220119 23.3216 23.8785 24.4507 23.8686 220123 25.8994 32.4678 28.8325 29.1153 220126 22.5218 23.6045 23.8123 23.3172 220133 25.4596 29.3911 29.8366 28.1948 220135 25.6522 28.3648 29.6837 27.9677 220153 22.9592 * * 22.9592 220154 22.4770 21.1563 23.3590 22.3695 220163 29.1143 29.2299 29.3552 29.2328 220171 24.5553 24.9261 26.9048 25.5207 230001 19.8020 20.0438 23.3051 20.9963 230002 22.7991 23.0439 24.3115 23.3442 230003 19.8420 21.2215 21.6493 20.9088 230004 23.1036 20.5005 22.4538 21.9617 230005 18.5644 17.0943 20.5596 18.6769 230006 19.1041 20.4978 21.1974 20.2494 230007 15.5538 * * 15.5538 230012 15.0803 * * 15.0803 230013 20.8018 22.2211 20.0954 21.0266 230015 20.1104 20.6464 21.9499 20.8811 230017 22.2822 22.9755 25.7900 23.6501 230019 22.2622 23.6674 23.8779 23.3381 230020 22.1280 21.8526 28.8386 23.8749 230021 18.9636 19.8256 20.5690 19.8347 230022 18.8006 21.9129 21.7265 20.8153 230024 23.7326 24.9664 26.2155 24.8592 230027 14.6950 19.6393 22.5114 18.5396 230029 19.4911 22.1782 25.2459 22.2502 230030 18.3916 18.6406 19.1742 18.7416 230031 19.3162 19.9465 19.4676 19.5690 230032 21.8845 24.8930 22.5952 23.1148 230034 19.0473 19.4366 17.9276 18.7511 230035 17.5109 17.7490 20.5906 18.5317 230036 23.2119 23.8398 25.2015 24.1096 230037 20.4747 23.2751 22.7382 22.1469 230038 23.5251 21.9692 21.4546 22.2952 230040 21.4393 20.7841 20.2451 20.8039 230041 20.3131 21.7364 23.2870 21.7251 230042 22.1043 21.3870 19.8523 21.0979 230046 25.5696 25.3206 26.1787 25.6837 230047 21.5381 22.3595 23.7737 22.5475 230053 25.4968 26.8917 23.3066 25.2933 230054 20.6963 20.8014 17.6968 19.8741 230055 20.7932 20.8492 20.8930 20.8452 230056 16.0766 17.8091 17.3516 17.0331 230058 20.4165 21.0303 21.6619 21.0283 230059 19.9240 20.7092 20.5651 20.3916 230060 19.8021 19.8987 21.0368 20.2439 230062 17.1540 18.8039 18.2283 18.0500 230063 20.4171 * * 20.4171 230065 22.3459 22.7416 23.3414 22.8607 230066 22.1768 23.0475 23.2790 22.8376 230069 23.2076 24.2470 25.0212 24.1384 230070 20.2505 21.5666 21.1658 21.1081 230071 22.9052 23.1337 23.6398 23.2244 230072 20.6944 20.4456 22.6533 21.2484 230075 20.0545 22.5866 22.3632 21.5991 230076 24.4547 24.7010 26.7244 25.2068 230077 21.0178 20.2823 22.6153 21.3059 230078 17.5577 17.9868 19.1638 18.2565 230080 19.7687 20.2104 19.1810 19.7086 230081 19.0345 19.0199 20.0464 19.3283 230082 18.2992 19.0419 18.2165 18.5095 230085 20.2096 23.4996 24.5765 22.7898 230086 18.9420 20.1730 20.1060 19.7404 230087 18.9034 19.9700 20.6619 19.7714 230089 23.9100 22.6994 22.7774 23.0814 230092 20.0145 20.7738 22.2629 21.0588 230093 20.4655 20.6314 21.0274 20.7091 230095 17.3313 17.6444 18.0582 17.6864 230096 22.8410 22.7785 24.3004 23.2947 230097 21.2854 21.1254 22.5006 21.6504 230099 21.1933 21.7513 21.7402 21.5696 230100 17.1336 17.3842 18.1823 17.5576 230101 20.0932 20.5315 22.5159 20.9964 230103 22.7696 11.3429 18.5254 17.4039 230104 23.1457 24.1238 25.5606 24.3812 230105 21.5210 22.6098 23.0086 22.4180 230106 20.7997 21.6825 22.9909 21.8109 230107 16.5966 17.1386 18.9985 17.6147 230108 18.8631 20.3437 21.4592 20.2385 230110 18.9825 19.7262 20.0544 19.5843 230113 14.9411 * * 14.9411 230115 18.4050 19.6281 21.0361 19.6522 230116 16.5419 14.5692 15.6064 15.5368 230117 25.9318 25.6797 25.4341 25.6737 230118 21.3028 20.6797 20.2770 20.7229 230119 21.1918 22.6555 23.9898 22.6112 230120 18.5264 20.3306 20.6105 19.6370 230121 20.3158 21.3342 21.0568 20.9014 230122 20.9078 * * 20.9078 230124 20.3608 18.9981 20.9641 20.0945 230128 24.9081 24.0724 24.4952 24.4850 230130 23.5170 22.1775 23.5123 23.0660 230132 26.6386 26.1946 27.3497 26.7222 230133 17.6894 17.1058 19.0770 17.9441 230135 22.5258 20.5637 18.4193 20.8744 230137 19.1813 * * 19.1813 230141 22.1299 22.4570 24.4560 22.9910 230142 22.2940 23.5621 24.9830 23.5261 230143 16.3043 16.7948 18.2700 17.1074 230144 22.1108 23.4237 23.3295 22.9371 230145 20.2542 19.2638 17.9811 19.0315 230146 20.5044 21.2260 22.3838 21.3821 230147 21.8496 23.2755 * 22.5377 230149 20.7691 18.8005 19.9577 19.8029 230151 22.1713 23.3967 24.1404 23.2068 230153 19.5633 18.7403 20.0098 19.4472 230154 15.4456 15.4362 16.7152 15.8739 230155 17.2076 20.5409 20.9053 19.4860 230156 24.7587 25.6228 27.2254 25.8423 230157 20.3667 17.3571 * 18.9586 230159 20.0749 * * 20.0749 230162 21.4636 21.7148 22.7984 21.9769 230165 23.0106 23.8881 24.5193 23.7930 230167 21.5048 22.9745 24.1064 22.8649 230169 23.0652 24.3874 28.1039 25.0117 230171 13.3863 17.1282 16.1129 15.4610 230172 20.6417 21.4675 22.1709 21.4477 230174 23.0272 22.7304 23.5025 23.0851 230175 16.8909 * 14.4932 15.4643 230176 22.7772 23.8204 24.6518 23.7400 230178 16.9156 17.3030 17.3428 17.1968 230180 15.8769 18.5744 19.6062 17.9856 230184 19.0604 19.7717 20.4831 19.7582 230186 19.5337 15.7837 19.1289 18.1131 230188 15.7112 16.2975 16.8687 16.3031 230189 16.6838 17.9218 19.1990 17.9352 230190 26.8196 26.4687 24.4643 25.9234 230191 19.0013 18.4861 20.6633 19.3446 230193 19.7066 19.8287 21.5358 20.3443 230195 21.7775 22.9228 23.4647 22.7456 230197 24.0184 24.0854 25.4494 24.4929 230199 19.4451 20.6580 22.4592 20.8791 230201 17.2141 18.0787 18.2486 17.8664 230204 25.4181 23.4966 24.5127 24.4525 230205 14.3788 15.9314 18.1551 16.1081 230207 20.6375 21.2483 20.9059 20.9181 230208 16.0733 16.7454 17.4925 16.7635 230211 18.6744 21.8581 21.1245 20.4277 230212 23.3021 24.2611 24.6420 24.0563 230213 15.1908 15.5469 17.1062 15.9226 230216 20.3359 21.0710 22.2137 21.1969 230217 21.2707 22.2698 24.1455 22.5496 230219 19.1549 20.0442 18.1277 19.1400 230222 22.1785 21.9711 23.2545 22.4802 230223 21.1528 22.6887 25.2666 22.9884 230227 23.7259 22.3155 25.8826 23.9496 230230 22.2385 22.3097 22.1703 22.2333 230235 16.8684 17.7197 18.3341 17.6456 230236 24.3835 25.9676 25.2273 25.2169 230239 18.0942 17.8168 18.9790 18.2974 230241 19.1000 20.7297 20.4217 20.0924 230244 21.7413 22.2697 23.1175 22.3742 230253 20.5945 21.0433 22.7706 21.4304 230254 21.9402 22.6335 23.3714 22.6370 230257 19.6982 21.3880 23.1794 21.3083 230259 22.2393 22.3969 23.1768 22.6077 230264 17.1319 17.4864 18.4075 17.6504 230269 23.3105 24.0992 24.3772 23.9435 230270 22.6187 22.5985 24.8925 23.3219 230273 22.9199 22.8715 24.1278 23.2898 230275 17.7487 20.8985 * 18.8231 230276 21.3722 25.8709 22.3313 22.8959 230277 23.1456 23.9771 24.2319 23.8212 230278 18.2110 * * 18.2110 230279 17.6973 17.8074 18.3256 17.9471 230280 15.6654 18.3497 * 16.7057 230283 27.9480 22.5082 * 24.9202 230287 * * 22.5420 22.5420 240001 24.6207 25.6936 26.6372 25.6759 240002 22.7981 23.2307 24.1694 23.4122 240004 25.1908 24.4030 25.6238 25.0604 240005 17.9563 20.3193 20.2389 19.4808 240006 25.1602 23.0715 25.7288 24.6342 240007 17.7625 19.0850 20.7189 19.1593 240008 20.2158 23.3783 22.7437 21.9832 240009 16.8965 17.1187 17.4518 17.1699 240010 23.6477 25.4752 28.3796 25.8852 240011 20.5192 21.5875 22.5188 21.5240 240013 20.3282 21.7544 25.1560 22.2201 240014 23.0025 24.2610 25.2306 24.1808 240016 20.4017 22.2011 23.3772 21.9959 240017 18.3585 18.9272 19.3431 18.8677 240018 20.8501 18.4268 23.6092 20.7339 240019 22.1501 23.1477 24.0613 23.1411 240020 21.1937 20.8849 20.6378 20.8948 240021 18.7515 20.1457 19.0469 19.2586 240022 21.7889 21.3234 23.0394 22.0529 240023 21.5087 22.8224 22.3002 22.1691 240025 18.8345 20.0308 20.7672 19.8809 240027 19.1017 16.7758 18.3837 18.0732 240028 19.7918 25.1934 * 22.5025 240029 21.1329 20.0164 23.0440 21.3549 240030 18.8547 20.1653 20.9799 20.0254 240031 18.1566 19.3983 21.7620 19.6652 240036 22.2460 22.1721 22.5423 22.3294 240037 19.2345 20.1195 21.4275 20.2550 240038 25.3061 24.3957 26.3886 25.3874 240040 20.4813 23.1352 22.8191 22.1112 240041 19.2864 21.8655 21.9054 20.9373 240043 17.7335 16.9859 18.2388 17.6591 240044 18.8411 20.3339 22.5750 20.4995 240045 21.1396 24.1557 24.2936 23.2125 240047 22.6152 23.8098 25.3136 23.8879 240050 25.2983 21.6499 23.1719 22.7044 240051 19.9195 22.5855 23.2612 21.9129 240052 20.7749 * 22.3485 21.5706 240053 22.9611 23.8693 24.2783 23.7568 240056 23.4226 23.7139 24.8549 24.0398 240057 24.2159 24.8686 25.4292 24.8727 240058 14.9697 18.4009 19.0506 17.2677 240059 23.6215 23.7808 25.3847 24.2488 240061 27.2603 25.9951 27.9151 27.0571 240063 23.7866 24.4031 25.4760 24.5591 240064 23.2860 22.8578 24.6785 23.6296 240065 12.7867 14.8734 14.4623 14.0357 240066 23.0698 24.1143 25.5163 24.2946 240069 19.8282 21.7991 23.3241 21.6103 240071 20.2101 21.2463 22.5319 21.3438 240072 21.1824 20.9529 21.5455 21.2291 240073 16.0840 17.3559 17.9013 17.1144 240075 21.2654 21.3357 21.9160 21.5185 240076 21.8795 22.3280 23.6130 22.6447 240077 15.3794 20.3445 22.1509 19.1544 240078 23.9150 25.1082 25.9495 25.0087 240079 18.4338 18.8345 18.2929 18.5204 240080 24.3399 25.5619 26.0031 25.2885 240082 18.3555 18.7995 20.2018 19.1212 240083 19.7637 21.0317 22.3289 20.9906 240084 19.4739 21.7421 23.1951 21.4482 240085 22.5736 20.9778 20.7535 21.3852 240086 16.9392 18.1401 18.1497 17.7863 240087 18.8352 21.3323 21.2116 20.4135 240088 21.6858 23.1056 24.6260 23.0939 240089 20.7239 21.1989 21.3949 21.1104 240090 19.2968 19.2166 21.0856 19.8725 240093 18.7092 20.2400 20.7138 19.9194 240094 20.9446 22.0247 22.5923 21.8995 240096 20.1644 21.0417 20.2992 20.4825 240097 24.2662 27.9496 29.7597 27.1621 240098 21.3467 24.2296 23.9626 23.2314 240099 14.4649 15.4964 18.8139 15.9924 240100 20.8302 20.8325 24.1875 21.9081 240101 19.2120 19.9837 22.1329 20.4409 240102 14.6067 16.3659 15.5114 15.4871 240103 19.1540 18.7510 21.0182 19.5968 240104 23.2178 23.5351 25.2485 24.0080 240105 14.3965 * * 14.3965 240106 23.5148 23.5005 23.9677 23.6780 240107 20.3983 20.9004 21.2163 20.8360 240108 15.3547 18.2427 17.6500 16.9347 240109 13.5537 16.3216 15.1369 14.9110 240110 19.4828 21.0277 21.7340 20.7301 240111 17.2100 17.8617 19.9712 18.3046 240112 15.8350 16.6244 17.2437 16.5628 240114 16.2505 17.3682 18.3415 17.5274 240115 23.7765 23.8675 24.6174 24.0872 240116 16.6731 18.3520 17.3460 17.3960 240117 18.0636 17.9941 18.7656 18.2986 240119 20.6126 21.8289 23.0230 21.7338 240121 23.4018 22.2266 22.4858 22.6970 240122 19.1811 21.2876 20.7795 20.4095 240123 16.5098 18.3941 18.9494 17.8731 240124 19.4400 20.4728 21.2023 20.3644 240125 12.3627 14.9708 17.3846 15.0136 240127 15.8966 17.9724 16.4294 16.7198 240128 17.2513 16.3608 17.5611 17.0478 240129 14.4212 16.5209 17.7242 16.1756 240130 14.9399 16.4271 17.7634 16.3549 240132 23.0669 23.1452 24.4301 23.5642 240133 19.2126 19.5293 20.8958 19.9049 240135 14.3069 15.7015 15.6298 15.1560 240137 20.3750 21.5073 21.6644 21.1797 240138 15.2062 16.7332 18.9731 16.7753 240139 20.8053 20.5496 21.8580 21.0743 240141 23.8066 23.1009 23.6622 23.5109 240142 25.2770 29.2238 24.0719 25.9878 240143 16.6172 20.4266 20.7307 19.0810 240144 18.2604 21.4469 23.1661 20.7059 240145 17.2778 19.0689 17.6747 18.0668 240146 16.0652 16.5412 17.3275 16.6788 240148 18.8779 19.5204 19.5372 19.2785 240150 13.8786 20.8331 23.3857 18.4647 240152 21.1678 22.4744 24.1818 22.6586 240153 16.5412 19.3336 17.7399 17.7721 240154 17.5769 21.5052 21.5859 20.1583 240155 19.8762 20.9385 23.6944 21.5112 240157 17.4168 13.7309 * 15.5390 240160 15.9492 15.9014 16.4990 16.1163 240161 15.7996 16.8809 18.0542 16.8888 240162 16.6292 19.1542 19.3296 18.3301 240163 18.8320 20.4760 22.2009 20.3835 240166 17.3233 19.4131 19.4496 18.7799 240169 16.6725 16.3958 * 16.5195 240170 18.8762 20.3779 21.5994 20.2122 240171 17.2886 18.5172 19.6732 18.5083 240172 18.2852 20.8606 20.3699 19.7027 240173 17.2655 18.5187 18.3183 18.0300 240179 17.5116 20.4004 17.7557 18.4699 240184 15.3793 16.8917 17.6979 16.5493 240187 19.9230 21.2736 23.2471 21.4869 240193 17.8226 18.4664 * 18.1403 240196 24.3472 25.3479 26.1827 25.3447 240200 14.3415 14.9076 18.7517 15.8336 240207 24.1127 25.2814 26.1748 25.2384 240210 24.2218 24.5664 25.3031 24.7274 240211 19.7399 30.6260 34.7849 25.7741 250001 18.4233 19.2756 20.2019 19.2920 250002 17.2501 18.6938 19.6081 18.5060 250003 17.6539 16.7570 18.7331 17.7215 250004 17.8868 18.3860 19.2913 18.5189 250005 12.5993 12.5834 13.7341 13.0041 250006 16.9048 17.5192 19.6894 17.9911 250007 19.2913 19.7562 20.9757 19.9959 250008 14.1760 15.8506 15.8096 15.2607 250009 18.5610 17.7283 17.1686 17.8180 250010 13.3905 14.6101 16.0233 14.5948 250012 14.1623 16.7579 17.4032 16.1420 250015 13.5274 11.7249 16.6522 13.7345 250017 17.9410 20.5976 18.8850 19.0991 250018 11.9311 13.1687 14.7291 13.0932 250019 16.7425 18.0956 19.9070 18.3382 250020 13.4476 16.2698 19.6575 16.1595 250021 9.4318 10.5844 12.7242 10.6438 250023 13.9116 12.3434 13.8210 13.3756 250024 12.7127 12.9899 14.8394 13.4135 250025 19.0390 20.3625 21.9075 20.5374 250027 14.9519 14.5445 15.1790 14.8945 250029 16.4834 16.0682 14.8216 15.7783 250030 17.3636 26.6173 25.5089 23.0726 250031 17.9715 18.3825 19.8779 19.1622 250032 17.1339 17.5957 * 17.3669 250033 17.8257 15.0941 16.9132 16.6524 250034 16.6988 17.0399 19.1875 17.6568 250035 15.2353 16.8349 18.3861 16.7093 250036 15.8445 16.1913 17.6247 16.6012 250037 15.4325 12.7156 14.3994 14.0734 250038 16.8454 17.7019 18.8434 17.7665 250039 14.1556 15.1409 16.4502 15.2329 250040 17.3430 18.3364 19.6513 18.4442 250042 16.3867 17.6531 18.3858 17.4884 250043 16.0729 16.6500 18.4025 16.9554 250044 16.1218 16.7321 19.1860 17.3262 250045 22.0839 21.8988 22.7225 22.2606 250047 13.3706 14.7461 * 13.9984 250048 16.8932 17.6649 19.4976 18.0474 250049 11.6715 12.1635 12.8275 12.2266 250050 14.3949 15.1159 16.0234 15.1991 250051 9.3464 10.4900 10.1212 9.9666 250057 15.9237 16.1838 16.3204 16.1462 250058 15.5327 15.7197 16.2623 15.8399 250059 16.2845 16.6494 17.7592 16.8861 250060 13.0301 16.1804 12.6893 13.8440 250061 11.0308 11.5108 12.0186 11.5214 250063 13.2540 13.3092 15.0894 13.8432 250065 12.8853 13.6904 15.0507 13.8065 250066 15.6760 16.1742 17.2711 16.3375 250067 16.4120 16.8522 18.3773 17.2393 250068 13.6768 13.4127 13.2644 13.4415 250069 17.8960 16.8980 18.2097 17.6479 250071 14.3781 12.3488 13.1934 13.2742 250072 18.2218 18.9487 21.0602 19.2655 250076 10.5098 * * 10.5098 250077 12.2564 13.7404 13.9479 13.2870 250078 15.6336 15.9739 17.1972 16.2928 250079 16.2712 16.5835 16.1483 16.3337 250081 17.3325 19.0358 18.1848 18.1653 250082 16.0975 17.1427 17.3096 16.8599 250083 14.2634 16.6065 16.3054 15.6454 250084 17.0189 20.6429 21.0870 19.3827 250085 14.3797 15.4477 16.7377 15.5314 250088 17.8674 18.2736 19.3976 18.4880 250089 13.4238 14.3027 15.0238 14.2301 250093 15.2044 16.1506 16.8647 16.0778 250094 18.0852 18.5063 18.9681 18.5063 250095 17.0039 17.4217 18.4944 17.6334 250096 19.0688 19.0584 19.3630 19.1609 250097 16.9905 15.5741 16.3328 16.3172 250098 13.1341 18.3874 17.9180 16.1645 250099 14.8528 15.1265 15.9867 15.3437 250100 17.1682 17.8688 19.8795 18.3539 250101 18.4685 17.7194 17.6704 17.9924 250102 23.9329 18.9348 * 21.2970 250104 18.2502 18.7651 19.0165 18.6823 250105 14.5401 15.5133 16.1480 15.4020 250107 15.1496 15.0737 16.5635 15.5581 250109 22.1551 21.3867 24.5760 22.6981 250112 15.5610 16.3640 16.6447 16.1593 250117 16.1225 16.9787 15.9335 16.3432 250119 15.2199 16.1218 16.5700 15.9756 250120 15.3433 16.7182 18.1428 16.6322 250122 18.9417 19.2990 19.8033 19.3541 250123 18.8690 18.7863 22.1376 19.9106 250124 13.1823 13.2490 14.3551 13.5956 250125 20.8895 21.2660 21.3711 21.1778 250126 18.2355 21.9101 19.0168 19.6297 250128 14.0048 16.1418 15.9958 15.4423 250131 12.6056 12.4557 11.2470 12.0464 250134 17.0671 18.5142 21.4489 18.9054 250136 18.9689 21.3497 20.0333 20.0576 250138 18.4028 20.4550 19.3446 19.3211 250141 19.0113 19.6692 21.6835 20.2708 250145 10.2507 11.2120 11.2021 10.8489 250146 14.4924 14.7781 15.4061 14.8913 250148 18.0980 19.4233 23.1459 20.1203 250149 12.9569 15.2318 15.7537 14.6277 250150 * 21.8599 * 21.8599 260001 18.0971 20.1560 20.9602 19.7021 260002 22.1183 21.6597 23.4259 22.4118 260003 14.6553 15.4482 16.0721 15.3980 260004 13.0133 13.7035 15.2735 13.9164 260005 19.5554 23.9681 22.2119 21.8900 260006 19.7467 20.0994 22.1692 20.6408 260008 13.8495 16.8893 18.2114 15.8498 260009 18.5080 18.2863 19.0654 18.6237 260011 19.1027 19.5059 20.3279 19.6368 260012 14.3645 17.1662 17.3810 16.3363 260013 15.9884 16.1825 17.3772 16.4946 260015 16.5822 17.8817 18.0070 17.4241 260017 16.7916 16.9914 17.9796 17.2888 260018 12.0060 12.5301 13.6120 12.7676 260019 18.6113 * 18.3629 18.4928 260020 20.5142 20.2241 21.0314 20.5884 260021 22.1017 21.6237 23.3527 22.2918 260022 17.2462 17.7772 18.7707 17.9082 260023 16.4705 17.8649 18.5665 17.6119 260024 15.2356 15.7815 15.6095 15.5379 260025 15.4935 17.0965 18.2804 16.9786 260027 21.2977 22.0362 23.1505 22.1110 260029 19.7484 21.1858 20.1832 20.3332 260030 12.5118 11.9215 12.8349 12.4289 260031 19.4921 19.7249 22.5379 20.4276 260032 20.1988 19.6728 20.1817 20.0177 260034 17.4233 20.4902 20.5439 19.5050 260035 13.1065 13.0071 15.1611 13.8141 260036 16.7430 18.8104 19.9593 18.5490 260039 14.1866 14.6644 15.9689 14.9611 260040 17.3099 18.0140 18.5132 17.9641 260042 18.7567 18.7514 20.8821 19.5084 260044 15.9927 15.9206 16.7879 16.2332 260047 19.0112 19.2247 19.8178 19.3380 260048 20.0885 21.0602 22.4800 21.2299 260050 15.6908 16.8520 17.6687 16.7168 260052 18.0553 18.0914 19.1044 18.4413 260053 15.2236 16.5166 17.4110 16.3851 260054 20.0199 20.6242 23.0188 21.1083 260055 12.0118 15.4214 17.9547 14.9547 260057 17.4636 19.7144 16.5704 17.9947 260059 16.1000 17.0546 16.2074 16.4474 260061 14.7175 15.7112 17.1343 15.8685 260062 20.1477 21.3138 21.9287 21.1699 260063 18.2309 18.8973 19.7231 18.9234 260064 16.5934 17.8033 18.3749 17.5653 260065 19.4382 20.0975 20.6671 20.0563 260066 14.9640 15.3460 15.3139 15.2114 260067 14.2249 15.1837 14.5499 14.6334 260068 20.2418 19.4240 20.7947 20.1541 260070 * 13.9510 18.7384 16.1582 260073 14.2550 15.9182 16.9496 15.7508 260074 19.0350 19.8915 20.4033 19.8192 260077 18.6473 19.4482 20.5830 19.5877 260078 15.6381 14.9463 16.0586 15.5564 260079 14.2985 16.1453 16.4816 15.5347 260080 13.5384 14.6832 13.1617 13.7147 260081 21.0151 20.3053 20.2471 20.5212 260082 15.9407 15.9858 18.2853 16.7287 260085 20.4669 20.7051 21.5137 20.8993 260086 14.3164 15.2927 16.7579 15.4677 260091 19.9987 21.5464 22.0772 21.4012 260094 18.0085 18.5395 19.7308 18.8006 260095 19.6944 20.7292 21.6999 20.6994 260096 23.0282 22.5972 22.8259 22.8155 260097 16.5582 19.0632 18.6965 18.1123 260100 15.7047 16.6523 16.5439 16.3025 260102 20.1264 20.6361 21.2133 20.6454 260103 18.5957 19.7146 19.9144 19.3556 260104 21.0138 20.3176 21.6624 21.0040 260105 24.7223 24.8181 22.8005 24.0843 260107 19.8422 20.4269 22.5214 20.7581 260108 19.4609 20.0034 20.9029 20.1514 260109 13.9129 14.8181 15.9724 14.8936 260110 17.8375 18.3227 19.5633 18.5673 260113 14.6756 16.2223 16.1346 15.6436 260115 19.2259 17.4698 19.3873 18.6920 260116 16.2774 14.9812 16.0187 15.7314 260119 16.8836 17.2942 18.0725 17.4218 260120 16.3755 16.4904 17.6811 16.8504 260122 14.9697 16.0931 16.3700 15.8295 260123 14.6444 14.6822 15.2926 14.8761 260127 18.3572 18.4026 18.1342 18.2957 260128 13.0481 12.6414 13.2942 12.9961 260131 17.7686 18.4154 18.0395 18.0595 260134 16.2832 17.5127 17.1341 16.9643 260137 17.9531 19.4697 19.5976 19.0342 260138 22.6491 23.2364 23.1213 22.9952 260141 19.1580 19.1893 19.6237 19.3180 260142 17.1248 17.3084 18.2023 17.5590 260143 12.7867 13.9040 15.4688 13.9600 260147 14.0778 14.7769 15.8522 14.8908 260148 11.8674 11.3524 12.6651 11.9425 260158 12.3005 12.7699 13.9790 13.0499 260159 20.3177 19.7951 20.9636 20.3519 260160 15.8394 16.5792 18.4007 16.9325 260162 19.5655 21.4099 20.7331 20.5870 260163 16.4245 15.8593 16.8300 16.3731 260164 14.9372 15.1211 16.7279 15.6074 260166 20.1025 21.1224 22.4071 21.2079 260172 15.4163 16.0772 16.4854 15.9816 260173 12.8523 14.2090 15.5733 14.3947 260175 16.9023 17.5625 18.3632 17.6144 260176 26.8712 21.6044 23.2414 23.9990 260177 21.2578 21.9014 22.9091 22.0689 260178 19.6638 20.2796 20.8189 20.2016 260179 21.4906 22.7185 21.4470 21.8753 260180 19.5819 18.9881 19.5983 19.3863 260183 20.0712 21.3175 23.7057 21.6731 260186 19.3238 19.6026 21.0675 20.0580 260188 20.6388 22.5060 23.7475 22.1881 260189 11.3004 16.4233 * 13.8239 260190 18.5168 19.3419 21.6994 19.8001 260191 17.9812 18.1604 19.6784 18.6471 260193 21.1588 20.2577 22.2030 21.2172 260195 17.7237 19.7068 * 18.7154 260197 19.2840 20.5453 * 19.7846 260198 11.9751 19.7552 21.7926 16.7576 260200 20.5339 20.6888 21.7031 21.0210 260205 17.6210 * * 17.6210 270002 28.9959 19.2387 19.0221 21.4738 270003 22.0995 22.5019 20.7277 21.7202 270004 19.6292 19.4834 20.1821 19.8074 270006 16.0238 17.0715 15.1006 15.9252 270007 11.3143 13.8824 15.5780 13.1858 270009 17.2292 20.8238 20.7031 19.5097 270011 20.2669 21.1653 21.8086 21.0508 270012 19.7346 19.7878 20.7913 20.0975 270014 19.0872 19.9859 20.4321 19.8518 270016 19.6717 18.6149 17.9984 18.9093 270017 21.0800 20.0152 22.1046 21.0660 270019 18.1099 15.4128 18.5111 17.2358 270021 17.1787 16.9457 18.0515 17.3782 270023 22.2639 22.7181 22.7162 22.5721 270026 17.5102 18.0568 20.1673 18.5919 270027 13.1392 17.2091 17.2005 15.5928 270028 21.1492 19.1177 19.6212 19.9204 270029 16.5666 17.3710 18.2097 17.3728 270032 17.7393 18.7811 19.3937 18.6694 270033 16.9602 18.4876 20.7060 18.6303 270035 16.8295 16.4302 17.9822 17.0833 270036 14.2537 16.8552 16.1031 15.5470 270039 15.9368 19.6796 20.3800 18.4120 270040 18.8145 20.1242 20.1887 19.6792 270041 19.0327 25.8153 * 21.5554 270044 16.7710 17.5137 19.2939 17.7721 270048 17.0154 18.0666 17.4506 17.4823 270049 22.2444 22.2540 22.0263 22.1740 270050 16.7110 19.9356 19.6317 18.7001 270051 20.2735 20.1950 20.0386 20.1652 270052 14.4773 14.7009 17.1932 15.3511 270057 21.1317 20.6714 20.1507 20.6215 270058 14.7481 16.1412 18.4780 16.2593 270059 14.7530 19.1808 16.9303 16.8245 270060 15.2727 20.4148 21.3776 18.5305 270063 12.6108 15.1049 16.4553 14.5559 270073 14.4569 16.1937 16.6083 15.6741 270079 15.6873 16.7048 19.5493 17.1331 270080 16.3171 15.0705 16.6010 15.9696 270081 15.6262 16.7389 18.0543 16.7908 270082 17.3443 23.1245 23.3209 21.2882 270083 18.4432 17.8554 16.8420 17.6939 270084 16.6243 16.2958 15.7062 16.1694 280001 17.3541 18.1831 18.7137 18.0270 280003 22.3179 23.0213 20.0498 21.6193 280005 19.2405 23.6949 20.1943 21.0207 280009 19.8145 20.9643 23.2300 21.3319 280010 17.4859 20.0462 * 18.1962 280011 15.8573 15.9614 16.2281 16.0212 280013 22.8063 22.5163 24.0852 23.1972 280014 15.9596 16.8368 16.7109 16.5080 280015 17.0281 16.6939 18.0207 17.2299 280017 14.2059 13.9939 16.9884 15.1266 280018 15.1328 15.4496 16.6439 15.7480 280020 19.9667 21.2467 21.9587 21.0976 280021 17.1048 17.6345 19.1263 17.9823 280022 16.7179 16.8184 15.3785 16.3083 280023 25.8494 22.3433 21.5761 23.0011 280024 14.2186 15.0380 15.8747 15.0019 280025 15.5850 21.4764 22.2214 19.5445 280026 16.6861 16.5851 18.7258 17.3359 280028 17.3176 18.0793 19.1080 18.1555 280029 23.1292 24.4359 17.1351 21.6012 280030 24.5366 24.7723 26.3542 25.1586 280031 13.5654 9.6321 9.6951 11.0351 280032 18.8964 19.1191 20.5246 19.5206 280033 15.7583 17.4745 17.9841 17.1215 280035 15.9170 16.6872 18.6089 16.9364 280037 16.7952 17.1064 14.8049 16.2282 280038 17.0878 18.2503 18.9305 18.0758 280039 16.0442 16.1587 17.0153 16.4148 280040 19.5333 20.9896 21.5426 20.7346 280041 16.4083 16.5503 16.6889 16.5558 280042 16.1191 16.6239 16.4684 16.3973 280043 16.6570 17.5937 16.8186 17.0314 280045 16.9048 15.7630 17.7408 16.7631 280046 17.9221 17.3214 17.9752 17.7358 280047 18.3407 17.4735 21.3143 18.9885 280048 15.8723 15.8100 17.9319 16.5389 280049 18.3605 18.4365 19.4589 18.7530 280050 16.6432 20.0379 * 18.4507 280051 15.6336 17.1942 19.6206 17.2054 280052 14.0819 14.1201 14.9903 14.4198 280054 18.7992 18.7575 19.4049 18.9732 280055 13.5667 13.8129 14.2046 13.8644 280056 12.6475 15.6135 15.6442 14.4971 280057 18.0454 20.0686 21.4754 19.8186 280058 19.6752 21.4868 22.8105 21.3952 280060 19.7527 20.7022 22.4677 20.9351 280061 17.1629 18.6370 20.2066 18.7084 280062 14.4896 15.6018 16.1708 15.4336 280064 16.2977 16.8330 18.2196 17.1053 280065 19.2932 20.7370 21.6999 20.6166 280066 11.6621 11.7207 12.2225 11.8688 280068 9.4943 10.5987 10.5103 10.1786 280070 17.7400 22.6201 18.7211 19.4766 280073 17.4244 17.7698 18.3496 17.8530 280074 16.4310 17.3143 13.6025 15.4955 280075 15.5327 13.2230 13.3154 13.8859 280076 14.8469 16.7488 16.1939 15.8857 280077 19.2068 20.0148 21.1883 20.1246 280079 10.4540 16.6117 17.1519 13.6519 280080 15.3308 16.9487 16.1902 16.1919 280081 21.0771 20.9606 23.3805 21.7809 280082 14.3399 14.6173 15.4420 14.8136 280083 18.2992 21.5336 20.8995 20.2370 280084 12.5836 13.6536 13.2158 13.1411 280085 20.4302 20.4825 20.8532 20.5742 280088 20.2961 * * 20.2961 280089 18.1668 18.9567 19.9003 18.9565 280090 14.1362 15.1274 * 14.6858 280091 15.8436 16.1866 16.3456 16.1284 280092 14.1945 14.7912 13.3032 14.1038 280094 17.6873 16.3474 16.9180 16.9734 280097 14.1734 13.8223 14.1870 14.0603 280098 13.0029 12.5875 12.4995 12.6927 280101 13.5261 16.9973 10.5153 13.1647 280102 14.0102 * * 14.0102 280104 13.2819 16.2167 15.5949 14.8930 280105 18.6575 21.0735 23.7103 21.1232 280106 16.1247 16.0679 16.3564 16.1791 280107 13.3311 14.4679 * 13.8480 280108 17.5625 17.1961 18.5134 17.7698 280109 12.6803 12.4408 * 12.5540 280110 12.7546 14.2136 13.0278 13.3282 280111 21.8773 19.6283 19.3508 20.2354 280114 15.7160 17.3076 17.1154 16.7114 280115 16.7041 18.1480 18.3464 17.7487 280117 17.7276 18.8279 20.3819 18.9864 280118 16.8687 18.6524 17.8891 17.8029 280123 14.0637 11.8582 23.6682 15.2035 280125 16.1332 16.3944 17.2718 16.5861 290001 22.8226 22.7450 24.1873 23.2686 290002 17.2554 16.5419 16.7948 16.8714 290003 22.8840 24.2175 24.4237 23.8452 290005 19.4888 21.9814 22.7804 21.4325 290006 21.8070 22.4063 19.9226 21.3745 290007 29.7706 30.9075 30.2824 30.3297 290008 20.6190 24.1255 26.9216 23.3785 290009 23.3620 23.9373 24.5919 23.9575 290010 15.6423 16.4476 20.8387 17.4968 290011 20.1564 21.1234 19.7410 20.3076 290012 21.8275 25.0430 25.3963 24.1843 290013 18.2713 15.7932 20.2914 17.8815 290014 18.9743 18.7829 20.2762 19.3806 290015 22.3487 19.4504 20.2336 20.6208 290016 14.3542 23.8656 21.8030 19.3661 290019 21.2509 22.2045 22.5584 22.0258 290020 20.8733 21.2380 19.5039 20.6806 290021 21.5806 22.9488 23.4950 22.6778 290022 24.5468 25.5011 24.8144 24.9547 290027 16.7786 13.3769 13.1463 14.2467 290032 22.8447 23.9504 26.8557 24.6837 290036 * 12.9074 * 12.9074 290038 20.6753 27.7030 26.0836 23.3519 290039 25.3864 25.5024 26.2466 25.7352 290041 * 25.9905 27.0613 26.6211 290042 * 18.7527 18.7669 18.7611 290043 * 27.9053 * 27.9053 300001 22.0909 23.8567 25.7142 23.9386 300003 22.9111 24.1297 25.3252 24.1024 300005 20.7545 22.2858 22.0518 21.6894 300006 23.7793 18.9745 22.2642 21.6739 300007 20.2372 20.6325 21.3633 20.7580 300008 20.7702 19.6149 20.9207 20.4237 300009 18.0602 20.0938 20.1193 19.3850 300010 19.3940 20.2130 21.0316 20.1973 300011 22.4325 23.0279 23.8390 23.0923 300012 24.5673 24.5619 25.8581 25.0347 300013 19.1247 20.1669 20.0983 19.8032 300014 20.3292 20.1774 21.6705 20.7353 300015 20.4916 19.6627 22.8966 21.0797 300016 21.8659 17.8148 15.1311 18.1853 300017 21.6563 22.7191 23.9651 22.8162 300018 21.2381 21.6385 22.9623 21.9864 300019 20.9753 19.6728 20.5801 20.4037 300020 21.9165 22.6627 23.0806 22.5724 300021 18.6211 19.3101 20.2585 19.4039 300022 18.3507 19.1875 20.1635 19.2197 300023 22.1210 22.7649 22.1896 22.3579 300024 19.9116 21.5842 22.2235 21.2127 300028 17.4075 20.0778 21.4207 19.6713 300029 22.5748 22.6013 23.8415 23.0427 300033 17.1869 17.1632 17.4836 17.2725 300034 25.5182 24.4975 25.2355 25.1020 310001 28.1329 27.4730 28.6540 28.0966 310002 28.3434 27.9728 28.5941 28.3065 310003 29.1096 27.5624 28.8314 28.5051 310005 22.1146 22.9712 22.9664 22.6779 310006 21.5957 22.0894 24.1538 22.5976 310008 23.5084 24.7618 26.4989 24.9206 310009 23.6371 21.7094 23.2420 22.8675 310010 22.5682 23.1060 24.5471 23.4312 310011 23.1977 24.2885 25.4900 24.3173 310012 26.5242 26.6772 28.0541 27.1062 310013 21.2251 22.5603 23.0073 22.2711 310014 27.4614 23.1956 31.0374 27.0132 310015 27.4331 27.9684 * 27.7058 310016 24.3838 24.5206 25.4844 24.7602 310017 25.7902 24.5976 25.1634 25.1866 310018 22.8428 22.4779 24.1496 23.1662 310019 24.0542 24.9914 28.5952 25.8565 310020 24.1848 24.4152 25.0803 24.5523 310021 23.9369 25.4393 29.9117 26.2679 310022 21.2706 20.8258 21.2563 21.1130 310024 24.2353 24.9521 27.2475 25.4630 310025 24.3513 24.1812 25.5227 24.6926 310026 23.5491 22.1997 23.2895 22.9937 310027 21.8846 22.5696 24.4437 22.9152 310028 23.4577 23.9428 26.1931 24.5392 310029 22.6629 23.6610 25.2587 23.8421 310031 26.1567 26.6831 26.7174 26.5090 310032 24.3528 24.7404 25.4768 24.8830 310034 23.2729 24.1150 27.1303 24.7884 310036 20.1905 21.7187 23.0320 21.6137 310037 27.7823 28.1289 29.0864 28.3334 310038 26.7209 28.4893 28.4732 27.9039 310039 22.1754 22.7317 23.6605 22.8221 310040 26.1492 26.3573 26.5964 26.3696 310041 24.8960 23.5559 24.9733 24.4816 310042 23.2472 24.7678 25.7747 24.5600 310043 21.9022 21.6128 24.0238 22.3478 310044 21.6677 23.1549 23.3801 22.7473 310045 28.4854 28.9274 29.5452 28.9708 310047 25.1101 26.1921 25.9777 25.7489 310048 23.6118 25.2870 23.4189 24.0965 310049 24.8299 27.0842 25.6732 25.8686 310050 25.1752 24.7988 23.7735 24.5800 310051 27.1265 27.5378 28.5946 27.7258 310052 22.9326 23.3973 27.0616 24.3173 310054 26.1726 27.7376 26.9352 26.9153 310057 21.1686 22.2572 22.2630 21.9057 310058 26.5308 26.3765 25.9389 26.3360 310060 19.1992 20.0997 21.6211 20.2716 310061 23.2646 33.9582 23.4283 26.0987 310062 22.9073 * * 22.9073 310063 21.9045 22.1080 23.5217 22.4712 310064 24.8567 25.4822 25.3339 25.2160 310067 25.0888 23.9278 24.1943 24.4277 310069 23.7531 24.2329 25.4373 24.4865 310070 26.0903 28.2220 30.1143 28.0038 310072 21.7605 22.5611 25.0708 23.0824 310073 28.5149 26.2937 29.2805 27.9813 310074 23.8340 22.3588 24.1313 23.4934 310075 23.3266 24.4788 23.9771 23.9276 310076 30.0797 27.9918 31.4866 29.8824 310077 25.2500 26.1251 26.7227 26.0109 310078 23.8841 24.0587 24.5862 24.1519 310081 22.0762 22.4086 23.2059 22.5650 310083 23.8852 24.8204 25.0191 24.5773 310084 26.6753 24.6049 25.5110 25.5914 310086 22.1674 23.1719 23.5820 22.9629 310087 20.7243 21.1215 20.7434 20.8650 310088 22.3160 23.1722 24.2150 23.2258 310090 23.8284 24.8986 24.4746 24.3899 310091 22.7978 23.2969 24.5357 23.5110 310092 20.5165 21.6964 23.1341 21.7772 310093 22.4291 23.7251 24.0037 23.3380 310096 25.1572 24.5759 26.6982 25.4341 310105 25.5891 26.2537 25.1559 25.6770 310108 22.4756 23.8308 26.2036 24.1336 310110 21.8341 23.2146 23.1789 22.7903 310111 21.1066 22.1151 24.1731 22.4723 310112 23.6701 24.7914 24.2999 24.2528 310113 23.6841 23.1961 24.0930 23.6671 310115 21.7320 21.1645 23.4249 22.1167 310116 22.9812 23.6366 * 23.3055 310118 26.4625 26.1315 26.5619 26.3869 310119 33.6686 32.7858 29.1045 31.7976 310120 23.9681 23.3200 22.6526 23.3189 320001 19.1150 20.6225 21.0689 20.2496 320002 22.6175 23.0983 25.5144 23.6846 320003 15.9504 16.4642 16.4961 16.3037 320004 18.5824 19.6642 21.3681 19.9888 320005 21.6103 21.0411 22.4178 21.7283 320006 18.9019 20.3863 19.8672 19.6917 320009 18.2883 19.3500 20.3783 19.2661 320011 20.0601 18.5222 18.7099 19.0944 320012 16.4355 17.1764 14.3961 16.0417 320013 22.9573 24.5543 24.4795 24.0591 320014 16.3598 16.8412 21.7784 18.0981 320016 20.5398 18.8519 18.8763 19.4121 320017 18.6388 19.4498 20.4390 19.4898 320018 18.8479 19.2336 20.4375 19.5136 320019 24.4707 26.9637 24.4394 25.3985 320021 17.8705 19.1265 19.6950 18.8702 320022 16.1777 18.0606 19.9587 18.1477 320023 18.0548 17.8419 * 17.9685 320030 16.5495 18.6859 18.1556 17.7555 320031 19.6768 25.1715 18.2244 20.7137 320032 18.8097 20.6871 21.1628 20.1426 320033 25.0777 21.0621 21.9804 22.5777 320035 21.5186 15.0612 17.8058 17.7193 320037 17.0305 17.8280 17.6619 17.5121 320038 16.8117 22.2664 * 19.6948 320046 18.3190 18.9607 22.6251 20.0803 320048 19.9642 16.8769 * 18.3467 320063 18.3237 17.9089 14.4611 17.0236 320065 16.7933 18.6525 22.1138 18.8982 320067 33.8654 15.3228 16.8015 18.3132 320068 17.4785 18.5103 15.6681 17.1335 320069 13.0094 14.4212 15.7350 14.3622 320074 19.3406 20.2290 22.3403 20.2679 320079 18.2828 19.8555 19.9049 19.3010 330001 26.5533 27.3996 28.4974 27.5189 330002 26.5370 26.9341 26.6966 26.7185 330003 19.4102 18.9211 19.3972 19.2414 330004 22.5298 20.9501 22.5082 22.0002 330005 24.8338 22.1957 22.6137 22.8232 330006 25.0576 25.8006 26.2970 25.7013 330007 18.9024 * * 18.9024 330008 19.0045 19.2341 19.6770 19.3060 330009 30.6918 31.3435 30.9087 30.9793 330010 17.4512 16.6508 17.8935 17.3146 330011 18.2986 18.6748 18.7995 18.5936 330012 32.7624 * * 32.7624 330013 19.0856 19.6269 19.0995 19.2697 330014 32.3370 36.8669 32.4496 33.8020 330016 16.9717 16.8016 18.7194 17.4483 330019 35.9822 33.5369 31.5927 33.4812 330020 15.5527 15.1142 16.6952 15.7780 330023 24.4006 25.6512 26.6997 25.5866 330024 34.1682 37.3316 35.7485 35.6717 330025 16.2033 16.8687 17.6169 16.8903 330027 33.4738 35.5255 35.1046 34.6601 330028 28.2089 29.5294 31.7699 29.9762 330029 18.1567 17.0016 19.4377 18.2068 330030 17.4977 19.1085 18.0866 18.1511 330033 18.5353 17.4444 19.4402 18.4646 330034 31.3997 27.7738 38.2451 31.3373 330036 23.9874 25.2820 25.5888 24.9782 330037 16.1140 16.4866 18.3260 16.9831 330038 16.2549 17.3429 16.2997 16.6434 330041 24.5215 31.4871 29.5305 28.1630 330043 28.7467 27.4661 28.9622 28.3990 330044 20.0238 19.5219 19.9808 19.8437 330045 28.0758 27.9919 28.5267 28.2011 330046 32.4189 35.2703 38.1184 35.1742 330047 18.1815 18.5536 19.5561 18.7655 330048 17.8787 19.1093 19.6129 18.8634 330049 19.4993 20.5731 22.1523 20.7576 330053 17.4430 17.8082 17.8308 17.6930 330055 36.1109 32.8910 32.6387 33.8113 330056 30.4525 30.0945 29.8377 30.1337 330057 18.7478 19.3643 20.0995 19.4010 330058 17.0014 17.7672 18.1007 17.6091 330059 34.1705 34.2426 35.0121 34.4519 330061 25.7331 25.4082 26.8580 25.9786 330062 17.6067 18.1318 18.4662 18.0774 330064 33.1269 33.6447 35.1422 33.9496 330065 19.8940 19.9305 20.2835 20.0284 330066 19.5611 18.8707 19.5272 19.3115 330067 20.9443 22.1065 23.6836 22.2657 330072 30.8019 30.4171 30.3737 30.5362 330073 16.2898 16.4518 16.5166 16.4181 330074 18.0005 17.7308 18.7081 18.1472 330075 17.2298 17.6385 18.9699 17.9293 330078 16.7949 18.7884 18.0362 17.8405 330079 17.4555 18.7622 18.9398 18.3917 330080 29.2686 31.4424 28.3401 29.6840 330084 18.0435 19.3216 19.0261 18.8002 330085 20.2926 20.6203 22.8312 21.2658 330086 31.2980 23.6496 26.2979 27.1579 330088 25.6626 25.7940 26.7583 26.0739 330090 19.3954 19.2112 20.4314 19.6779 330091 19.0953 19.7776 21.6004 20.1526 330092 14.0671 13.3723 17.2083 14.8861 330094 17.5585 18.1582 18.7259 18.1488 330095 20.1073 21.1096 21.1809 20.7563 330096 17.9641 18.5149 20.0370 18.8403 330097 16.2169 16.4433 15.8232 16.1519 330100 27.0661 29.0916 28.9956 28.3021 330101 32.4105 31.5914 34.7119 32.9505 330102 17.5755 19.0058 21.0057 19.0881 330103 15.7197 16.8110 17.8864 16.8159 330104 31.6471 31.2074 31.9154 31.5867 330106 40.2686 35.3775 35.1434 36.7949 330107 28.5580 27.7797 28.9225 28.4199 330108 17.3605 18.0786 18.5194 17.9737 330111 19.5314 15.9321 13.3352 15.9787 330114 17.3522 17.0581 19.1162 17.8316 330115 17.4430 17.4684 13.0722 15.4701 330116 24.4622 14.9610 16.8567 18.1237 330118 20.6936 * * 20.6936 330119 34.8385 33.1179 33.5653 33.8391 330121 16.1052 16.3385 17.1869 16.5359 330122 20.8204 20.2417 23.0384 21.3559 330125 19.8494 19.7638 20.3093 19.9745 330126 23.7938 23.8957 24.8787 24.2123 330127 31.9046 30.7356 33.9627 32.2469 330128 29.0222 30.8242 27.7350 29.2603 330132 15.7633 14.3673 14.8704 15.0313 330133 37.2494 35.3576 37.5192 36.5906 330135 18.7120 22.2670 23.5662 21.3289 330136 18.2422 20.1043 20.0552 19.4517 330140 19.1438 19.3615 20.2951 19.5989 330141 26.4956 26.7096 27.5960 26.9363 330144 14.0566 16.2517 17.1513 15.7880 330148 16.8151 16.2782 16.7251 16.6024 330151 16.0714 15.7594 15.2233 15.6663 330152 30.5409 30.8314 33.4288 31.5069 330153 18.9689 18.1776 19.4417 18.8671 330157 22.0792 22.3804 23.1743 22.5628 330158 25.7569 27.1228 29.3163 27.3406 330159 19.1536 19.4998 20.2601 19.6219 330160 32.7840 29.5885 30.7893 30.9997 330162 27.1166 27.6010 27.9705 27.5570 330163 18.7816 20.7456 21.4143 20.2444 330164 19.8647 20.9003 20.5006 20.4195 330166 15.0954 15.4420 17.0637 15.8309 330167 29.3634 30.2346 32.0728 30.4495 330169 37.2655 35.4794 36.3690 36.3400 330171 25.5307 24.8035 24.8515 25.0649 330175 17.3290 18.3116 18.8201 18.1260 330177 17.2907 16.3704 16.6059 16.7542 330179 13.4999 13.8953 15.8620 14.3577 330180 16.8787 17.9877 19.2670 17.9995 330181 32.5192 33.0908 34.2919 33.2777 330182 32.9371 33.6531 33.3363 33.3137 330183 19.9207 20.6164 19.6980 20.0807 330184 30.0400 31.3706 28.4726 30.0103 330185 25.6112 26.8612 27.8585 26.7622 330188 20.9587 18.8000 20.2849 20.0186 330189 15.1253 18.4498 23.5589 18.7634 330191 18.6206 19.0348 19.4168 19.0266 330193 36.5481 30.2260 32.5496 32.9872 330194 34.6785 35.2036 35.6486 35.1819 330195 33.3254 34.8966 29.8157 32.7136 330196 30.8165 30.5799 25.9671 29.2151 330197 17.6646 18.3527 19.2237 18.4045 330198 24.6038 24.8590 25.4472 24.9692 330199 28.7609 30.5409 26.0228 28.5436 330201 32.1149 28.7861 27.6320 29.6019 330202 31.4435 31.2575 31.9777 31.5574 330203 20.7575 25.0345 25.7916 23.7288 330204 29.4418 32.2005 28.4140 30.0233 330205 20.5793 22.3490 24.9040 22.5611 330208 26.1822 26.6682 27.3170 26.7219 330209 23.9924 25.1281 26.8546 25.3803 330211 19.5064 19.5405 20.0006 19.6855 330212 21.7705 24.7681 24.4902 23.6390 330213 18.7722 19.6796 20.1166 19.4878 330214 36.4447 32.4292 32.2640 33.3003 330215 19.6926 17.9863 19.0726 18.8818 330218 21.4796 21.1890 21.4747 21.3812 330219 23.9908 23.4310 25.1792 24.1748 330221 27.8485 33.3796 29.5535 30.2856 330222 18.3666 18.5571 19.3148 18.7515 330223 17.6199 17.8306 19.0773 18.1866 330224 19.6410 20.4309 20.7773 20.2793 330225 25.5823 27.0379 28.0523 26.7760 330226 16.6711 23.1859 16.9198 18.3930 330229 16.8026 17.5326 18.2554 17.5103 330230 29.7626 29.6283 30.6937 29.9984 330231 30.0923 32.7200 25.2793 29.5345 330232 17.9083 19.1787 19.6181 18.8942 330233 30.9241 44.1265 42.3510 37.9819 330234 35.1777 35.0720 35.8927 35.3813 330235 21.0842 19.5880 20.1255 20.2820 330236 29.5913 31.3463 30.9816 30.6263 330238 15.6245 17.3976 17.5807 16.8401 330239 17.4462 18.5079 18.9953 18.2764 330240 29.7082 30.7321 32.0049 30.7179 330241 24.6076 23.8638 24.7545 24.4065 330242 28.2612 27.6384 28.3561 28.0883 330245 17.6767 18.5161 20.7167 19.0400 330246 28.1090 28.1205 29.8777 28.6473 330247 28.5310 27.3937 32.5858 29.3555 330249 16.2687 17.1320 17.6846 17.0482 330250 19.5823 19.9619 20.7381 20.1092 330254 18.4057 15.9123 15.7864 16.7695 330258 29.7426 31.8910 32.6745 31.4411 330259 26.2661 25.9994 26.3620 26.2118 330261 25.7244 27.9766 30.0489 27.8583 330263 20.4149 18.7378 19.5057 19.6112 330264 22.8672 22.8099 24.6387 23.4672 330265 18.0193 17.6301 21.1215 18.8985 330267 24.5183 24.5939 27.8255 25.6678 330268 13.0595 15.9060 16.8358 15.2987 330270 34.4254 36.0824 31.3908 33.9198 330273 23.1511 26.0565 27.0454 25.3482 330275 19.0548 18.7268 * 18.9109 330276 18.2870 19.0228 19.2611 18.8572 330277 18.3169 19.1761 20.7851 19.4340 330279 19.5983 20.7107 21.7827 20.6371 330285 23.5264 24.0491 25.9154 24.4664 330286 26.7633 27.7762 28.0994 27.5677 330290 33.5056 30.4706 34.3439 32.7503 330293 16.2158 16.9238 17.2262 16.7522 330304 26.7683 27.3562 29.2207 27.7999 330306 27.3798 29.5937 25.6970 27.5466 330307 21.0673 21.7257 23.1148 21.9912 330314 24.5444 25.9937 25.5405 25.3155 330316 27.6102 27.9543 27.9277 27.8310 330327 16.4611 20.3874 20.1705 18.8688 330331 31.6216 33.1276 31.0718 31.9586 330332 27.6914 25.3689 27.6955 26.9473 330333 29.1931 * 28.8841 29.0179 330336 29.7689 29.8294 29.1415 29.5860 330338 22.4581 21.2670 23.6142 22.4472 330339 20.0111 20.1028 20.2382 20.1121 330340 28.8419 28.4129 29.4512 28.8934 330350 30.8889 30.9763 33.5493 31.7771 330353 32.1984 34.2431 34.2260 33.5106 330357 36.5928 34.1846 36.8598 35.8981 330372 28.8482 33.3771 27.8854 29.8144 330381 31.0091 31.8602 * 31.4219 330385 35.6722 33.2246 33.4159 34.1965 330386 17.6383 20.4231 21.4363 19.4104 330389 30.2505 37.3749 27.6223 31.1985 330390 31.1577 30.8744 33.4372 31.7841 330393 26.4958 27.8352 33.6061 29.1012 330394 19.2392 18.9343 19.6892 19.2847 330395 32.8749 32.7494 30.2846 32.0161 330396 34.8648 30.7961 29.1753 31.7581 330397 33.9061 32.6068 38.3281 34.7790 330398 28.7707 29.2872 * 28.9084 330399 32.9100 33.3012 32.7149 32.9707 330400 * 16.2707 16.8168 16.5566 340001 18.1814 19.7093 21.8572 19.9040 340002 20.8858 20.5253 22.2638 21.3163 340003 20.2540 19.5145 19.6545 19.8018 340004 19.0695 20.9863 23.0890 21.0811 340005 15.8205 16.7176 16.3073 16.2815 340006 16.9818 16.5709 16.1379 16.5756 340007 17.2356 18.3399 18.3760 17.9959 340008 21.2889 20.4157 22.0774 21.2828 340009 20.5023 20.9178 20.6155 20.6734 340010 18.3380 19.4302 20.6547 19.5049 340011 13.6554 14.4798 17.4534 15.1697 340012 18.8701 17.5112 19.3651 18.5479 340013 20.1747 19.4613 21.5130 20.3981 340014 20.5748 27.7888 21.9804 22.9126 340015 20.1562 19.4676 20.3493 19.9875 340016 17.5404 18.8958 19.4160 18.6049 340017 19.4192 20.2775 20.6263 20.1119 340018 14.0930 18.1751 16.4611 16.0927 340019 14.8980 15.2887 15.9037 15.3369 340020 18.6334 18.0897 19.2392 18.6598 340021 19.8020 20.5813 22.0220 20.7507 340022 17.8178 18.7714 20.6484 19.0742 340023 18.5414 19.3146 19.2617 19.0575 340024 17.3824 17.9130 19.1430 18.1515 340025 17.2648 18.4628 19.1770 18.3029 340027 18.0816 19.4548 19.4907 19.0172 340028 18.4787 19.9403 20.6496 19.7560 340030 21.1420 22.4709 24.0238 22.4825 340031 14.6951 14.6370 15.4935 14.9011 340032 20.0049 20.7444 21.7127 20.8112 340035 20.2312 18.9930 18.5883 19.2823 340036 18.2190 17.7619 18.4203 18.1226 340037 16.6576 17.5829 18.3655 17.5271 340038 17.3762 18.1493 20.3091 18.5547 340039 20.5876 21.3711 22.2939 21.4440 340040 20.4282 20.7237 21.1020 20.7582 340041 15.1419 15.5873 16.3200 15.6803 340042 16.9298 17.0034 19.1386 17.6977 340044 18.8687 18.0863 18.9562 18.6425 340045 13.0538 13.6182 20.2641 14.9554 340047 20.0602 20.0744 20.7061 20.2776 340049 19.2050 19.5127 17.2986 18.6550 340050 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340091 20.5923 20.3861 21.1892 20.7475 340093 16.3276 16.8903 16.5452 16.5873 340094 19.0406 * 20.8816 19.9881 340096 17.8189 19.4696 20.9686 19.4268 340097 18.8412 18.2399 20.0302 19.0440 340098 21.4135 21.9578 23.5280 22.3354 340099 16.8305 15.3752 16.9979 16.3421 340101 13.9994 15.6509 20.7841 16.3562 340104 13.0462 11.5169 12.1845 12.2454 340105 20.2954 * * 20.2954 340106 17.7220 18.1211 19.1147 18.3112 340107 18.0205 19.3197 20.7601 19.3267 340109 18.7746 19.0532 19.3357 19.0640 340111 16.3344 16.5976 17.2127 16.7260 340112 14.7562 15.5142 16.9592 15.7587 340113 21.2906 21.9883 24.0277 22.4262 340114 21.2166 20.7261 21.7750 21.2327 340115 19.7578 21.7586 24.7924 21.8733 340116 20.4255 20.6800 21.6616 20.9285 340119 18.8507 19.5827 20.5394 19.6919 340120 15.0410 15.8240 16.9847 15.9742 340121 16.3295 17.8771 19.0420 17.7638 340123 16.9114 18.9078 21.5041 19.1720 340124 15.5779 17.4185 17.5411 16.8707 340125 19.7164 20.2748 * 19.9923 340126 18.8100 19.3734 20.7395 19.6489 340127 19.3925 19.3842 21.4797 20.0982 340129 20.4605 20.6521 21.0773 20.7569 340130 19.7422 19.8707 20.5851 20.0891 340131 19.7908 21.3849 23.2478 21.4650 340132 17.3448 17.5711 17.7110 17.5495 340133 16.4766 17.2138 16.9829 16.8955 340137 21.0249 31.7702 * 23.8273 340138 20.7618 * * 20.7618 340141 21.3754 21.4986 22.4525 21.7877 340142 17.1525 18.0766 18.1824 17.8038 340143 21.3604 24.4098 21.9304 22.5287 340144 20.9113 22.9183 22.8634 22.2296 340145 20.1081 19.9233 21.5958 20.6005 340146 15.9203 17.3051 19.1306 17.3989 340147 19.6827 20.5520 21.5912 20.6397 340148 18.5875 18.9912 20.6790 19.3782 340151 16.7275 18.4733 19.0779 18.0943 340153 20.6420 20.7533 21.7375 21.0743 340155 20.5792 23.1021 24.8963 22.8382 340158 18.1439 19.0843 20.0921 19.1509 340159 17.3893 19.0338 18.3028 18.2386 340160 16.1778 16.7170 17.1963 16.7262 340162 14.3472 * * 14.3472 340164 21.2523 21.5769 * 21.4120 340166 20.0434 20.8270 22.0519 21.0278 340168 15.2919 15.6071 15.4250 15.4443 340171 21.5973 22.4779 22.7304 22.3095 340173 19.3353 21.0898 23.3690 21.3475 350001 14.9080 16.6551 15.6193 15.7235 350002 17.5259 18.3459 19.1931 18.3399 350003 18.2470 19.2840 20.0663 19.1912 350004 20.6518 23.7016 25.1976 23.1394 350005 18.3792 19.9156 20.7467 19.6757 350006 18.4107 19.0343 19.1257 18.8317 350007 13.3292 13.8824 13.9966 13.7234 350008 20.4777 22.3783 23.1361 21.9692 350009 19.1611 18.3688 19.3668 18.9603 350010 16.2808 16.6272 16.7774 16.5574 350011 18.2008 19.1944 20.6809 19.2312 350012 15.7033 18.2524 16.0990 16.7533 350013 16.4579 17.2596 17.5935 17.0893 350014 16.8403 18.0999 18.2003 17.6546 350015 16.3397 17.1071 16.5368 16.6512 350016 11.6524 * * 11.6524 350017 17.6278 17.5124 18.0840 17.7360 350018 14.4928 16.4939 16.3210 15.7222 350019 19.3063 20.1608 20.6743 20.0169 350021 16.2898 17.7123 16.3394 16.7592 350023 17.9048 17.4983 18.3253 17.9187 350024 14.7529 15.4788 15.7510 15.3010 350025 17.1199 15.0469 14.6099 15.5234 350027 15.0835 15.5178 17.5882 15.9431 350029 13.5219 14.6173 * 14.0747 350030 17.7209 18.1131 18.7182 18.1761 350033 14.9012 16.0870 16.0903 15.6588 350034 18.7245 19.6445 * 19.1773 350035 10.4570 11.7675 12.6496 11.6111 350038 17.6666 19.6854 19.0500 18.7554 350039 17.0361 16.6278 14.8599 16.1842 350041 14.6680 19.1341 23.1150 18.5427 350042 16.7402 19.3309 19.3370 18.2440 350043 16.8876 16.7433 17.6722 17.1008 350044 10.2154 11.0601 10.9690 10.7163 350047 14.4628 18.0094 19.9749 17.4882 350049 14.8019 18.1993 16.7131 16.4253 350050 11.4921 12.2183 * 11.8525 350051 17.7279 17.0653 16.4587 17.0939 350053 14.6398 15.9160 16.5484 15.6473 350055 14.5691 15.7916 15.8572 15.3943 350056 14.8293 15.0995 15.7752 15.2147 350058 15.9378 16.7034 15.8171 16.1663 350060 10.3666 10.3076 10.5325 10.3988 350061 15.7269 18.8790 19.3748 18.0353 360001 17.0791 19.6655 18.5766 18.4186 360002 18.0139 18.2613 19.6145 18.5918 360003 22.7471 22.7521 23.2905 22.9196 360006 21.8048 22.4436 22.8554 22.3622 360007 18.0941 14.8213 15.3656 16.0665 360008 18.5439 18.7961 19.8034 19.0500 360009 18.9322 18.9935 19.6087 19.1932 360010 19.2288 19.1852 20.4671 19.6517 360011 19.3835 21.3659 19.4581 19.9957 360012 19.9881 20.0525 21.8759 20.5910 360013 20.6021 21.3690 22.3407 21.4314 360014 20.2390 20.7419 22.9930 21.3333 360016 17.8065 21.2505 21.4202 20.0256 360017 21.7543 22.2740 22.6535 22.2073 360018 23.5219 24.6686 24.6694 24.2429 360019 18.7147 20.6480 21.4708 20.1693 360020 21.7806 22.1751 21.7288 21.8938 360024 19.8508 20.1352 20.9408 20.3040 360025 20.3638 20.2531 20.9266 20.5175 360026 18.2222 17.9523 18.6739 18.2838 360027 21.0406 21.7650 22.6915 21.8330 360028 17.0177 18.7174 * 17.7935 360029 18.7622 19.2928 19.7246 19.2680 360030 17.5748 17.6058 19.0313 18.0839 360031 19.3858 21.0687 21.0481 20.5037 360032 18.6559 19.8020 19.8367 19.4058 360034 14.9534 17.9594 19.1248 17.3380 360035 20.5557 21.0674 21.0533 20.8877 360036 20.2107 20.9916 21.4665 20.8874 360037 23.5094 23.1674 23.8620 23.5454 360038 21.2467 19.9415 20.9651 20.7274 360039 18.7791 19.0013 19.1934 18.9931 360040 18.1618 18.7425 19.9750 18.9827 360041 19.5744 19.7968 21.2727 20.2776 360042 17.4306 17.1952 19.3774 17.9518 360044 17.0612 17.6882 17.8417 17.5521 360045 22.1471 22.4018 22.8112 22.4244 360046 20.4755 20.4607 21.4292 20.8030 360047 17.1871 15.2922 15.8279 16.0315 360048 22.5857 22.4890 25.6259 23.4295 360049 20.4564 20.8393 * 20.6400 360050 12.9873 15.0568 15.6847 14.5392 360051 20.8338 20.8757 21.2225 20.9792 360052 19.6233 18.7931 19.8278 19.4110 360054 17.2574 17.4911 17.5714 17.4428 360055 21.5585 21.4112 22.8755 21.9415 360056 19.0474 20.6968 23.2385 21.0356 360057 15.0146 15.8569 16.0395 15.6552 360058 18.6992 19.3306 19.0440 19.0197 360059 20.5618 19.9304 23.2129 21.1909 360062 20.7588 21.9195 24.4898 22.4391 360063 18.4512 17.5108 20.2671 18.6964 360064 20.4846 20.0615 20.9202 20.4850 360065 20.0532 19.6199 22.0853 20.5895 360066 21.6015 22.8175 23.8834 22.7933 360067 15.3157 14.2745 17.3024 15.5854 360068 21.2789 22.6227 22.2094 22.0456 360069 16.6982 14.6597 18.5382 16.4901 360070 17.3758 18.8406 19.4700 18.5552 360071 17.9756 19.0302 19.6873 18.9152 360072 18.1467 19.0166 20.8819 19.3874 360074 20.8275 18.5889 19.9876 19.7904 360075 22.4523 26.0663 27.6992 24.6791 360076 20.0700 20.3317 21.0402 20.4919 360077 21.1053 21.5517 22.2964 21.6371 360078 21.4392 22.6490 22.6075 22.2329 360079 22.1096 21.6644 23.9491 22.5122 360080 17.3892 17.6369 18.0392 17.6871 360081 21.7342 20.4614 20.7477 20.9963 360082 22.9460 20.7610 22.9390 22.1817 360084 20.4894 22.0492 22.1699 21.5674 360085 21.9051 21.5151 24.8010 22.5708 360086 19.5378 19.3701 20.5858 19.8561 360087 20.1684 20.7969 21.1621 20.7100 360088 24.0097 24.0822 20.5703 22.7567 360089 18.3881 18.1941 19.5260 18.6947 360090 21.0376 20.8971 21.2072 21.0517 360091 21.3126 21.8447 22.6510 21.9522 360092 20.4534 21.5073 20.9588 20.9684 360093 19.3292 19.0261 21.0134 19.7919 360094 18.8780 20.1227 21.1952 20.0119 360095 20.4149 19.8521 21.3505 20.5395 360096 18.2215 19.6726 20.9838 19.6144 360098 19.5314 19.8178 20.7942 20.0486 360099 18.5855 19.6241 20.8801 19.7171 360100 17.8989 18.0442 20.0683 18.5932 360101 21.3914 20.2635 24.1551 21.8064 360102 19.4345 18.5367 * 19.0252 360106 18.9752 19.1778 18.9779 19.0463 360107 19.7599 22.1359 * 20.9636 360108 17.5832 20.0681 19.0870 18.9015 360109 20.1032 19.9237 17.3564 18.9331 360112 22.5589 24.6335 25.7920 24.1917 360113 24.2654 20.8154 18.4832 21.0469 360114 17.8761 18.7509 19.4212 18.7051 360115 18.8059 20.7652 21.0104 20.2115 360116 18.8882 18.8319 20.1408 19.2675 360118 19.3732 19.9141 21.0235 20.1425 360121 22.1093 22.2175 21.9111 22.0788 360123 20.3236 20.9792 21.9985 21.1330 360125 19.0774 20.5508 21.6675 20.3325 360126 19.0036 24.5387 * 21.4419 360127 17.5882 16.5559 18.2150 17.4610 360128 16.1243 17.0515 17.5495 16.8959 360129 15.5002 16.6114 17.2309 16.4330 360130 17.2009 18.4539 19.8906 18.4639 360131 19.2241 18.4688 20.4123 19.3509 360132 19.9171 21.3493 21.0162 20.7647 360133 19.4316 20.2857 22.1957 20.5231 360134 20.6876 20.9564 21.4024 21.0100 360136 17.7827 18.2194 18.5687 18.1837 360137 20.1756 22.3648 23.1642 21.8556 360140 20.2791 21.2881 18.3463 19.9463 360141 23.0016 23.5343 23.5006 23.3475 360142 17.0059 18.3188 19.6189 18.3226 360143 20.1989 21.0336 20.9158 20.7118 360144 23.2191 20.9033 20.9386 21.6583 360145 19.6413 20.0513 21.2931 20.3252 360147 16.6616 17.6779 18.7258 17.7129 360148 19.2816 19.1393 20.3120 19.5918 360149 19.9808 * * 19.9808 360150 21.1327 22.3620 23.1858 22.2110 360151 16.6019 19.2788 20.5594 18.6756 360152 20.8328 21.6005 20.8782 21.1044 360153 15.4132 16.7399 16.1021 16.0822 360154 14.3270 14.3593 14.8550 14.5038 360155 22.5347 22.2112 22.2805 22.3386 360156 17.8787 18.9095 19.9382 18.8811 360159 20.2841 21.5695 22.7992 21.5782 360161 19.1983 20.6160 19.9054 19.9030 360163 20.7275 21.2689 22.1012 21.3886 360165 18.2571 18.2417 19.6205 18.6959 360166 18.7321 * * 18.7321 360170 16.4653 20.4407 19.3099 18.5975 360172 18.6720 19.8909 22.3294 20.3872 360174 19.9725 20.5399 20.5874 20.4239 360175 21.1685 21.5450 22.0274 21.5958 360176 15.9430 16.6228 17.6291 16.7269 360177 18.7898 18.9576 19.6992 19.1509 360178 18.8704 16.7962 18.0773 17.9514 360179 21.1309 20.7069 21.9617 21.2476 360180 21.3826 21.0146 18.0143 20.0375 360184 19.1224 * * 19.1224 360185 18.7291 19.4858 20.0848 19.4376 360186 18.3246 20.7572 18.1254 19.0367 360187 18.5109 19.6535 20.8423 19.6414 360188 17.1044 18.3057 16.4329 17.3292 360189 17.8981 18.5940 19.0481 18.4968 360192 21.6365 22.7846 23.9969 22.7928 360194 17.1884 17.6140 19.3901 18.0653 360195 19.9302 20.5828 21.2083 20.5836 360197 20.0603 20.5062 21.6110 20.7240 360200 16.2306 17.9623 19.5866 17.8050 360203 16.3181 15.9609 17.9698 16.7236 360204 22.2494 * * 22.2494 360210 20.9955 21.8629 21.5961 21.4839 360211 19.9895 20.6081 22.0011 20.8512 360212 21.1123 20.6987 21.0632 20.9556 360213 19.4765 19.0584 20.5448 19.6749 360218 18.9469 18.8204 20.7709 19.5181 360230 21.9763 20.8042 21.2417 21.3193 360231 12.9588 14.4168 12.7388 13.3090 360234 23.2588 20.6131 17.6716 20.3070 360236 17.8426 21.4628 20.5998 19.8666 360239 20.1854 19.2375 20.9440 20.0997 360241 23.5318 25.3741 23.7679 24.1749 360243 14.8694 * * 14.8694 360245 16.4622 15.9782 16.7956 16.4127 360247 16.3092 17.0776 * 16.6743 360249 * 25.4331 * 25.4331 360251 * * 21.3149 21.3149 360252 * * 27.1728 27.1728 370001 22.5214 24.1929 21.8743 22.8253 370002 14.7315 15.4333 16.1853 15.4106 370004 19.3236 18.5233 22.0173 19.9087 370005 15.1654 15.3881 * 15.2760 370006 16.6484 16.4995 15.7367 16.2765 370007 15.2905 15.8312 14.4961 15.2449 370008 16.6566 17.5553 18.5253 17.5877 370011 14.9701 15.6178 16.1757 15.5584 370012 11.7265 12.4942 13.3824 12.5268 370013 19.3398 18.9584 19.3237 19.2083 370014 20.6512 20.2858 22.7976 21.2589 370015 17.0319 20.8765 18.6446 18.7763 370016 19.1191 19.1613 19.7706 19.3517 370017 12.6400 13.6531 * 13.1855 370018 18.5107 17.7054 18.7928 18.3360 370019 14.2277 14.6216 16.1367 14.9616 370020 14.3798 15.1035 15.6057 15.0288 370021 12.0474 12.9030 * 12.4760 370022 17.2344 17.3724 18.2109 17.5986 370023 17.7630 17.5148 18.1255 17.8019 370025 17.4988 18.4815 19.1013 18.3736 370026 18.3371 18.0412 18.6982 18.3516 370028 18.4445 21.1292 22.1765 20.5544 370029 16.4924 18.2580 19.3285 17.9453 370030 16.3269 16.5803 18.1779 17.0344 370032 18.2821 18.1538 18.9050 18.4517 370033 13.5216 11.3210 15.3857 13.3051 370034 15.6386 15.6288 16.2204 15.8253 370035 25.5764 * * 25.5764 370036 12.4026 12.4070 11.7667 12.1865 370037 16.7012 18.9556 20.6493 18.6793 370038 13.3084 13.0210 15.4551 13.8393 370039 15.5206 19.4498 22.3915 18.9462 370040 14.4672 15.5109 16.8127 15.5746 370041 16.7356 16.2316 14.7346 15.7346 370042 14.9175 15.2764 15.9005 15.3820 370043 15.9534 17.0892 19.8318 17.5204 370045 10.1994 11.3560 11.6163 10.9883 370046 18.8334 * * 18.8334 370047 16.7554 17.8769 18.4743 17.6862 370048 18.2150 15.6803 17.0785 16.9957 370049 20.7176 19.4868 20.3405 20.1537 370051 11.6736 12.5171 11.4943 11.8576 370054 16.9049 18.0787 19.2294 17.9957 370056 18.4558 18.1432 18.9395 18.5020 370057 16.7261 15.1228 16.0301 15.9579 370059 18.1386 18.3314 20.1182 18.8407 370060 16.5403 19.3051 17.5989 17.7984 370063 14.4132 16.7342 * 15.4260 370064 10.9676 11.9954 11.6347 11.5257 370065 16.6898 18.1349 18.2406 17.6615 370071 16.1439 16.4567 * 16.2906 370072 14.4742 13.6519 12.5765 13.5464 370076 13.5694 14.3555 15.4067 14.4469 370078 18.4086 19.2412 15.2513 17.4148 370079 16.6861 16.9201 17.5915 17.0209 370080 13.9239 14.7323 14.3546 14.3090 370082 13.9634 15.0669 16.9715 15.2230 370083 13.1519 13.1810 15.6824 14.0210 370084 22.0545 13.1197 15.6184 16.0638 370085 11.2842 48.1271 * 16.2341 370086 15.4404 11.1900 * 13.0199 370089 16.0966 17.2638 17.9243 17.0970 370091 19.1698 20.1822 20.8553 20.0806 370092 14.9802 15.7678 16.8432 15.8798 370093 18.4600 19.7008 22.1966 20.1375 370094 18.0002 19.5462 19.5565 19.0506 370095 12.6383 13.4202 14.5909 13.5521 370097 22.9714 23.2056 19.0437 21.4568 370099 15.4549 19.4646 18.1467 17.5179 370100 14.0168 18.8274 12.9784 15.1185 370103 19.2353 18.2685 23.1347 19.9596 370105 21.3352 20.7890 25.1252 22.1529 370106 18.5485 20.3651 21.5826 20.1129 370108 12.3279 12.7470 14.0190 13.0228 370112 14.8539 15.3039 14.3384 14.8216 370113 16.1046 17.6107 19.9767 17.8205 370114 16.5268 17.8941 17.9757 17.4836 370121 22.5611 21.3099 19.3414 20.9750 370122 15.0645 15.4375 * 15.2280 370123 18.9159 19.0313 19.7958 19.2564 370125 15.6284 13.9436 14.4664 14.6695 370126 23.9654 15.8020 * 19.5933 370131 17.5689 15.7261 * 16.5772 370133 10.9575 12.9545 16.1855 13.3276 370138 16.4005 17.5551 17.4574 17.1263 370139 14.8612 14.9964 16.0898 15.3115 370140 16.0721 17.1393 17.4950 16.9403 370141 18.4101 20.7798 19.8606 19.6250 370146 12.6402 13.0399 13.9900 13.2166 370148 20.6458 20.6612 26.6722 22.4333 370149 16.1850 17.0929 18.0699 17.1239 370153 17.8352 16.4669 16.5267 16.9839 370154 15.5127 15.6093 16.6687 15.9283 370156 13.9255 14.5696 15.4303 14.6173 370158 15.6917 15.6994 16.3637 15.9128 370159 28.0536 21.1267 25.3240 24.1146 370163 17.6361 20.4217 * 18.9027 370165 13.0910 13.0375 12.9569 13.0294 370166 17.2849 21.0797 19.4219 19.1747 370169 12.5243 12.7138 14.8384 13.3173 370176 15.9476 18.9951 19.6537 18.1230 370177 11.2536 14.6481 14.1304 13.3001 370178 10.5726 11.6200 9.8655 10.5383 370179 17.2829 21.3002 23.8404 20.1287 370183 10.2945 16.9318 16.6061 14.0419 370186 13.6192 15.4533 16.3671 15.1316 370190 14.1397 19.3570 20.6398 17.5727 370192 18.4614 19.6967 21.8343 20.0562 370198 21.3136 * * 21.3136 370200 * 22.5299 18.3941 20.2627 370201 * * 18.2548 18.2548 370202 * * 16.4919 16.4919 370203 * * 23.5454 23.5454 380001 20.3127 26.4822 25.1542 23.6052 380002 24.0241 21.9185 23.2479 22.9299 380003 21.7826 20.9007 23.8074 22.1844 380004 23.1451 23.3609 24.5418 23.6963 380005 24.0838 25.0750 24.7476 24.6467 380006 21.2731 21.3520 20.5914 21.0574 380007 25.2995 32.2678 25.9239 27.5188 380008 20.7063 22.3004 21.6133 21.5417 380009 23.8104 24.3851 25.1040 24.4366 380010 23.7488 22.7276 24.1931 23.5774 380011 21.1151 20.3357 20.6759 20.7167 380013 18.6818 19.8180 20.3705 19.6316 380014 24.6574 25.9828 26.6038 25.7705 380017 26.0578 25.3954 21.9236 24.5037 380018 22.3525 22.9822 24.8661 23.4431 380019 22.1215 20.8176 21.1743 21.3400 380020 20.1464 22.9568 23.9978 22.4898 380021 21.1590 23.8499 24.4365 23.1615 380022 22.6408 24.5974 25.6255 24.2510 380023 20.5462 21.3831 23.4328 21.9485 380025 26.3652 26.9346 26.9398 26.7561 380026 20.4706 20.6972 22.7561 21.3218 380027 20.8647 21.5490 22.2573 21.6028 380029 19.4246 20.1471 22.0371 20.5671 380031 23.3181 20.3396 23.7634 22.5126 380033 25.2454 27.1343 26.6899 26.3003 380035 22.4099 23.9719 25.6016 23.9444 380036 27.1587 27.2157 * 27.1858 380037 21.9158 22.1774 23.4798 22.5697 380038 26.0869 26.7759 28.1436 26.9990 380039 23.1746 22.8048 25.7614 23.8428 380040 26.2717 22.5477 22.6412 23.5906 380042 21.1176 24.4172 21.6793 22.3496 380047 23.0718 24.2524 25.2591 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380090 29.2702 24.9351 30.4223 28.0439 380091 27.5560 25.3062 28.7846 27.2892 390001 19.2989 19.6732 20.3350 19.7868 390002 21.8353 19.7833 21.0159 20.9278 390003 17.1371 18.1025 18.0436 17.7426 390004 19.2277 20.3204 20.0557 19.8647 390005 17.3506 16.9472 19.0218 17.7359 390006 20.2959 21.1786 21.8940 21.0893 390007 21.7506 21.3839 * 21.5715 390008 17.8297 18.2743 19.3496 18.4745 390009 20.6507 20.6241 22.5580 21.2847 390010 17.5127 17.3335 18.1275 17.6598 390011 18.1717 18.3257 18.2751 18.2595 390012 20.6523 21.0610 22.1912 21.3051 390013 19.2698 19.6562 20.2186 19.7244 390015 13.1337 13.7352 14.3138 13.7169 390016 16.9892 17.1133 17.3854 17.1611 390017 16.7493 18.6113 18.5869 17.9293 390018 21.3626 19.0279 20.0672 20.1854 390019 16.7848 17.7258 18.7609 17.7608 390022 21.5064 24.8468 24.7121 23.6803 390023 21.8270 22.1044 23.5236 22.6164 390024 24.9437 25.4606 27.7643 26.0343 390025 15.6155 15.5523 14.5309 15.2361 390026 22.3902 22.9718 * 22.6895 390027 26.8878 29.5940 * 28.2192 390028 22.7700 23.6571 22.7820 23.0704 390029 21.5729 21.2661 24.4753 22.2475 390030 17.9580 18.6887 18.9093 18.5094 390031 19.2755 18.8162 19.1781 19.0917 390032 17.8041 21.5105 18.7616 19.2843 390035 20.2029 22.3591 21.9021 21.4643 390036 19.9880 19.7671 20.1769 19.9773 390037 21.0616 20.4263 19.9175 20.4619 390039 17.1046 17.5300 17.6176 17.4167 390040 15.9612 16.6876 17.4451 16.6853 390041 19.8080 20.4397 19.6159 19.9368 390042 22.7693 22.5775 21.7857 22.3776 390043 17.2607 17.4764 17.9549 17.5603 390044 20.2813 20.9831 21.3382 20.8726 390045 18.5574 19.4677 * 19.0190 390046 20.7303 21.7445 21.8760 21.4470 390047 27.6661 26.9709 * 27.3457 390048 19.0920 19.7992 18.8322 19.2254 390049 21.1217 22.1586 22.7306 21.9927 390050 22.8808 22.2639 24.7169 23.2216 390051 25.7910 28.1385 * 26.8617 390052 20.9306 20.1195 21.2367 20.7439 390054 17.8852 18.4975 19.5598 18.6230 390055 24.2211 23.4017 25.7327 24.4723 390056 17.7858 19.3901 21.4121 19.5072 390057 20.2059 20.2395 21.6693 20.6975 390058 19.7379 20.3520 20.7930 20.2983 390061 21.2392 23.8722 22.8728 22.6127 390062 16.6721 17.3750 17.4710 17.1692 390063 20.0125 19.4965 20.1696 19.9019 390065 19.9361 20.0473 20.2930 20.0884 390066 19.8539 18.9296 18.9776 19.2407 390067 20.9688 20.8162 21.9905 21.2535 390068 18.3158 19.1109 21.6408 19.5148 390069 19.6466 * * 19.6466 390070 16.1988 21.8549 22.7909 20.2250 390071 15.7165 16.0100 18.9416 16.7655 390072 16.3133 16.9232 15.1402 16.1159 390073 20.5581 21.2623 22.2009 21.3579 390074 18.4806 18.3093 19.5799 18.7617 390075 17.9840 18.7695 19.5744 18.6643 390076 20.2475 21.3290 19.7719 20.4342 390078 19.2089 19.0156 20.5750 19.5586 390079 18.3312 18.9269 19.2984 18.8525 390080 18.8028 21.4707 22.2449 20.7685 390081 24.8351 24.7461 25.6575 25.0775 390083 * * 26.1660 26.1660 390084 16.4026 20.2529 17.0197 17.7133 390086 18.5265 18.3563 * 18.4381 390088 23.6173 23.9506 * 23.7777 390090 21.6437 21.3759 20.5444 21.2031 390091 18.1569 18.3770 18.8545 18.4554 390093 17.7171 18.4442 20.0135 18.7217 390095 16.3357 16.6930 17.9697 16.9815 390096 19.1171 22.4382 21.5922 20.9351 390097 23.5963 25.2845 24.8005 24.5139 390100 20.7859 20.9263 21.1186 20.9469 390101 17.9499 18.5039 17.0447 17.8109 390102 19.0461 21.5496 18.0199 19.5593 390103 18.4312 18.8667 20.4422 19.2092 390104 15.9008 16.3255 16.2440 16.1553 390106 16.6666 16.8439 * 16.7557 390107 19.5178 20.9841 20.6024 20.3811 390108 21.0899 21.3142 21.2602 21.2184 390109 16.4597 16.5299 17.4540 16.8127 390110 21.5282 21.6464 21.6005 21.5915 390111 27.5193 33.3971 27.0087 29.3495 390112 14.9427 15.0065 14.8634 14.9388 390113 19.1945 19.3634 19.9496 19.4908 390114 19.6295 20.9533 19.8004 20.1209 390115 23.3461 21.4287 21.9789 22.1926 390116 21.4877 21.3671 22.6783 21.8481 390117 17.9393 18.0769 18.2543 18.0888 390118 18.3440 18.9507 16.9990 18.1121 390119 18.2951 18.8815 19.3946 18.8604 390121 20.8780 19.1315 20.6253 20.2089 390122 17.1902 17.7734 15.5438 16.7430 390123 20.8344 21.3974 21.8434 21.3548 390125 16.7983 17.5446 17.0975 17.1374 390126 20.6498 * * 20.6498 390127 21.7724 22.4555 22.8787 22.3758 390128 19.6792 19.3165 19.9764 19.6532 390130 17.7049 18.3695 18.5519 18.2059 390131 16.0986 19.2096 18.7142 17.9603 390132 21.1931 22.8414 24.1878 22.7048 390133 23.3489 24.7561 24.1814 24.0439 390135 21.5782 22.1905 21.8152 21.8560 390136 16.9737 20.6286 16.8505 18.1580 390137 17.5687 18.5397 19.1432 18.3744 390138 19.6212 20.6936 20.7726 20.3703 390139 24.4515 23.9757 23.8019 24.0822 390142 26.8086 28.8877 28.3448 28.0760 390145 20.3731 20.4228 20.4964 20.4300 390146 18.7922 18.6505 20.1788 19.1967 390147 20.9651 21.2492 21.7600 21.3199 390150 20.7294 20.3155 20.8970 20.6500 390151 21.6000 22.5206 23.6072 22.6096 390152 20.3353 19.4017 20.2581 19.9941 390153 23.7013 22.9707 23.3587 23.3403 390154 17.4036 16.7052 17.8774 17.3537 390156 21.8498 22.6398 * 22.2353 390157 19.6578 19.1783 20.2647 19.6975 390160 21.4810 19.4463 18.8676 19.8186 390161 16.4799 * * 16.4799 390162 21.4095 21.9188 21.4600 21.5967 390163 16.8013 17.7564 18.1415 17.5746 390164 24.6765 24.9750 25.0347 24.8814 390166 19.0405 19.7978 19.8899 19.5577 390167 19.8973 * * 19.8973 390168 18.7400 18.8863 19.6875 19.1127 390169 20.2382 22.0547 22.7920 21.7176 390170 26.5891 24.7973 * 25.6898 390173 18.5370 18.6613 18.7403 18.6472 390174 25.4189 25.3307 25.7174 25.4826 390176 17.8740 20.8368 21.7650 20.0495 390178 16.6993 17.0534 17.1142 16.9526 390179 21.6901 21.8593 21.6191 21.7220 390180 25.7074 26.5541 26.7743 26.3551 390181 19.4654 19.3832 18.8681 19.2465 390183 17.8306 17.9848 17.4535 17.7535 390184 20.8060 20.9349 21.1941 20.9693 390185 18.8798 20.3877 20.3301 19.8556 390189 20.0889 20.3338 19.0797 19.7997 390191 16.3240 17.2270 17.1919 16.8998 390192 17.4537 17.6597 17.1875 17.4275 390193 16.7874 18.1209 17.3804 17.3866 390194 20.7953 21.2689 21.0549 21.0283 390195 24.6855 24.1793 23.4250 24.1067 390197 19.2690 20.7998 22.1769 20.7816 390198 15.9721 15.8833 16.6803 16.1535 390199 17.0515 17.3865 17.7763 17.3987 390200 15.1399 15.4012 18.2456 16.2785 390201 20.6296 20.3533 21.3291 20.7767 390203 20.9432 21.4989 22.4685 21.6448 390204 20.1779 22.9616 22.1541 21.7608 390206 18.4027 * * 18.4027 390209 17.4792 18.7059 16.8200 17.6370 390211 17.8638 18.4213 19.4552 18.6187 390213 18.8555 19.1553 19.3776 19.1155 390215 20.7084 21.2032 23.5953 21.7981 390217 19.1406 19.9837 19.9665 19.6808 390219 18.8292 19.6226 20.1311 19.5227 390220 18.7178 17.7916 * 18.2413 390222 21.5739 22.1548 22.7491 22.1668 390223 23.6482 22.1775 18.9493 21.4503 390224 15.3015 13.7518 17.2173 15.1752 390225 18.6125 18.7290 19.0364 18.7963 390226 21.8268 21.8481 22.7772 22.1197 390228 19.4083 19.8180 20.2703 19.8379 390231 22.7544 19.4798 21.3811 21.0947 390233 19.4887 20.2309 20.6673 20.1413 390235 25.0857 21.4200 19.9925 22.7713 390236 16.2397 17.8735 19.1427 17.7118 390237 19.5230 22.3011 * 20.8354 390238 17.8211 17.1055 18.1956 17.6820 390244 15.4611 15.6402 13.8845 14.9996 390245 26.0194 24.5076 * 25.2650 390246 18.9733 25.0556 22.3892 21.9107 390247 20.9526 21.2151 * 21.0479 390249 12.7920 13.1657 14.1062 13.3677 390256 23.2734 22.2773 22.3540 22.6670 390258 21.9207 22.6852 23.8318 22.8365 390260 21.9509 21.5982 * 21.7740 390262 18.2379 * 18.8942 18.5346 390263 20.6855 20.3796 20.6348 20.5647 390265 20.3580 20.4950 20.4760 20.4411 390266 17.1666 17.1966 17.5653 17.3117 390267 21.2974 19.2665 19.9578 20.2867 390268 21.3486 22.0909 22.2046 21.8827 390270 19.0925 19.2074 20.6793 19.6201 390278 18.2865 17.7176 18.5776 18.2038 390279 14.3241 14.8655 15.8080 14.9814 390283 * 22.5490 * 22.5490 390284 * 34.3904 * 34.3904 390285 * * 29.1270 29.1270 390286 * * 22.9746 22.9746 390287 * * 30.3252 30.3252 390288 * * 26.9662 26.9662 390289 * * 22.8963 22.8963 390290 * * 30.5037 30.5037 390291 * * 20.0272 20.0272 390293 * * 23.5285 23.5285 400001 9.9463 10.5757 10.7531 10.4326 400002 10.1417 13.0494 13.3684 12.2030 400003 10.8821 12.4078 11.2726 11.5031 400004 8.9864 8.5648 9.0781 8.8776 400005 9.5632 7.7432 9.7802 8.9053 400006 10.3444 10.1048 10.4988 10.3215 400007 6.4490 8.0174 8.1974 7.5138 400009 8.4207 8.8650 8.7341 8.6758 400010 10.6518 10.8011 9.1359 10.1542 400011 7.4979 8.5426 8.6252 8.2277 400012 8.2412 8.4728 8.6538 8.4546 400013 8.4579 9.2624 9.8197 9.2598 400014 9.5235 9.4798 10.2712 9.7458 400015 10.9505 14.4076 15.5827 13.3370 400016 13.2756 13.3922 13.7001 13.4570 400017 8.6421 9.2577 9.9167 9.2527 400018 10.4557 10.6208 10.5583 10.5484 400019 10.4332 10.8940 11.5139 11.0095 400021 10.6988 12.1434 12.7462 11.9145 400022 11.5861 12.2199 13.0411 12.2767 400024 7.8984 9.2409 9.0826 8.6750 400026 5.6454 5.8335 7.4280 6.2931 400027 9.5899 * * 9.5899 400028 8.8597 19.1794 8.9567 8.9909 400031 8.2660 * * 8.2660 400032 10.5498 10.0448 10.1898 10.2599 400044 11.9704 11.9486 12.8671 12.2011 400048 9.1701 15.1405 11.5104 11.4186 400061 12.4493 13.0988 10.3664 11.9076 400079 * 9.7203 8.7218 9.1657 400087 9.5097 9.8534 8.6480 9.3956 400094 8.9116 7.9187 8.8387 8.5180 400098 9.3308 9.7791 10.4312 9.8607 400102 9.8536 9.9903 8.5290 9.4812 400103 11.2069 11.5359 11.8454 11.4791 400104 11.0672 10.7292 7.9552 10.3151 400105 9.3049 9.0556 10.6028 9.5117 400106 9.3123 9.2187 9.8694 9.4766 400109 10.9826 11.8760 * 11.4480 400110 10.3326 10.5277 10.7228 10.5456 400111 9.5583 10.9665 12.3311 11.0412 400112 10.1755 10.8694 11.0634 10.7058 400113 9.2238 8.3168 9.3955 8.9859 400114 9.0496 7.0510 9.9477 8.5888 400115 9.8244 8.5487 7.2203 8.5322 400117 10.2295 10.8756 11.3351 10.8116 400118 9.4398 11.4051 11.4317 10.7997 400120 9.5274 10.6584 10.9315 10.3832 400121 7.8052 9.8322 8.7584 8.8340 400122 8.1911 7.6413 9.1638 8.3405 400123 7.8099 10.2367 10.3955 9.4702 400124 12.0999 12.2452 12.7323 12.3713 400125 * 10.2056 10.5997 10.3924 410001 23.2808 23.1738 22.4972 22.9875 410004 22.4801 21.0638 22.8898 22.1691 410005 23.1444 22.7170 23.8848 23.2434 410006 23.3968 23.8700 22.7636 23.3233 410007 22.1452 23.1325 22.4988 22.5921 410008 23.0662 24.9726 24.4170 24.1518 410009 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19.4992 420037 21.7908 22.7099 23.5244 22.7289 420038 17.6726 18.6568 20.0181 18.7610 420039 15.8385 18.3017 17.7880 17.2992 420043 19.4521 19.7570 19.6834 19.6347 420048 18.4367 18.8070 20.4905 19.2520 420049 17.5854 19.4049 20.6238 19.1796 420051 19.5001 19.1555 19.8549 19.5061 420053 16.9599 18.1657 19.0780 18.0364 420054 18.2702 20.2574 20.2275 19.5600 420055 19.2048 16.8717 18.6782 18.0932 420056 14.8695 15.1835 16.5491 15.4839 420057 15.9849 20.5266 22.1312 19.6895 420059 15.8160 17.1483 18.2093 17.0936 420061 16.5555 17.3543 17.7047 17.2228 420062 17.8205 21.7469 20.9032 20.1974 420064 16.7227 16.0794 19.7067 17.5583 420065 19.6902 19.9435 19.2150 19.5969 420066 15.1804 18.0042 19.5366 17.5193 420067 18.8610 19.7824 20.7769 19.8307 420068 18.5030 18.5481 20.2580 19.1326 420069 17.0788 18.1298 18.9003 18.0124 420070 18.0057 17.3876 18.8535 18.0764 420071 19.4482 20.3902 20.1145 19.9887 420072 13.8550 15.0158 18.2531 15.7212 420073 19.1604 19.9986 20.2697 19.8499 420074 16.9292 18.0967 18.1839 17.6249 420075 14.2931 12.8158 15.0132 14.0442 420078 20.7317 21.9082 22.7156 21.7962 420079 20.8639 21.0874 21.3177 21.0994 420080 22.3443 21.9968 * 22.1649 420082 20.4653 21.7210 22.7391 21.6447 420083 20.1472 22.6376 24.0994 22.2410 420085 19.9603 21.6791 22.0071 21.2571 420086 25.7179 20.2878 23.7341 23.0645 420087 19.1403 19.8388 20.8217 19.9506 420088 17.1938 19.9919 21.8979 19.5872 420089 20.2537 20.5360 21.3954 20.7386 420091 18.8687 20.3092 21.8367 20.2654 420093 17.4689 18.3902 19.1299 18.3060 420095 * * 33.4632 33.4632 420096 * * 26.4863 26.4863 430004 18.5438 19.6344 19.2737 19.1454 430005 16.3059 16.4560 17.3400 16.6979 430007 14.1078 14.6331 15.1494 14.6319 430008 17.6640 18.1323 18.5234 18.0977 430010 17.1766 19.8191 16.5750 17.7180 430011 16.9848 17.4750 18.3648 17.6074 430012 17.2775 17.6997 19.2921 18.0907 430013 18.1338 18.4817 18.8978 18.5085 430014 16.8925 20.2387 20.9118 19.1361 430015 18.0019 18.2875 18.8998 18.3871 430016 19.4759 20.8850 21.2191 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430066 14.3557 15.6660 14.5957 14.8566 430073 16.1133 15.3776 16.5112 15.9989 430076 12.7608 13.9883 15.2453 13.9494 430077 19.3012 19.8558 20.4361 19.8699 430079 13.6836 14.1815 14.4154 14.0719 430089 17.8908 17.9790 17.5100 17.7870 430090 21.5239 21.5974 23.5180 22.2918 430091 19.2146 18.1567 21.6239 20.0217 430092 * 21.3807 19.7644 20.5428 430093 * 19.5013 23.3009 21.3125 440001 14.8713 15.5897 17.2282 15.8569 440002 19.1498 20.3740 21.4299 20.3167 440003 18.3658 19.3042 20.3756 19.3464 440006 19.6021 21.4055 23.1483 21.3134 440007 12.1230 14.8959 14.0612 13.6386 440008 17.2848 18.8994 20.3303 18.7894 440009 17.8424 17.4831 18.4068 17.9080 440010 19.9829 16.3283 13.3692 16.2699 440011 17.6948 18.3375 19.3165 18.4706 440012 15.9837 19.5739 19.6437 18.4174 440014 15.9195 16.1143 15.0656 15.7064 440015 18.2632 22.0659 21.6106 20.5435 440016 15.4097 16.2964 14.6142 15.3378 440017 19.6215 20.4563 20.2241 20.0945 440018 16.4115 17.4995 18.1059 17.3355 440019 20.0416 21.5402 23.2963 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20.4903 17.3863 440057 12.7925 13.7257 14.4363 13.6135 440058 18.8118 19.1878 17.1548 18.4084 440059 18.5418 19.6018 20.8882 19.6895 440060 18.0586 19.7916 20.7628 19.4260 440061 14.9708 22.5525 16.9234 17.8112 440063 19.3222 19.8371 18.8061 19.2994 440064 17.7652 18.9809 18.2678 18.2991 440065 18.5825 18.8296 19.2282 18.8924 440067 16.2811 17.2397 18.2973 17.2997 440068 19.4695 19.3668 19.4392 19.4232 440070 13.7035 14.0437 18.0064 15.1918 440071 17.0186 19.7836 * 18.2110 440072 17.5995 19.1522 20.0691 18.8963 440073 19.1714 19.5554 19.6290 19.4550 440078 15.0849 16.0188 17.1645 15.9789 440081 18.3587 19.3454 20.7215 19.5016 440082 22.2857 22.6855 22.5590 22.5073 440083 14.8525 13.7423 13.7630 14.1806 440084 13.4378 13.7731 13.8085 13.6799 440091 19.6114 20.1065 20.1359 19.9669 440100 13.8437 14.7113 15.9969 14.8524 440102 14.3510 14.5500 16.0783 14.9840 440103 20.3052 18.6990 * 19.4877 440104 22.4403 22.6754 21.7135 22.2610 440105 16.7131 17.1172 18.1375 17.2950 440109 16.0446 17.7443 17.6399 17.0830 440110 21.1716 17.4816 18.4998 18.8996 440111 23.2425 23.2254 23.2111 23.2266 440114 14.4997 15.0036 18.5327 16.0830 440115 17.4514 18.5457 18.7054 18.2287 440120 17.2384 16.3115 19.8997 17.7817 440125 15.6588 19.4115 19.6848 18.2807 440130 17.8223 17.4857 19.0905 18.1589 440131 15.5048 16.1214 19.9883 17.1760 440132 16.6553 16.8871 17.9186 17.1418 440133 21.5313 23.0891 18.7556 21.1283 440135 19.2010 22.2005 22.5452 21.4251 440137 14.5632 15.0070 15.3530 14.9670 440141 13.5308 15.9429 17.6819 15.3875 440142 15.7287 16.8855 17.1483 16.5303 440143 17.7821 18.2061 18.6844 18.2206 440144 17.6415 18.3859 18.8127 18.2853 440145 17.0608 18.3948 18.3832 17.9140 440147 21.4304 26.1464 25.3766 24.0818 440148 19.2435 19.4598 19.3769 19.3574 440149 16.6923 18.4281 18.4869 17.8895 440150 20.1411 20.3006 21.2942 20.5974 440151 17.4248 18.3928 19.8977 18.5439 440152 21.0287 22.7664 26.2972 22.9356 440153 16.7769 16.5716 18.1975 17.1720 440156 29.5557 21.7577 21.9374 23.7510 440157 16.9265 18.4249 15.5316 17.0209 440159 17.7158 20.9371 21.4914 19.6375 440161 21.8013 22.8816 23.3891 22.6977 440162 14.7637 15.5534 19.8075 16.5656 440166 19.6684 19.2159 19.6632 19.5183 440168 18.6535 19.1509 21.1947 19.6498 440173 18.6402 19.1812 21.0284 19.6315 440174 17.3294 18.0865 19.3966 18.2367 440175 20.0802 18.5186 19.9065 19.4762 440176 18.0294 19.2208 19.8448 19.0126 440180 19.7773 20.2184 17.8427 19.2624 440181 16.4878 17.7709 19.0915 17.6551 440182 17.7487 19.7094 18.1953 18.4985 440183 22.7067 21.3465 22.2401 22.0840 440184 17.2037 16.8880 18.6890 17.3933 440185 19.3870 21.2188 21.1226 20.6133 440186 19.3948 19.7983 18.0450 19.1060 440187 18.9713 17.5872 16.0274 17.5444 440189 * 18.5252 22.2555 20.3772 440192 19.0839 19.1705 19.1976 19.1524 440193 19.0811 18.6999 19.9078 19.2111 440194 19.8682 22.4562 21.9609 21.4700 440197 21.9618 21.8503 22.5282 22.1263 440200 17.9575 19.8078 17.8595 18.5432 440203 18.3400 16.2861 16.9819 17.1896 440206 16.4429 * * 16.4429 440210 11.0218 11.9815 12.3270 11.8072 440211 14.8972 * * 14.8972 440212 17.0685 * * 17.0685 440213 19.5760 * * 19.5760 440214 * 28.0285 * 28.0285 440215 * 22.2928 * 22.2928 440217 * * 19.2834 19.2834 450002 21.3749 21.4836 21.5141 21.4583 450004 16.6723 16.7850 15.9549 16.5100 450005 18.3600 16.6396 16.6354 17.2368 450007 16.9681 19.1910 17.7721 17.9505 450008 17.0832 17.6582 19.3637 18.0034 450010 16.5001 17.6677 18.5058 17.7858 450011 17.1942 20.8102 18.9490 18.9450 450014 17.9495 17.5815 18.4937 17.9967 450015 18.9895 21.6773 23.3972 21.2507 450016 18.4463 18.3456 18.9063 18.5621 450018 21.4788 23.2293 * 22.2764 450020 17.8415 19.1153 18.4454 18.4795 450021 23.0843 23.3630 22.5937 23.0174 450023 16.0831 17.6360 19.2810 17.6838 450024 17.3518 18.5985 19.5584 18.5411 450025 17.0004 * * 17.0004 450028 18.8764 19.1658 19.5905 19.2141 450029 17.4716 17.7425 19.7835 18.3585 450031 22.2222 29.6945 29.6772 27.1869 450032 17.3317 14.6530 20.8525 17.3455 450033 19.7437 21.0222 21.4646 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22.0609 21.2553 450080 17.4553 18.6212 19.7834 18.5898 450081 16.3448 17.5737 19.0276 17.6152 450082 16.1585 16.8677 * 16.5390 450083 21.5884 23.3754 20.9315 21.9323 450085 18.3602 20.0085 15.7805 17.8575 450087 22.0273 21.9320 23.4141 22.4951 450090 15.0939 15.5796 19.9180 16.7400 450092 16.8260 17.9520 15.7252 16.8197 450094 21.3158 23.2863 25.2158 23.1854 450096 17.8813 18.6802 19.3681 18.6265 450097 19.5723 19.7187 20.4932 19.9373 450098 20.5754 19.0454 19.3458 19.6276 450099 19.2258 20.4181 19.0079 19.5047 450101 17.1330 17.7928 * 17.4479 450102 18.6707 19.8793 21.4361 19.9466 450104 16.6744 17.0821 17.6834 17.1430 450107 25.1986 24.1094 20.9852 23.2733 450108 15.6324 15.2797 16.9845 15.9966 450109 13.8127 10.5973 17.7226 13.4301 450110 19.5821 * * 19.5821 450111 19.6350 21.4908 * 20.6248 450112 16.0441 18.1026 17.3725 17.2066 450113 20.9777 20.8306 20.7782 20.8679 450118 17.9053 * * 17.9053 450119 20.2853 20.2030 20.1335 20.2023 450121 20.4641 21.9198 22.0485 21.4762 450123 15.7618 14.1755 17.5051 15.6216 450124 22.7480 22.5208 22.6668 22.6449 450126 21.7233 21.4789 22.5290 21.9115 450128 18.2184 18.1446 18.4178 18.2629 450130 20.4156 18.9211 19.3882 19.5769 450131 19.2589 17.4168 17.7234 18.0882 450132 18.1713 21.8089 19.7672 19.9308 450133 23.6366 26.0763 24.4799 24.6993 450135 21.0306 20.4068 25.8775 22.4267 450137 22.4590 23.4346 21.3644 22.3582 450140 20.2280 17.3370 19.6205 19.0889 450143 14.5270 15.0871 16.7371 15.4651 450144 18.1121 17.4309 20.6880 18.7404 450145 15.6078 16.1895 16.4087 16.0604 450146 17.8572 15.5030 17.4391 16.8224 450147 18.9363 19.0477 20.0805 19.3489 450148 18.6758 20.4923 20.9373 20.1433 450149 19.7521 21.7219 22.6138 21.3072 450150 16.3719 17.8612 18.3079 17.5184 450151 15.2906 16.4209 16.3279 16.0117 450152 18.0061 17.7265 19.6105 18.4659 450153 19.4419 18.6514 18.8000 18.9747 450154 13.8731 13.9119 16.8748 14.8870 450155 11.5841 13.3456 20.0872 14.3751 450157 15.6371 15.3083 16.8569 15.9683 450160 16.6533 10.6852 18.7780 14.2553 450162 20.9560 21.9218 20.5032 21.1178 450163 17.5403 17.8028 19.0727 18.1175 450164 16.9741 17.7180 18.7101 17.7835 450165 13.9218 17.3283 14.9478 15.3028 450166 11.4772 11.0541 11.3813 11.3012 450169 13.1990 * * 13.1990 450170 14.2997 14.3234 15.8525 14.8194 450176 16.9674 17.2576 18.2050 17.4802 450177 14.9241 15.2419 14.8306 14.9994 450178 17.8508 16.0280 15.8729 16.5762 450181 15.5622 18.6936 18.3600 17.5713 450184 21.1263 20.0821 20.3941 20.5023 450185 14.0714 11.5228 13.2613 12.8423 450187 16.6945 18.5053 20.6388 18.5641 450188 14.3938 15.1954 16.9407 15.5553 450191 20.1222 20.9512 20.5883 20.5559 450192 20.3795 21.2497 20.1419 20.5690 450193 23.1963 23.1639 24.9007 23.7654 450194 20.5187 20.7745 20.5396 20.6114 450196 17.1955 17.8993 20.2663 18.3910 450200 18.7387 19.2228 19.6496 19.1969 450201 16.9908 17.1463 17.7763 17.3128 450203 20.6712 19.3978 19.6050 19.8895 450209 19.0811 20.0140 21.0205 19.9890 450210 13.9758 16.3470 16.7204 15.7370 450211 17.9857 18.8114 18.7305 18.5258 450213 17.7631 19.0651 18.5334 18.4589 450214 19.0475 20.5070 21.0485 20.1729 450217 12.8457 12.7647 13.1840 12.9276 450219 15.3976 17.6884 18.3602 17.1605 450221 16.3700 15.2120 16.1398 15.8866 450222 20.3129 19.8967 23.2779 21.1824 450224 24.9046 20.1579 16.2433 19.9276 450229 16.4503 16.7853 * 16.6236 450231 19.1564 19.1746 20.7709 19.7438 450234 16.1945 16.3003 16.5793 16.3818 450235 15.2332 16.3115 17.5349 16.3996 450236 16.6703 16.4957 17.0092 16.7226 450237 20.7930 19.0325 * 19.8837 450239 17.1308 17.8401 18.8416 17.9241 450241 12.5675 16.4240 16.6046 14.9426 450243 11.9099 13.6416 11.2035 12.2464 450246 16.5478 16.7959 22.7940 18.4445 450249 12.0302 11.7658 10.6467 11.4953 450250 10.2844 13.6787 * 11.6004 450253 12.2402 13.2177 14.5492 13.3367 450258 16.0466 16.7337 17.0724 16.6100 450264 13.8929 14.5956 17.2825 15.2193 450269 12.3594 12.7717 12.9555 12.7319 450270 12.8381 14.4792 13.6733 13.6110 450271 16.6319 16.7831 17.9808 17.1692 450272 19.9331 18.4344 20.5888 19.6562 450276 13.1155 14.0745 14.0779 13.7681 450278 14.8291 15.2950 14.4871 14.8427 450280 22.2984 22.2936 20.3286 21.5973 450283 14.5664 15.1950 15.8684 15.2590 450288 16.2502 18.8935 13.5248 16.2231 450289 20.3104 20.3460 20.8745 20.5057 450292 16.9693 20.5335 17.7154 18.2921 450293 16.0132 16.2721 16.4077 16.2364 450296 21.6000 22.3430 * 21.9845 450299 21.5672 * 21.0398 21.2895 450303 12.4582 12.8996 14.3353 13.2442 450306 13.8216 14.2047 13.6333 13.8808 450307 16.4622 17.0691 17.6757 17.0817 450309 13.1480 13.3771 14.8823 13.8094 450315 22.8140 21.4684 23.8151 22.6579 450320 20.0946 20.6596 24.6129 21.4772 450321 13.1752 14.7344 14.4710 14.1070 450322 22.7667 29.1884 28.9834 26.4969 450324 17.7886 19.1692 20.9081 19.2343 450327 11.7511 13.3639 10.9732 11.8932 450330 18.9425 19.8066 20.8820 19.9093 450334 12.8051 13.8392 13.9839 13.5301 450337 17.1073 25.5708 * 20.0638 450340 17.6914 * 15.2368 16.4876 450341 18.9429 * 20.8814 19.8654 450346 17.5367 18.9475 19.2769 18.6527 450347 17.1099 19.3475 19.9109 18.7748 450348 13.9535 13.3585 15.0069 14.1063 450351 18.4116 19.3159 20.4537 19.4007 450352 18.7480 20.1871 21.2035 20.1227 450353 17.7539 16.0003 16.9105 16.8643 450355 11.9473 11.8933 12.8876 12.2285 450358 22.3235 23.0206 24.9765 23.4327 450362 15.8847 18.1983 18.1247 17.3786 450369 15.2233 15.3122 16.0667 15.5405 450370 12.6061 16.1369 18.7539 15.9177 450371 24.6339 16.0236 17.7591 19.2388 450372 20.0924 22.0746 21.4050 21.1434 450373 17.4183 17.9554 17.5600 17.6501 450374 13.6099 15.1750 15.0146 14.5995 450378 23.5789 23.4599 24.4143 23.8974 450379 22.7632 22.8756 25.1931 23.6182 450381 16.4166 16.7112 16.6476 16.5958 450388 19.2499 19.7408 20.6670 19.9390 450389 18.1797 18.8448 19.3156 18.7899 450393 20.2784 22.4992 21.1805 21.2450 450395 18.3768 18.0024 17.5236 17.9433 450399 15.7845 15.3491 16.3333 15.8319 450400 19.5379 18.6668 18.8375 18.9844 450403 20.1989 22.8430 24.7645 22.7028 450411 14.4832 15.1121 15.9178 15.1698 450417 13.4983 15.3591 15.2713 14.6933 450418 21.9161 21.9690 22.2511 22.0447 450419 20.6325 23.2551 22.4552 22.1296 450422 26.4848 28.0257 28.0395 27.5279 450423 22.7132 * * 22.7132 450424 18.9741 18.7895 * 18.8834 450429 13.8723 * * 13.8723 450431 19.6304 22.0361 21.7369 21.1141 450438 19.5028 15.4553 20.7791 18.3025 450446 13.0986 20.7592 * 16.2045 450447 18.0376 18.0377 19.3864 18.4641 450451 18.8948 18.2988 17.7525 18.2807 450457 24.7880 19.6569 * 21.9578 450460 15.1765 14.6523 15.8434 15.2180 450462 22.6212 22.1144 18.6080 21.0035 450464 13.2931 15.5908 15.8121 14.8193 450465 15.5650 15.4731 19.3928 16.5297 450467 10.6184 17.0004 18.9388 14.4801 450469 19.6269 22.1930 22.0389 21.2453 450473 19.9761 19.7148 18.3813 19.2637 450475 16.3404 16.9269 19.0010 17.4228 450484 16.8131 18.9825 19.2310 18.3714 450488 19.3457 19.2173 21.5440 20.0301 450489 9.9326 16.3584 17.8779 13.9861 450497 15.0886 16.2997 15.9325 15.7828 450498 13.8551 14.4713 15.9479 14.7991 450508 18.8069 19.0991 19.2176 19.0434 450514 21.3243 20.0144 20.7064 20.6957 450517 27.8815 14.3191 17.6011 18.7482 450518 19.8116 21.4873 20.7355 20.6380 450523 20.0792 21.0393 20.8469 20.6355 450530 22.8623 21.1634 22.0810 22.0042 450534 19.9376 20.1520 19.7227 19.9301 450535 19.6645 21.0513 21.5449 20.7286 450537 20.8438 20.1161 20.6100 20.5223 450539 16.4921 18.7559 19.3681 18.2066 450544 23.9283 23.6652 22.7282 23.5339 450545 19.5558 20.2823 21.0792 20.2860 450547 14.8248 18.1524 19.3002 17.4255 450551 16.9439 16.6237 16.1437 16.5621 450558 22.2574 20.7404 21.3116 21.4292 450563 19.9218 22.0708 21.8171 21.3374 450565 16.2652 17.3803 17.8058 17.1566 450570 18.9532 19.0336 * 18.9910 450571 17.5598 18.2784 19.5325 18.4467 450573 12.2502 17.3518 17.5455 15.5608 450574 14.5965 14.6128 14.8549 14.6891 450575 19.3925 22.5621 24.0386 22.1410 450578 15.4783 18.0925 17.2863 16.9084 450580 15.8321 16.7374 17.8552 16.8065 450583 15.6580 14.4411 15.1202 15.0631 450584 14.2321 14.6735 14.9237 14.6266 450586 14.3773 13.8248 15.2831 14.4737 450587 17.0230 18.0219 17.6291 17.5412 450591 17.8981 17.7795 18.6275 18.1113 450596 22.5420 21.6729 21.9445 22.0245 450597 17.0776 17.6179 19.0641 17.9259 450603 11.6442 23.5572 23.4924 18.9348 450604 16.4535 17.6582 18.6241 17.5848 450605 21.1400 19.4580 19.7400 20.0918 450609 15.9753 17.0986 14.1776 15.7466 450610 18.9924 21.5191 22.1792 21.1877 450614 17.9853 16.5754 * 17.2230 450615 14.8562 15.2956 14.9323 15.0244 450617 20.3387 20.8919 21.5004 20.9383 450620 15.8380 16.0987 16.1315 16.0378 450623 22.1950 23.1270 25.1122 23.4424 450626 18.1673 18.4349 20.5225 19.1158 450628 20.5611 18.6093 19.9760 19.7367 450630 21.6876 20.9605 23.1840 21.9334 450631 20.0417 21.6736 21.7853 21.1405 450632 11.7587 13.9147 15.1416 13.5343 450633 19.5183 19.4949 * 19.5064 450634 23.5333 22.9877 23.0470 23.1838 450638 23.1437 22.1704 23.8335 23.0423 450639 23.1936 21.6421 22.5182 22.4301 450641 16.5125 15.7578 15.1716 15.8348 450643 18.7054 16.8152 18.9088 18.1638 450644 23.6587 22.7721 24.5834 23.7084 450646 19.8274 19.1433 22.5667 20.4055 450647 24.7981 24.2763 25.0549 24.7111 450648 14.8488 15.0305 14.1565 14.6469 450649 16.4496 16.6577 16.7303 16.6187 450651 22.7664 22.7112 25.4679 23.6985 450652 13.4389 17.2445 * 14.7103 450653 18.1834 19.2349 19.5306 18.9413 450654 14.5258 14.5423 15.5858 14.8899 450656 17.6723 18.2606 18.5874 18.1828 450658 16.2657 17.2630 * 16.7212 450659 22.2550 23.0108 22.9344 22.7256 450661 19.7160 18.9071 19.5504 19.3935 450662 18.2284 19.3152 20.7973 19.5367 450665 15.2015 16.1319 14.2377 15.2093 450666 20.3248 20.2549 * 20.2912 450668 20.6965 21.0972 21.2002 20.9938 450669 21.7632 21.6746 22.5150 22.0051 450670 16.8893 20.2632 26.0785 20.9643 450672 21.8559 21.4927 23.2623 22.2025 450673 13.9620 13.7005 14.5310 14.0919 450674 22.2796 22.2426 21.9624 22.1483 450675 22.4961 21.4479 23.3954 22.4703 450677 22.6839 20.6556 21.3718 21.5395 450678 23.2617 24.1301 25.1841 24.1797 450683 20.9143 22.8699 21.9705 21.8695 450684 19.7005 21.9962 22.2380 21.3152 450686 16.5661 16.4632 17.4746 16.8354 450688 19.6250 20.1831 21.7691 20.5644 450690 21.6578 22.4707 27.2399 23.4791 450694 17.4758 18.1872 18.5520 18.0935 450696 24.9636 * * 24.9636 450697 18.8405 19.4949 19.4424 19.2742 450698 14.6680 15.4750 16.5111 15.5420 450700 14.6421 15.9050 13.9129 14.8191 450702 20.8223 21.3739 19.3495 20.4688 450704 20.9821 20.7987 18.1835 19.7101 450705 30.0116 22.1809 18.7138 22.5666 450706 21.2072 22.0884 22.4329 21.9400 450709 20.8889 22.1490 21.9270 21.6715 450711 19.8126 19.8581 21.0779 20.2689 450712 13.6240 15.9298 11.7861 13.6660 450713 20.8065 22.6986 23.6017 22.4678 450715 22.0413 22.5988 24.8068 23.2060 450716 20.5544 20.9074 20.8913 20.7944 450717 20.7192 20.6551 22.0243 21.1286 450718 19.6886 22.1765 22.9582 21.6590 450723 19.7563 20.8213 22.1695 20.9457 450724 20.3235 20.3706 23.4039 21.3348 450727 13.5458 17.9172 24.7672 17.9685 450728 17.5284 19.8879 14.8030 17.2831 450730 22.0819 23.0054 24.5952 23.2900 450733 20.7693 20.2199 21.6162 20.8632 450735 13.8767 * * 13.8767 450742 22.7655 21.8392 22.8135 22.4714 450743 18.8937 19.6015 20.5017 19.6892 450746 12.7904 30.2657 * 19.3854 450747 19.2585 20.3914 19.9818 19.8850 450749 16.2130 19.1678 17.2391 17.6065 450750 14.6914 13.8098 * 14.2686 450751 21.2198 19.9995 19.8170 20.4240 450754 16.0860 16.7145 16.7688 16.5644 450755 17.9904 19.8743 19.5916 19.1939 450757 13.8675 14.9434 15.5327 14.7530 450758 21.8669 19.0221 22.6196 21.1578 450760 17.4852 19.2225 20.4209 19.0477 450761 13.6152 15.7681 14.6511 14.6112 450763 18.2123 18.6092 18.9713 18.6032 450766 22.4348 23.3879 25.4057 23.7704 450769 14.5858 18.4163 17.3037 16.4629 450770 16.5458 19.0183 19.2518 18.2668 450771 22.4542 21.8268 21.4199 21.8514 450774 17.9964 16.2948 * 17.1404 450775 19.8897 21.3504 22.6526 21.2920 450776 15.7750 14.1720 13.4287 14.1843 450777 21.0682 19.0380 18.3119 19.5171 450779 21.4546 21.6642 22.1453 21.7809 450780 19.1498 19.0914 20.0824 19.4503 450785 18.4976 * * 18.4976 450788 19.1463 19.6469 19.9597 19.6478 450794 18.2229 * * 18.2229 450795 16.6494 22.5753 27.0250 21.6046 450796 16.5362 19.2059 * 17.7667 450797 15.9188 16.4923 20.2356 17.4420 450798 9.4634 * * 9.4634 450801 17.5669 17.9548 17.9759 17.8371 450802 19.9168 17.1435 18.2460 18.3472 450803 18.3767 21.6653 * 20.6031 450804 19.4846 19.0893 20.5225 19.7061 450806 * * 18.8211 18.8211 450807 11.3192 13.4306 18.4410 13.7054 450808 16.9915 17.4917 18.1728 17.5602 450809 20.0202 19.7899 21.8610 20.5411 450811 19.0961 19.9168 21.6115 20.3503 450813 15.9166 14.5392 15.3780 15.2272 450815 * 21.2741 * 21.2741 450819 * 16.5521 * 16.5521 450820 * 26.8348 24.6742 25.7177 450822 * 22.8556 24.8702 23.9136 450823 * * 17.9756 17.9756 450824 * * 25.7488 25.7488 450825 * * 15.3546 15.3546 450827 * * 20.1310 20.1310 450828 * * 17.7667 17.7667 450829 * * 14.7121 14.7121 460001 21.7996 22.2735 23.5485 22.5533 460003 20.0452 22.6289 * 21.2787 460004 21.3744 21.7234 23.1289 22.0969 460005 19.7069 22.5252 23.0189 21.6769 460006 20.6252 21.0700 22.1648 21.3374 460007 20.8026 21.1922 22.0409 21.4007 460008 18.8661 19.1153 22.6808 20.2069 460009 21.9016 22.5295 23.1146 22.5111 460010 21.9830 22.4948 23.8996 22.8204 460011 18.8660 19.7674 24.6789 20.7963 460013 20.7326 20.1936 * 20.4776 460014 18.3865 18.5370 * 18.4531 460015 20.6593 21.0470 22.4872 21.4209 460016 18.2408 21.9105 19.0910 19.6368 460017 17.7103 18.9929 * 18.3294 460018 17.6235 17.0063 17.0385 17.1969 460019 16.2671 17.8690 19.3442 17.7589 460020 17.3467 17.2663 18.1542 17.5580 460021 21.0470 21.5174 23.1368 21.9697 460022 20.1534 21.3614 20.7539 20.7266 460023 22.3535 22.9265 24.1825 23.1937 460025 19.4247 17.3494 17.4070 17.9267 460026 19.9241 20.2576 21.1759 20.4671 460027 21.8868 22.2955 21.4833 21.8607 460029 20.5154 20.8366 22.7658 21.3471 460030 17.6071 17.1383 18.1423 17.6207 460032 21.1006 21.4832 21.0286 21.1954 460033 19.5372 19.2664 20.2389 19.6949 460035 16.0021 16.1685 15.6979 15.9450 460036 23.5893 23.4573 24.2651 23.7927 460037 18.6850 17.7399 19.0115 18.4898 460039 24.9134 24.4808 24.5134 24.6186 460041 21.0623 20.2035 21.6676 20.9770 460042 18.8814 19.5662 20.9858 19.8725 460043 24.4779 23.2819 25.1366 24.2896 460044 21.4696 21.8485 23.6604 22.3504 460046 18.2224 * * 18.2224 460047 23.0433 22.7524 23.4965 23.0972 460049 19.6483 20.8283 21.5241 20.8906 460051 19.4761 22.1758 21.8595 21.1765 460052 * 19.8961 20.1989 20.0325 470001 20.2299 21.3817 21.7774 21.1523 470003 23.6949 22.0563 23.4163 23.0458 470004 16.8842 18.1879 17.3576 17.4706 470005 21.9191 23.1808 22.6589 22.5826 470006 17.8699 20.2829 21.0835 19.7003 470008 19.6069 20.1969 20.3833 20.0728 470010 20.2961 21.0616 22.3913 21.2927 470011 21.7675 22.2415 24.1306 22.7075 470012 18.5339 18.9444 19.8831 19.1162 470015 19.5366 20.2125 21.8204 20.4728 470018 21.5426 21.2406 23.1159 21.9638 470020 20.6643 21.5688 21.9911 21.4308 470023 20.4511 21.7139 22.5334 21.5811 470024 20.8510 21.9807 23.2738 22.0567 490001 21.9755 20.0570 21.4952 21.1603 490002 15.2287 15.7365 16.5198 15.8281 490003 19.1040 20.3237 20.7688 20.0621 490004 19.2126 19.7074 20.7390 19.8866 490005 20.5517 21.3318 22.9490 21.6702 490006 15.9537 12.3253 19.8977 16.1242 490007 18.7740 19.8938 20.5265 19.7370 490009 23.9344 23.7659 24.7602 24.1271 490010 21.7424 * * 21.7424 490011 18.6071 19.8042 19.8179 19.3919 490012 15.9973 15.2965 16.0994 15.7867 490013 17.3318 18.2396 18.3901 17.9911 490014 25.8315 23.5266 27.8907 25.6619 490015 19.6363 20.0667 21.4500 20.3969 490017 18.4361 19.3854 * 18.9126 490018 18.3435 18.5508 19.7456 18.8862 490019 19.6178 21.0124 21.6790 20.8153 490020 18.5691 19.3424 20.9212 19.6001 490021 19.3945 20.0496 21.2263 20.2509 490022 21.2183 22.3380 24.3008 22.6504 490023 20.6694 21.5683 22.8400 21.7338 490024 17.7221 18.4314 19.7501 18.7524 490027 16.2761 16.7556 17.5178 16.8693 490030 9.1789 8.6446 * 8.9749 490031 14.9539 16.0003 17.4262 16.1268 490032 22.4262 21.4037 22.2041 22.0055 490033 21.1723 19.2908 24.3589 21.5324 490037 16.3759 17.0113 16.7752 16.7116 490038 21.0218 17.6324 18.6012 18.9881 490040 22.7061 24.1266 24.8808 23.9273 490041 18.3589 18.7987 17.9942 18.3695 490042 16.4666 17.0972 18.1733 17.2802 490043 22.1574 22.1068 24.0198 22.7114 490044 18.3137 19.7842 18.4845 18.8757 490045 20.5468 20.5558 21.8453 21.0100 490046 18.4825 19.9102 19.7466 19.3960 490047 25.0438 18.7614 20.0837 20.6715 490048 18.4361 19.5417 20.9110 19.5970 490050 23.0729 23.3668 23.8519 23.4357 490052 16.8600 16.4787 17.6096 16.9745 490053 15.6996 16.8410 17.7363 16.7991 490054 15.4734 19.5780 22.5136 19.1813 490057 19.9210 20.3160 20.7806 20.3441 490059 20.8662 21.4801 24.1516 22.0719 490060 17.6308 18.5917 19.3525 18.5249 490063 28.6536 26.1930 * 27.3515 490066 20.6972 19.8352 21.5920 20.7067 490067 17.0195 17.8487 18.6469 17.8519 490069 17.3297 20.7582 21.5228 19.7588 490071 21.8879 23.3511 23.9246 23.0331 490073 20.7960 26.0957 * 23.1759 490075 18.6983 19.2156 20.2001 19.3654 490077 21.3670 22.6504 22.4133 22.1262 490079 17.0815 17.7016 17.5839 17.4571 490084 16.7834 18.0555 18.9679 17.9259 490085 17.4584 17.6158 19.2494 18.1150 490088 16.4362 17.9141 19.1415 17.7397 490089 17.7692 18.2290 19.6501 18.5835 490090 17.0199 17.5799 19.2094 17.9357 490091 20.8734 25.0272 23.6634 22.9282 490092 16.9533 16.4360 * 16.7160 490093 17.3711 17.8275 18.9442 18.0549 490094 18.9204 22.3033 20.2020 20.4445 490097 15.5780 16.9518 16.1076 16.1614 490098 15.1403 16.0488 18.5355 16.5130 490099 17.9665 18.3985 19.2604 18.5294 490100 22.5010 * * 22.5010 490101 24.7616 23.5553 25.7804 24.7017 490104 25.6889 40.2529 * 29.6601 490105 18.5765 21.4428 * 19.7749 490106 17.6596 26.3821 31.8566 22.3213 490107 23.5240 22.9283 23.9962 23.5071 490108 20.2112 24.1232 24.8596 22.6562 490109 23.6620 25.9475 23.0609 24.1978 490110 16.5131 18.1561 18.8042 17.8380 490111 17.1768 17.8510 19.6489 18.2093 490112 21.4532 22.1162 23.2843 22.3013 490113 23.2235 23.9043 26.1840 24.4577 490114 17.3047 18.0359 18.8920 18.0825 490115 16.5203 16.8537 18.4499 17.2731 490116 16.6170 17.2040 18.2935 17.3997 490117 14.0104 14.7944 15.9284 14.9234 490118 21.4674 23.2022 24.2668 22.9444 490119 17.9147 18.6046 18.9640 18.4840 490120 19.3707 20.5777 20.4547 20.1460 490122 23.8801 23.8198 26.6681 24.7636 490123 17.7461 19.3056 20.0920 19.0902 490124 22.0884 21.3818 23.6526 22.4301 490126 18.6844 20.4294 19.0782 19.3248 490127 16.0516 16.5993 17.6437 16.7293 490129 22.5885 28.6868 * 23.5799 490130 16.4322 17.6943 18.6406 17.5834 490132 18.6570 18.4671 19.1742 18.7508 500001 22.1896 24.4829 25.2411 23.9385 500002 21.6332 19.8476 22.9942 21.4749 500003 24.2814 24.4333 25.1200 24.6216 500005 22.3955 24.3870 26.6971 24.3513 500007 26.0599 21.9911 24.7889 24.1708 500008 25.3064 26.1737 27.2852 26.2556 500011 24.0162 24.6554 25.7263 24.7924 500012 20.7032 24.2799 24.5450 23.0771 500014 24.3419 24.0990 25.0490 24.4936 500015 23.9297 24.9923 25.8775 24.9616 500016 24.3938 24.9439 25.1227 24.8306 500019 22.4213 23.2054 23.5730 23.0604 500021 25.9198 27.6490 25.9403 26.4613 500023 26.6535 27.1025 32.3079 28.0325 500024 23.7472 26.6452 26.2113 25.5094 500025 26.4810 24.4825 27.2601 26.0674 500026 23.8005 26.9884 26.6108 25.7916 500027 22.2158 25.1125 27.5909 24.9753 500028 19.2675 18.9556 19.0261 19.0887 500029 17.9237 18.5042 19.3130 18.5707 500030 24.9039 26.3828 28.5297 26.6182 500031 29.2707 23.6099 25.8542 26.0586 500033 22.3527 22.5462 23.8994 22.9522 500036 22.1096 23.6333 25.1255 23.5838 500037 20.7139 21.4059 22.1774 21.4194 500039 23.8918 24.0007 25.4225 24.4379 500041 23.9608 25.4376 24.7070 24.7067 500042 22.9125 * * 22.9125 500043 20.9459 22.0466 24.1745 22.4162 500044 23.3364 24.2212 24.7816 24.1154 500045 20.8881 24.0526 24.6265 23.0766 500048 22.1906 20.3207 20.6333 21.0462 500049 24.0489 24.5997 26.5857 25.0314 500050 22.0065 22.6563 23.0804 22.6053 500051 24.8203 25.9447 26.7628 25.8820 500053 23.9397 22.8399 24.2492 23.6675 500054 22.8829 23.8089 25.7815 24.1708 500055 23.7446 23.8622 23.7988 23.8022 500057 18.2737 19.0479 20.5812 19.3310 500058 24.7882 24.1106 26.5679 25.1920 500059 23.3506 26.6270 25.3528 25.0566 500060 25.0233 28.3655 29.6030 27.5162 500061 21.7013 20.8624 24.5908 22.4271 500062 18.6329 19.0557 19.1685 18.9583 500064 25.5748 26.7000 27.5791 26.6387 500065 21.9308 23.5671 24.0966 23.2140 500068 19.6574 19.2638 20.9278 19.9560 500069 21.3592 21.4542 22.4158 21.7566 500071 19.1906 19.1428 22.3253 20.1059 500072 25.3928 25.2001 25.7734 25.4637 500073 21.2469 21.7698 22.5222 21.8777 500074 18.9679 19.5981 20.6120 19.7482 500077 22.8536 23.9410 24.5407 23.7721 500079 24.2036 23.1041 24.7946 24.0303 500080 15.6630 18.3883 18.8188 17.4053 500084 23.4032 24.4044 24.5678 24.1531 500085 21.4403 20.4517 20.7422 20.8523 500086 23.3288 22.8829 24.2556 23.4907 500088 23.2701 25.2478 25.2774 24.5589 500089 18.7080 19.7166 20.3478 19.5281 500090 16.1576 20.4429 21.7716 18.7859 500092 16.7913 19.2028 20.3058 18.6898 500094 18.5835 15.7866 17.6625 17.4874 500096 21.0151 23.3564 25.1135 23.2107 500097 19.7706 20.8774 21.4423 20.6699 500098 16.3511 15.2040 13.5203 15.0572 500101 19.7337 15.8000 19.8614 18.4197 500102 20.9389 21.8963 23.1307 22.0050 500104 22.8154 24.9389 24.7875 24.1421 500106 18.6041 19.1465 17.1066 18.3020 500107 18.1201 17.9489 17.4641 17.8401 500108 26.2939 28.6229 26.1609 27.0259 500110 21.4553 22.9775 23.5941 22.6736 500118 23.8397 24.8034 24.7875 24.4924 500119 22.4373 22.1192 23.9939 22.8469 500122 22.4268 23.5264 24.4462 23.5112 500123 20.3181 19.6646 21.7133 20.7526 500124 23.2836 23.7742 24.6591 23.9700 500125 15.1112 14.7910 15.6304 15.1911 500129 26.1575 25.4685 25.2082 25.5438 500132 15.6717 23.1822 21.9915 20.2081 500134 17.7457 17.2430 15.9791 16.9729 500139 22.2297 22.3053 23.7993 22.7606 500141 23.8838 29.9695 28.1014 27.3199 500143 18.0343 18.2570 18.7523 18.3736 500146 21.6003 * * 21.6003 510001 19.1492 20.0429 20.2514 19.8050 510002 20.1527 17.6392 19.1517 18.9313 510005 14.2503 13.8621 13.8641 13.9934 510006 18.7313 19.9609 19.9760 19.5653 510007 21.2729 21.6761 23.0072 22.0021 510008 18.3296 19.0513 20.1039 19.1754 510012 15.8390 15.6089 15.8596 15.7743 510013 17.8527 19.5798 18.3486 18.5734 510015 14.9039 16.7311 17.1595 16.3249 510018 18.5269 18.5358 18.3023 18.4548 510020 13.1837 14.1211 15.7512 14.3266 510022 20.1763 21.5770 21.4336 21.0418 510023 16.0129 16.7777 17.6516 16.8122 510024 19.0941 18.7461 19.6521 19.1601 510026 13.6888 13.7952 14.8785 14.0865 510027 17.2900 18.5945 20.5222 18.7968 510028 20.0628 19.9208 22.4826 20.8230 510029 17.7124 18.4668 16.3204 17.4181 510030 17.4198 17.7603 19.2558 18.1712 510031 28.6673 18.6341 19.3049 21.2106 510033 18.4082 18.4718 19.6900 18.8637 510035 16.5007 18.3164 21.7818 18.6703 510036 13.4559 13.8786 15.0266 14.0903 510038 15.8132 15.5576 15.9821 15.7873 510039 16.9398 17.1461 17.4002 17.1582 510043 14.0662 13.1308 14.4202 13.8751 510046 17.3821 18.5896 18.7424 18.2568 510047 19.8963 20.8101 21.2375 20.6123 510048 21.0407 17.1647 15.2886 17.8240 510050 16.9136 18.4036 18.3964 17.9380 510053 16.1036 17.5798 18.1046 17.2603 510055 23.7248 24.2133 25.6333 24.5104 510058 18.4156 18.4501 18.6025 18.4938 510059 16.5854 16.1044 17.3844 16.6208 510060 17.5594 * * 17.5594 510061 13.8204 14.1968 14.6774 14.2360 510062 19.3881 18.1588 19.7964 19.0922 510066 12.2943 * * 12.2943 510067 16.7161 17.3067 17.8816 17.3091 510068 18.7938 23.0452 19.4299 20.2577 510070 18.5146 18.7091 18.6226 18.6195 510071 17.2148 18.0278 18.8766 18.0317 510072 15.6262 15.9257 16.5279 16.0216 510077 18.0668 18.2947 20.4521 18.9028 510080 17.4485 16.3453 18.5318 17.3501 510081 13.6359 11.9701 10.4972 11.9879 510082 17.4538 13.5946 16.0014 15.5120 510084 17.2395 13.5339 14.9683 15.2567 510085 17.5624 18.6227 19.0175 18.4360 510086 13.4763 14.2241 16.3413 14.6710 510088 * 14.8854 16.2850 15.6272 520002 19.7447 19.6755 19.3159 19.5604 520003 17.1248 18.7956 18.7507 18.2896 520004 19.6512 20.4591 18.8843 19.6231 520006 21.5313 21.4884 22.4099 21.7879 520007 16.2001 18.4629 18.3959 17.6275 520008 22.8024 24.9395 24.4927 24.0917 520009 18.6002 21.4638 19.8142 19.9388 520010 22.7703 22.3311 25.4845 23.5468 520011 20.7410 21.5223 21.6945 21.3155 520013 20.3965 20.5944 22.1009 21.0588 520014 17.1646 18.0841 19.2760 18.1480 520015 18.6078 19.7672 21.0428 19.8323 520016 17.3018 18.4320 19.5656 18.4077 520017 19.6008 19.4780 21.1409 20.0934 520018 21.1941 21.5279 22.1929 21.6736 520019 19.5440 20.9164 21.8870 20.7980 520021 21.3471 21.9531 22.8484 22.1016 520024 14.0175 14.4750 16.4879 15.0572 520025 18.2430 20.3838 21.9529 20.1629 520026 21.5453 20.8546 22.7429 21.7237 520027 19.9324 21.5868 22.0947 21.2079 520028 21.2852 22.5941 22.0333 21.9368 520029 19.5750 21.4197 21.6729 20.8760 520030 20.5039 21.6311 22.7239 21.6241 520031 20.4814 20.9875 21.2809 20.8937 520032 19.5697 21.1069 24.1092 21.5816 520033 19.2954 20.2520 21.0088 20.1750 520034 17.1282 20.4307 21.2944 19.6400 520035 18.9452 18.7135 19.7990 19.1719 520037 20.6686 21.6017 23.0801 21.8015 520038 19.6294 20.6130 21.2769 20.4835 520039 20.7641 23.3687 21.8688 21.9128 520040 20.4677 21.2023 23.0710 21.5679 520041 17.1959 18.4117 17.6529 17.7461 520042 18.5843 19.5466 20.6354 19.6057 520044 18.4014 19.1877 21.4913 19.6621 520045 20.5917 21.2427 21.9812 21.2870 520047 18.3048 20.3487 21.0370 19.8304 520048 20.6583 19.8926 20.3488 20.2938 520049 20.3559 20.1667 21.8271 20.7868 520051 21.6497 24.0460 23.4366 23.0036 520053 17.3945 18.0851 18.7234 18.0684 520054 15.1747 16.8363 16.6278 16.1750 520057 19.0872 19.8492 20.6959 19.9036 520058 19.7283 21.2500 23.6794 21.5351 520059 20.9913 21.5796 21.9452 21.5150 520060 17.9258 18.8232 20.3357 19.0291 520062 19.1482 19.7038 21.5525 20.1564 520063 19.6136 20.5262 21.2774 20.4843 520064 22.7423 22.0917 23.7144 22.8379 520066 22.8837 24.0087 24.1733 23.6290 520068 18.9943 19.6855 19.9595 19.5384 520069 20.2934 20.1770 21.7233 20.5221 520070 18.5938 19.4261 20.0096 19.3562 520071 18.7304 19.9866 22.0066 20.1801 520074 20.4601 20.9007 21.6636 20.9770 520075 19.8457 20.7301 22.1894 20.9388 520076 17.6088 19.5878 20.6155 19.2421 520077 17.7830 18.7119 18.1077 18.2004 520078 21.3380 21.7545 20.5734 21.2201 520082 17.7405 * * 17.7405 520083 23.8849 23.5787 24.2131 23.8898 520084 20.8427 23.5446 21.8102 22.0208 520087 20.3624 20.7821 22.2579 21.1364 520088 20.6312 21.8931 22.3921 21.5920 520089 21.5456 22.1055 23.1221 22.2509 520090 18.9343 20.3645 20.9069 20.0854 520091 20.9927 20.9440 22.2218 21.3884 520092 17.6500 18.6248 19.7870 18.7181 520094 20.3611 20.6179 21.3082 20.7652 520095 20.3269 18.6425 21.8172 20.1804 520096 19.7757 20.6668 21.6803 20.7358 520097 20.2354 20.8016 22.2375 21.1096 520098 22.3348 23.4707 23.4273 23.0928 520100 18.3832 19.4788 20.5366 19.4712 520101 19.5186 19.9875 20.0164 19.8451 520102 20.1898 21.0138 22.1413 21.1139 520103 19.4809 20.1092 22.2765 20.6137 520107 20.3747 21.7907 23.8421 21.9354 520109 19.1303 19.7609 20.3208 19.7432 520110 20.4494 21.0055 22.3923 21.3276 520111 17.7834 17.7673 18.2744 17.9282 520112 19.1797 18.9577 17.6226 18.3876 520113 21.1485 21.8852 23.1852 22.0983 520114 16.6616 17.8476 18.5767 17.6415 520115 18.2980 19.2248 21.4279 19.6231 520116 19.8509 20.6922 22.2741 20.9026 520117 18.5414 18.3963 19.3653 18.7838 520118 14.2326 14.8626 13.9920 14.3519 520120 18.7437 * * 18.7437 520121 19.7305 20.8492 20.9422 20.5799 520122 16.2436 16.9335 16.9905 16.7143 520123 17.3980 17.7986 19.8134 18.4575 520124 17.2619 17.9205 19.2621 18.1369 520130 15.6845 16.6873 18.8845 17.0161 520131 18.7295 20.2591 21.0400 20.0321 520132 15.6379 18.1630 18.2634 17.2681 520134 18.0953 18.8150 19.6881 18.8725 520135 15.8246 17.3476 18.1026 17.0799 520136 19.8480 20.9050 21.3966 20.7380 520138 21.2260 22.5599 22.5773 22.1218 520139 20.9988 21.4042 22.8070 21.7325 520140 21.5207 22.3671 22.5459 22.1346 520142 20.5858 21.9432 21.4120 21.2420 520144 18.5701 19.9120 20.5864 19.6719 520145 18.2654 18.7958 20.3461 19.0923 520146 17.9585 18.2370 18.6337 18.2882 520148 17.2421 19.1502 20.5075 19.0048 520149 14.1901 12.8928 13.8614 13.6192 520151 17.3267 18.7070 19.3362 18.4627 520152 19.5858 22.5980 26.2402 22.5080 520153 15.9753 17.0863 18.3447 17.1026 520154 18.5403 19.5994 21.0486 19.7479 520156 21.3377 20.9638 20.7806 21.0121 520157 17.1974 19.6008 21.6821 19.4299 520159 18.6760 17.7649 21.8783 19.4305 520160 19.4173 20.5154 21.5266 20.5092 520161 19.4905 20.1102 21.4038 20.3456 520170 21.5233 21.9857 23.0867 22.2181 520171 17.4560 18.0785 18.1844 17.8993 520173 21.3016 20.9209 23.2955 21.8315 520177 22.7221 24.0139 25.1080 23.8746 520178 18.6936 20.9010 23.1509 20.7167 520188 13.9135 * * 13.9135 520189 * * 21.6813 21.6813 530002 19.3273 21.0560 23.0582 21.0877 530003 16.2139 15.9523 17.1646 16.4518 530004 15.0497 13.3788 17.4672 15.2335 530005 13.3529 15.3255 18.3704 15.7393 530006 18.5894 19.1305 20.7661 19.4956 530007 18.5161 17.7897 18.5286 18.3005 530008 18.8349 19.0113 19.0016 18.9483 530009 22.5009 21.7795 23.5839 22.6178 530010 21.6092 13.9536 12.3695 15.3501 530011 18.7354 19.4606 19.9212 19.3808 530012 18.9923 21.1854 22.5084 20.9252 530014 18.0869 18.4900 20.0422 18.9065 530015 22.4568 23.4040 24.6527 23.4897 530016 18.1562 19.3205 20.3647 19.2610 530017 16.3478 17.7736 20.9408 18.2556 530018 18.3783 19.5986 20.1226 19.3605 530019 18.5430 20.1097 18.1492 18.8643 530022 18.5002 19.6136 19.7902 19.3159 530023 20.1948 20.0677 21.6352 20.6416 530025 21.2598 22.0300 22.4816 21.9309 530026 17.0118 19.8969 20.9919 19.1178 530027 18.1664 25.5067 * 20.8124 530029 16.5092 19.3361 20.3046 18.6145 530031 18.3322 20.1734 23.2766 20.4477 530032 21.0361 20.0132 20.9856 20.6817 * Denotes wage data not available for the provider for that year. ** Based on the sum of the salaries and hours computed for Federal FYs 2001, 2002, and 2003. Table 3A.—FY 2003 and 3-Year* Average Hourly Wage for Urban Areas [*Based on the sum of the salaries and hours computed for Federal FYs 2001, 2002, and 2002] Urban area FY 2003 average hourly wage 3-Year average hourly wage Abilene, TX 21.3116 18.2370 Aguadilla, PR 10.6548 10.3692 Akron, OH 22.2695 21.8175 Albany, GA 24.9139 23.4370 Albany-Schenectady-Troy, NY 19.4516 19.0017 Albuquerque, NM 21.3374 20.9862 Alexandria, LA 18.1736 17.9283 Allentown-Bethlehem-Easton, PA 22.6105 22.2137 Altoona, PA 21.3848 20.7048 Amarillo, TX 20.8120 19.7427 Anchorage, AK 28.6899 28.2057 Ann Arbor, MI 25.7925 25.0051 Anniston, AL 18.6862 18.3987 Appleton-Oshkosh-Neenah, WI 20.8773 20.4112 Arecibo, PR 10.0744 10.0865 Asheville, NC 22.2638 21.2069 Athens, GA 23.7041 22.3198 Atlanta, GA 23.2034 22.5565 Atlantic-Cape May, NJ 25.4286 24.9782 Auburn-Opelika, AL 19.1001 18.3671 Augusta-Aiken, GA-SC 23.8329 21.9394 Austin-San Marcos, TX 21.9115 21.4039 Bakersfield, CA 23.4741 21.9163 Baltimore, MD 22.4354 21.6104 Bangor, ME 22.5137 21.5643 Barnstable-Yarmouth, MA 30.1848 30.2355 Baton Rouge, LA 19.2871 18.9071 Beaumont-Port Arthur, TX 19.2896 19.0451 Bellingham, WA 28.5297 26.6182 Benton Harbor, MI 20.6766 19.7627 Bergen-Passaic, NJ 27.8231 26.5455 Billings, MT 20.9586 20.9004 Biloxi-Gulfport-Pascagoula, MS 20.3045 19.0487 Binghamton, NY 19.3760 19.0441 Birmingham, AL 21.3884 19.7545 Bismarck, ND 18.0466 17.5136 Bloomington,IN 20.6895 19.8190 Bloomington-Normal, IL 21.1609 20.3703 Boise City, ID 21.6225 20.5010 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 25.9941 25.2200 Boulder-Longmont, CO 22.2777 21.7937 Brazoria, TX 19.8139 19.0124 Bremerton, WA 25.4225 24.4379 Brownsville-Harlingen-San Benito, TX 20.6770 19.9443 Bryan-College Station, TX 19.3399 19.2454 Buffalo-Niagara Falls, NY 21.7624 21.2368 Burlington, VT 23.3989 22.9310 Caguas, PR 10.1529 10.1915 Canton-Massillon, OH 20.7556 19.7901 Casper, WY 22.5084 20.9252 Cedar Rapids, IA 21.0377 19.8268 Champaign-Urbana, IL 22.9565 20.9245 Charleston-North Charleston, SC 18.6257 19.5755 Charleston, WV 20.1558 20.3125 Charlotte-Gastonia-Rock Hill, NC-SC 22.6242 21.3014 Charlottesville, VA 24.3357 23.7751 Chattanooga, TN-GA 20.8534 21.0504 Cheyenne, WY 20.0422 18.9065 Chicago, IL 25.4960 24.8000 Chico-Paradise, CA 22.6186 22.0636 Cincinnati, OH-KY-IN 21.4375 21.0209 Clarksville-Hopkinsville, TN-KY 19.2844 18.5774 Cleveland-Lorain-Elyria, OH 21.3730 21.1174 Colorado Springs, CO 22.9223 21.9346 Columbia, MO 20.0916 19.6531 Columbia, SC 20.6722 20.8728 Columbus, GA-AL 19.4319 18.9760 Columbus, OH 22.3157 21.5032 Corpus Christi, TX 18.7495 18.7846 Corvallis, OR 26.6038 25.7705 Cumberland, MD-WV 18.2292 18.3160 Dallas, TX 22.6072 22.1220 Danville, VA 20.2001 19.3654 Davenport-Moline-Rock Island, IA-IL 20.4000 19.6921 Dayton-Springfield, OH 21.5652 20.8876 Daytona Beach, FL 21.0017 20.3557 Decatur, AL 20.8473 19.7262 Decatur, IL 18.5380 18.0259 Denver, CO 23.9179 23.0032 Des Moines, IA 20.3902 19.9395 Detroit, MI 24.1574 23.4668 Dothan, AL 18.3729 17.7890 Dover, DE 21.7344 22.1849 Dubuque, IA 20.2381 19.4209 Duluth-Superior, MN-WI 24.0567 22.9550 Dutchess County, NY 24.8186 23.5537 Eau Claire, WI 20.7890 19.9433 El Paso, TX 21.0095 20.6428 Elkhart-Goshen, IN 22.6528 21.3565 Elmira, NY 19.7114 19.0237 Enid, OK 19.2869 18.8881 Erie, PA 20.7316 19.9094 Eugene-Springfield, OR 25.4725 24.9448 Evansville, Henderson, IN-KY 18.9808 18.5894 Fargo-Moorhead, ND-MN 22.4962 20.6192 Fayetteville, NC 20.6496 19.8938 Fayetteville-Springdale-Rogers, AR 18.8149 18.2982 Flagstaff, AZ-UT 24.8141 23.9367 Flint, MI 25.8296 24.8385 Florence, AL 18.2288 17.4228 Florence, SC 20.3953 19.6524 Fort Collins-Loveland, CO 22.8171 22.8018 Fort Lauderdale, FL 23.8406 22.9502 Fort Myers-Cape Coral, FL 21.7431 20.9253 Fort Pierce-Port St. Lucie, FL 22.5387 22.0206 Fort Smith, AR-OK 17.9611 17.8193 Fort Walton Beach, FL 22.1915 21.0734 Fort Wayne, IN 21.8421 20.4123 Fort Worth-Arlington, TX 22.1218 21.2887 Fresno, CA 23.7765 22.6843 Gadsden, AL 19.7302 19.2011 Gainesville, FL 22.3748 21.8054 Galveston-Texas City, TX 22.0810 22.2390 Gary, IN 22.2500 21.3750 Glens Falls, NY 19.1071 18.6348 Goldsboro, NC 20.6547 19.5049 Grand Forks, ND-MN 20.6675 19.9946 Grand Junction, CO 22.1097 21.1165 Grand Rapids-Muskegon-Holland, MI 22.1795 22.3013 Great Falls, MT 20.7913 20.0975 Greeley, CO 20.6781 21.0801 Green Bay, WI 22.0738 20.9151 Greensboro-Winston-Salem-High Point, NC 21.3171 20.8100 Greenville, NC 21.1020 20.7582 Greenville-Spartanburg-Anderson, SC 21.1013 20.4227 Hagerstown, MD 21.5280 20.1745 Hamilton-Middletown, OH 21.8081 20.7774 Harrisburg-Lebanon-Carlisle, PA 21.4204 21.2190 Hartford, CT 26.5589 25.6600 Hattiesburg, MS 17.6308 16.8808 Hickory-Morganton-Lenoir, NC 20.5993 20.3564 Honolulu, HI 25.5733 25.7139 Houma, LA 19.4770 18.2833 Houston, TX 22.4099 21.6980 Huntington-Ashland, WV-KY-OH 22.4054 21.7937 Huntsville, AL 20.4686 19.9112 Indianapolis, IN 22.6001 21.8532 Iowa City, IA 23.0524 21.9952 Jackson, MI 22.0543 20.8972 Jackson, MS 20.0348 19.3281 Jackson, TN 21.5461 20.3227 Jacksonville, FL 21.4789 20.7080 Jacksonville, NC 19.1386 17.6977 Jamestown, NY 18.5184 17.7951 Janesville-Beloit, WI 22.2956 21.6016 Jersey City, NJ 25.7550 25.2422 Johnson City-Kingsport-Bristol, TN-VA 19.1020 18.7739 Johnstown, PA 19.3481 19.3567 Jonesboro, AR 18.0006 17.9165 Joplin, MO 20.0064 19.0676 Kalamazoo-Battlecreek, MI 24.5797 23.6868 Kankakee, IL 22.0535 21.8916 Kansas City, KS-MO 22.5556 21.5044 Kenosha, WI 22.3994 21.6107 Killeen-Temple, TX 19.4230 20.6248 Knoxville, TN 20.9030 19.6266 Kokomo, IN 20.5813 20.5547 La Crosse, WI-MN 20.9920 20.5609 Lafayette, LA 19.6610 19.0691 Lafayette, IN 21.8803 20.4752 Lake Charles, LA 18.4643 17.2545 Lakeland-Winter Haven, FL 21.0679 20.4786 Lancaster, PA 21.0878 20.6617 Lansing-East Lansing, MI 22.5979 21.9294 Laredo, TX 19.5558 18.3090 Las Cruces, NM 20.4375 19.5136 Las Vegas, NV-AZ 25.3348 24.6305 1 Lawrence, KS 17.8290 Lawton, OK 18.9728 19.3040 Lewiston-Auburn, ME 21.2671 20.5697 Lexington, KY 19.8413 19.5837 Lima, OH 21.8791 21.1154 Lincoln, NE 20.5292 21.3398 Little Rock-North Little Rock, AR 20.7992 19.9953 Longview-Marshall, TX 19.7471 19.4279 Los Angeles-Long Beach, CA 27.6569 26.7968 Louisville, KY-IN 21.8834 21.1577 Lubbock, TX 17.7930 18.8697 Lynchburg, VA 21.4112 20.3454 Macon, GA 21.2905 20.2752 Madison, WI 23.4267 22.9567 Mansfield, OH 20.6712 19.6802 Mayaguez, PR 11.3157 10.6879 McAllen-Edinburg-Mission, TX 19.3599 18.9086 Medford-Ashland, OR 24.3865 23.3354 Melbourne-Titusville-Palm Bay, FL 24.7923 22.7180 Memphis, TN-AR-MS 20.3251 19.7569 Merced, CA 22.8511 21.9541 Miami, FL 22.6833 22.2549 Middlesex-Somerset-Hunterdon, NJ 26.3374 25.3182 Milwaukee-Waukesha, WI 22.7676 22.0856 Minneapolis-St. Paul, MN-WI 25.2239 24.5477 Missoula, MT 21.2713 20.8023 Mobile, AL 18.8082 18.2018 Modesto, CA 24.3874 23.6713 Monmouth-Ocean, NJ 25.9158 24.8978 Monroe, LA 18.8342 18.4736 Montgomery, AL 17.8451 16.9642 Muncie, IN 21.0399 22.2998 Myrtle Beach, SC 21.0194 19.6847 Naples, FL 22.5429 21.7594 Nashville, TN 21.7439 21.3869 Nassau-Suffolk, NY 30.9070 30.5534 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 28.6474 27.5560 New London-Norwich, CT 27.2742 26.4332 New Orleans, LA 20.8098 20.4020 New York, NY 32.3513 32.1379 Newark, NJ 26.4531 26.0261 Newburgh, NY-PA 26.2921 24.9278 Norfolk-Virginia Beach-Newport News, VA-NC 19.6667 19.0225 Oakland, CA 35.0027 33.9458 Ocala, FL 21.9054 21.0412 Odessa-Midland, TX 21.2320 21.2696 Oklahoma City, OK 20.6894 19.7355 Olympia, WA 25.4588 24.6677 Omaha, NE-IA 23.1988 21.8834 Orange County, CA 26.6831 25.4624 Orlando, FL 21.9294 21.4758 Owensboro, KY 19.0457 18.4790 Panama City, FL 20.5244 20.1345 Parkersburg-Marietta, WV-OH 18.8778 18.3560 Pensacola, FL 19.9673 18.7468 Peoria-Pekin, IL 20.3592 19.5705 Philadelphia, PA-NJ 24.5469 24.2416 Phoenix-Mesa, AZ 21.9868 21.5339 Pine Bluff, AR 18.0874 17.5370 Pittsburgh, PA 21.6212 21.3813 Pittsfield, MA 23.4852 22.9215 Pocatello, ID 19.6333 20.1279 Ponce, PR 12.0062 11.5028 Portland, ME 22.8379 21.6951 Portland-Vancouver, OR-WA 24.7759 24.4428 Providence-Warwick, RI 24.2778 24.0071 Provo-Orem, UT 23.4308 22.3948 Pueblo, CO 20.3670 19.5929 Punta Gorda, FL 17.3909 18.1956 Racine, WI 21.6444 20.8817 Raleigh-Durham-Chapel Hill, NC 23.1852 22.0116 Rapid City, SD 20.5485 19.8947 Reading, PA 21.4029 20.8900 Redding, CA 25.8663 25.3801 Reno, NV 24.5213 23.5887 Richland-Kennewick-Pasco, WA 26.6936 25.3323 Richmond-Petersburg, VA 22.3862 21.6142 Riverside-San Bernardino, CA 25.8718 24.9920 Roanoke, VA 20.0117 19.2433 Rochester, MN 28.1983 26.1811 Rochester, NY 21.0003 20.5991 Rockford, IL 21.7440 20.5098 Rocky Mount, NC 21.4359 20.3593 Sacramento, CA 26.7257 26.3878 Saginaw-Bay City-Midland, MI 22.3260 21.5138 St. Cloud, MN 22.4364 22.0902 1 St. Joseph, MO 19.7467 St. Louis, MO-IL 20.4806 20.0376 Salem, OR 24.0818 22.8500 Salinas, CA 33.9674 32.7871 Salt Lake City-Ogden, UT 23.0757 22.1425 San Angelo, TX 18.2955 18.0306 San Antonio, TX 19.8888 19.2241 San Diego, CA 25.8535 25.5476 San Francisco, CA 32.8557 31.7475 San Jose, CA 32.5657 31.2857 San Juan-Bayamon, PR 10.8224 10.5408 San Luis Obispo-Atascadero-Paso Robles, CA 26.1821 24.6268 Santa Barbara-Santa Maria-Lompoc, CA 24.3466 23.8325 Santa Cruz-Watsonville, CA 31.3417 31.0243 Santa Fe, NM 24.8842 23.5075 Santa Rosa, CA 30.3046 28.9555 Sarasota-Bradenton, FL 21.4760 21.7771 Savannah, GA 22.9060 22.0969 Scranton-Wilkes Barre-Hazleton, PA 19.5725 19.0594 Seattle-Bellevue-Everett, WA 26.6067 25.2916 Sharon, PA 18.2710 17.7451 Sheboygan, WI 20.1510 19.0711 Sherman-Denison, TX 21.4636 20.3959 Shreveport-Bossier City, LA 20.2644 19.8410 Sioux City, IA-NE 21.0135 19.6404 Sioux Falls, SD 20.9214 20.1349 South Bend, IN 22.7694 22.2819 Spokane, WA 25.2044 23.9682 Springfield, IL 19.9008 19.3840 Springfield, MO 19.5680 19.0448 Springfield, MA 25.4001 24.2504 State College, PA 20.7690 20.2726 Steubenville-Weirton, OH-WV 20.4503 19.4333 Stockton-Lodi, CA 24.0178 23.7561 Sumter, SC 18.8535 18.0764 Syracuse, NY 21.8886 21.3766 Tacoma, WA 25.4131 25.5054 Tallahassee, FL 19.6007 19.0869 Tampa-St. Petersburg-Clearwater, FL 20.9878 20.1427 Terre Haute, IN 19.9743 19.0303 Texarkana, AR-Texarkana, TX 18.7416 18.5107 Toledo, OH 22.6790 21.9714 Topeka, KS 20.5859 20.0981 Trenton, NJ 24.6268 23.3224 Tucson, AZ 20.6783 19.9418 Tulsa, OK 19.3121 19.1851 Tuscaloosa, AL 18.9045 18.2544 Tyler, TX 22.1901 21.3538 Utica-Rome, NY 19.6508 18.9705 Vallejo-Fairfield-Napa, CA 30.9785 29.7068 Ventura, CA 25.7748 24.7503 Victoria, TX 20.2675 18.8655 Vineland-Millville-Bridgeton, NJ 23.6746 23.2888 Visalia-Tulare-Porterville, CA 21.6029 21.2747 Waco, TX 20.2402 18.4397 Washington, DC-MD-VA-WV 24.9537 24.2243 Waterloo-Cedar Falls, IA 18.7281 18.3305 Wausau, WI 22.7239 21.6241 West Palm Beach-Boca Raton, FL 22.8320 21.9092 Wheeling, OH-WV 17.8084 17.4900 Wichita, KS 22.0087 21.3928 Wichita Falls, TX 18.4488 17.5804 Williamsport, PA 19.8310 18.8540 Wilmington-Newark, DE-MD 25.9552 24.8359 Wilmington, NC 21.7789 21.1031 Yakima, WA 24.5502 23.1867 Yolo, CA 21.9147 21.8929 York, PA 21.0167 20.7492 Youngstown-Warren, OH 21.8109 21.2943 Yuba City, CA 23.7087 23.3825 Yuma, AZ 19.9517 20.2223 1 The MSA is empty for FY 2003. The hospital(s) in the MSA received rural status under Section 401 of the Balanced Budget Refinement Act of 1999 (P.L. 106-113). The MSA is assigned the statewide rural wage index (see Table 4B). Table 3B.—FY 2003 and 3-Year* Average Hourly Wage for Rural Areas [*Based on the sum of the salaries and hours computed for Federal FYs 2001, 2002, and 2003] Nonurban area FY 2003 average hourly wage 3-Year average hourly wage Alabama 17.9036 16.8484 Alaska 28.3370 27.2338 Arizona 19.5067 19.0116 Arkansas 17.6380 16.8439 California 22.8280 21.9650 Colorado 20.9354 20.0304 Connecticut 28.7896 27.0512 Delaware 20.9850 20.7345 Florida 20.4812 19.8506 Georgia 18.9804 18.5484 Hawaii 23.7802 24.2085 Idaho 20.2336 19.5324 Illinois 19.0881 18.2692 Indiana 20.2273 19.4705 Iowa 19.3039 18.3140 Kansas 18.3139 17.4523 Kentucky 18.5767 17.8667 Louisiana 17.5606 17.0801 Maine 20.1286 19.5633 Maryland 20.3626 19.6588 Massachusetts 25.8847 25.2714 Michigan 20.5663 20.0744 Minnesota 21.2683 20.2498 Mississippi 17.8117 16.9666 Missouri 18.6096 17.6847 Montana 19.7008 19.3096 Nebraska 19.0466 18.2894 Nevada 21.8882 21.2045 New Hampshire 22.7236 21.9972 New Jersey 1 New Mexico 19.8780 19.2303 New York 19.8523 19.1400 North Carolina 20.0381 19.1521 North Dakota 18.0060 17.4398 Ohio 19.9481 19.3896 Oklahoma 17.6227 16.9222 Oregon 23.9321 22.8031 Pennsylvania 19.6030 19.1490 Puerto Rico 10.1187 10.0248 Rhode Island 1 South Carolina 19.7928 19.0083 South Dakota 18.1545 17.3648 Tennessee 18.1050 17.6144 Texas 17.8263 17.1186 Utah 21.6749 20.5059 Vermont 21.6208 20.9793 Virginia 19.5315 18.5749 Washington 23.6253 23.0484 West Virginia 18.5169 18.1434 Wisconsin 21.2222 20.2660 Wyoming 20.4416 19.7159 1 All counties within the State are classified as urban. Table 4A.—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Urban Areas Urban area (constituent counties) Wage index GAF 0040 Abilene, TX 0.9268 0.9493 Taylor, TX 0060 Aguadilla, PR 0.4634 0.5905 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH 0.9685 0.9783 Portage, OH Summit, OH 0120 Albany, GA 1.0835 1.0565 Dougherty, GA Lee, GA 0160 2 Albany-Schenectady-Troy, NY 0.8633 0.9042 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM 0.9372 0.9566 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA 0.7929 0.8531 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA 0.9833 0.9885 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA 0.9300 0.9515 Blair, PA 0320 Amarillo, TX Potter, TX 0.9051 0.9340 Randall, TX 0380 Anchorage, AK 1.2610 1.1721 Anchorage, AK 0440 Ann Arbor, MI 1.1217 1.0818 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL 0.8126 0.8675 Calhoun, AL 0460 2 Appleton-Oshkosh-Neenah, WI 0.9229 0.9465 Calumet, WI Outagamie, WI Winnebago, WI 0470 2 Arecibo, PR 0.4400 0.5699 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC 0.9682 0.9781 Buncombe, NC Madison, NC 0500 Athens, GA 1.0308 1.0210 Clarke, GA Madison, GA Oconee, GA 0520 1 Atlanta, GA 1.0091 1.0062 Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Pickens, GA Rockdale, GA Spalding, GA Walton, GA 0560 Atlantic-Cape May, NJ 1.1058 1.0713 Atlantic, NJ Cape May, NJ 0580 Auburn-Opelika, AL 0.8306 0.8806 Lee, AL 0600 Augusta-Aiken, GA-SC 1.0364 1.0248 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 1 Austin-San Marcos, TX 0.9529 0.9675 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 Bakersfield, CA 1.0186 1.0127 Kern, CA 0720 1 Baltimore, MD 0.9757 0.9833 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME 0.9791 0.9856 Penobscot, ME 0743 Barnstable-Yarmouth, MA 1.3127 1.2048 Barnstable, MA 0760 Baton Rouge, LA 0.8388 0.8866 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX 0.8389 0.8867 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA 1.2407 1.1592 Whatcom, WA 0870 Benton Harbor, MI 0.9072 0.9355 Berrien, MI 0875 1 Bergen-Passaic, NJ 1.2100 1.1394 Bergen, NJ Passaic, NJ 0880 Billings, MT 0.9114 0.9384 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS 0.8830 0.9183 Hancock, MS Harrison, MS Jackson, MS 0960 2 Binghamton, NY 0.8633 0.9042 Broome, NY Tioga, NY 1000 Birmingham, AL 0.9301 0.9516 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND 0.7881 0.8495 Burleigh, ND Morton, ND 1020 Bloomington, IN 0.8997 0.9302 Monroe, IN 1040 Bloomington-Normal, IL 0.9202 0.9446 McLean, IL 1080 Boise City, ID 0.9403 0.9587 Ada, ID Canyon, ID 1123 1 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 1.1304 1.0876 Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1125 Boulder-Longmont, CO 0.9688 0.9785 Boulder, CO 1145 Brazoria, TX 0.8617 0.9031 Brazoria, TX 1150 Bremerton, WA 1.1056 1.0712 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX 0.8992 0.9298 Cameron, TX 1260 Bryan-College Station, TX 0.8410 0.8882 Brazos, TX 1280 1 Buffalo-Niagara Falls, NY 0.9464 0.9630 Erie, NY Niagara, NY 1303 Burlington, VT 1.0176 1.0120 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR 0.4453 0.5746 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320 Canton-Massillon, OH 0.9026 0.9322 Carroll, OH Stark, OH 1350 Casper, WY 0.9788 0.9854 Natrona, WY 1360 Cedar Rapids, IA 0.9149 0.9409 Linn, IA 1400 Champaign-Urbana, IL 0.9983 0.9988 Champaign, IL 1440 2 Charleston-North Charleston, SC 0.8607 0.9024 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV 0.8765 0.9137 Kanawha, WV Putnam, WV 1520 1 Charlotte-Gastonia-Rock Hill, NC-SC 0.9839 0.9889 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 1540 Charlottesville, VA 1.0583 1.0396 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA 0.9069 0.9353 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 2 Cheyenne, WY 0.8890 0.9226 Laramie, WY 1600 1 Chicago, IL 1.1088 1.0733 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 2 Chico-Paradise, CA 0.9934 0.9955 Butte, CA 1640 1 Cincinnati, OH-KY-IN 0.9354 0.9553 Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 1660 Clarksville-Hopkinsville, TN-KY 0.8386 0.8864 Christian, KY Montgomery, TN 1680 1 Cleveland-Lorain-Elyria, OH 0.9295 0.9512 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 Colorado Springs, CO 0.9968 0.9978 El Paso, CO 1740 Columbia, MO 0.8737 0.9117 Boone, MO 1760 Columbia, SC 0.8990 0.9297 Lexington, SC Richland, SC 1800 Columbus, GA-AL 0.8450 0.8911 Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 1840 1 Columbus, OH 0.9705 0.9797 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX 0.8154 0.8696 Nueces, TX San Patricio, TX 1890 Corvallis, OR 1.1569 1.1050 Benton, OR 1900 2 Cumberland, MD-WV (MD Hospitals) 0.8855 0.9201 Allegany, MD Mineral, WV 1900 2 Cumberland, MD-WV (WV Hospitals) 0.8053 0.8622 Allegany, MD Mineral, WV 1920 1 Dallas, TX 0.9831 0.9884 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA 0.8785 0.9151 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL 0.8872 0.9213 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH 0.9378 0.9570 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL 0.9133 0.9398 Flagler, FL Volusia, FL 2030 Decatur, AL 0.9066 0.9351 Lawrence, AL Morgan, AL 2040 2 Decatur, IL 0.8301 0.8803 Macon, IL 2080 1 Denver, CO 1.0401 1.0273 Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA 0.8908 0.9239 Dallas, IA Polk, IA Warren, IA 2160 1 Detroit, MI 1.0506 1.0344 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL 0.8028 0.8603 Dale, AL Houston, AL 2190 Dover, DE 0.9452 0.9621 Kent, DE 2200 Dubuque, IA 0.8801 0.9163 Dubuque, IA 2240 Duluth-Superior, MN-WI 1.0462 1.0314 St. Louis, MN Douglas, WI 2281 Dutchess County, NY 1.0793 1.0536 Dutchess, NY 2290 2 Eau Claire, WI 0.9229 0.9465 Chippewa, WI Eau Claire, WI 2320 El Paso, TX 0.9137 0.9401 El Paso, TX 2330 Elkhart-Goshen, IN 0.9851 0.9898 Elkhart, IN 2335 2 Elmira, NY 0.8633 0.9042 Chemung, NY 2340 Enid, OK 0.8387 0.8865 Garfield, OK 2360 Erie, PA 0.9016 0.9315 Erie, PA 2400 Eugene-Springfield, OR 1.1077 1.0726 Lane, OR 2440 2 Evansville-Henderson, IN-KY (IN Hospitals) 0.8796 0.9159 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2440 Evansville-Henderson, IN-KY (KY Hospitals) 0.8254 0.8769 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN 0.9783 0.9851 Clay, MN Cass, ND 2560 Fayetteville, NC 0.9055 0.9343 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR 0.8182 0.8716 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT 1.0791 1.0535 Coconino, AZ Kane, UT 2640 Flint, MI 1.1233 1.0829 Genesee, MI 2650 Florence, AL 0.7960 0.8554 Colbert, AL Lauderdale, AL 2655 Florence, SC 0.8869 0.9211 Florence, SC 2670 Fort Collins-Loveland, CO 0.9923 0.9947 Larimer, CO 2680 1 Ft. Lauderdale, FL 1.0792 1.0536 Broward, FL 2700 Fort Myers-Cape Coral, FL 0.9456 0.9624 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL 0.9959 0.9972 Martin, FL St. Lucie, FL 2720 Fort Smith, AR-OK 0.7811 0.8444 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL 0.9651 0.9760 Okaloosa, FL 2760 Fort Wayne, IN 0.9499 0.9654 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800 1 Forth Worth-Arlington, TX 0.9620 0.9738 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA 1.0340 1.0232 Fresno, CA Madera, CA 2880 Gadsden, AL 0.8684 0.9079 Etowah, AL 2900 Gainesville, FL 0.9730 0.9814 Alachua, FL 2920 Galveston-Texas City, TX 0.9603 0.9726 Galveston, TX 2960 Gary, IN 0.9676 0.9777 Lake, IN Porter, IN 2975 2 Glens Falls, NY 0.8633 0.9042 Warren, NY Washington, NY 2980 Goldsboro, NC 0.8982 0.9291 Wayne, NC 2985 Grand Forks, ND-MN 0.9338 0.9542 Polk, MN Grand Forks, ND 2995 Grand Junction, CO 0.9824 0.9879 Mesa, CO 3000 1 Grand Rapids-Muskegon-Holland, MI 0.9664 0.9769 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT 0.9057 0.9344 Cascade, MT 3060 Greeley, CO 0.9219 0.9458 Weld, CO 3080 Green Bay, WI 0.9599 0.9724 Brown, WI 3120 1 Greensboro-Winston-Salem-High Point, NC 0.9270 0.9494 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC 0.9257 0.9485 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC 0.9177 0.9429 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD 0.9362 0.9559 Washington, MD 3200 Hamilton-Middletown, OH 0.9484 0.9644 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA 0.9315 0.9526 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 1 2 Hartford, CT 1.2520 1.1664 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 2 Hattiesburg, MS 0.7759 0.8405 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC 0.8958 0.9274 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI 1.1121 1.0755 Honolulu, HI 3350 Houma, LA 0.8470 0.8925 Lafourche, LA Terrebonne, LA 3360 1 Houston, TX 0.9746 0.9825 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH 0.9744 0.9824 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL 0.8901 0.9234 Limestone, AL Madison, AL 3480 1 Indianapolis, IN 0.9828 0.9882 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA 1.0025 1.0017 Johnson, IA 3520 Jackson, MI 0.9591 0.9718 Jackson, MI 3560 Jackson, MS 0.8713 0.9100 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN 0.9370 0.9564 Madison, TN Chester, TN 3600 1 Jacksonville, FL 0.9341 0.9544 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 2 Jacksonville, NC 0.8714 0.9100 Onslow, NC 3610 2 Jamestown, NY 0.8633 0.9042 Chautauqua, NY 3620 Janesville-Beloit, WI 0.9696 0.9791 Rock, WI 3640 Jersey City, NJ 1.1200 1.0807 Hudson, NJ 3660 Johnson City-Kingsport-Bristol, TN-VA (TN Hospitals) 0.8384 0.8863 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3660 2 Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals) 0.8494 0.8942 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680 2 Johnstown, PA 0.8525 0.8965 Cambria, PA Somerset, PA 3700 Jonesboro, AR 0.7906 0.8514 Craighead, AR 3710 Joplin, MO 0.8700 0.9090 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI 1.0689 1.0467 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL 0.9591 0.9718 Kankakee, IL 3760 1 Kansas City, KS-MO 0.9809 0.9869 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800 Kenosha, WI 0.9741 0.9822 Kenosha, WI 3810 Killeen-Temple, TX 0.8447 0.8909 Bell, TX Coryell, TX 3840 Knoxville, TN 0.9090 0.9368 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN 0.9031 0.9326 Howard, IN Tipton, IN 3870 2 La Crosse, WI-MN (WI Hospitals) 0.9229 0.9465 Houston, MN La Crosse, WI 3870 2 La Crosse, WI-MN (MN Hospitals) 0.9249 0.9479 Houston, MN La Crosse, WI 3880 Lafayette, LA 0.8550 0.8983 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN 0.9515 0.9665 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA 0.8030 0.8605 Calcasieu, LA 3980 Lakeland-Winter Haven, FL 0.9170 0.9424 Polk, FL 4000 Lancaster, PA 0.9171 0.9425 Lancaster, PA 4040 Lansing-East Lansing, MI 0.9827 0.9881 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX 0.8504 0.8950 Webb, TX 4100 Las Cruces, NM 0.8888 0.9224 Dona Ana, NM 4120 1 Las Vegas, NV-AZ 1.1018 1.0686 Mohave, AZ Clark, NV Nye, NV 4150 Lawrence, KS 0.7964 0.8556 Douglas, KS 4200 Lawton, OK 0.8251 0.8766 Comanche, OK 4243 Lewiston-Auburn, ME 0.9249 0.9479 Androscoggin, ME 4280 Lexington, KY 0.8629 0.9040 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH 0.9515 0.9665 Allen, OH Auglaize, OH 4360 Lincoln, NE 0.9133 0.9398 Lancaster, NE 4400 Little Rock-North Little Rock, AR 0.9045 0.9336 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX 0.8588 0.9010 Gregg, TX Harrison, TX Upshur, TX 4480 1 Los Angeles-Long Beach, CA 1.2044 1.1358 Los Angeles, CA 4520 1 Louisville, KY-IN 0.9517 0.9667 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX 0.7809 0.8442 Lubbock, TX 4640 Lynchburg, VA 0.9311 0.9523 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA 0.9296 0.9512 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI 1.0188 1.0128 Dane, WI 4800 Mansfield, OH 0.8989 0.9296 Crawford, OH Richland, OH 4840 Mayaguez, PR 0.4921 0.6153 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX 0.8419 0.8888 Hidalgo, TX 4890 Medford-Ashland, OR 1.0605 1.0410 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL 1.0782 1.0529 Brevard, Fl 4920 1 Memphis, TN-AR-MS 0.8839 0.9190 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 Merced, CA 0.9937 0.9957 Merced, CA 5000 1 Miami, FL 0.9878 0.9916 Dade, FL 5015 1 Middlesex-Somerset-Hunterdon, NJ 1.1454 1.0974 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 1 Milwaukee-Waukesha, WI 0.9901 0.9932 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 1 Minneapolis-St. Paul, MN-WI 1.0969 1.0654 Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Sherburne, MN Washington, MN Wright, MN Pierce, WI St. Croix, WI 5140 Missoula, MT 0.9250 0.9480 Missoula, MT 5160 Mobile, AL 0.8181 0.8715 Baldwin, AL Mobile, AL 5170 Modesto, CA 1.0606 1.0411 Stanislaus, CA 5190 1 Monmouth-Ocean, NJ 1.1290 1.0866 Monmouth, NJ Ocean, NJ 5200 Monroe, LA 0.8191 0.8723 Ouachita, LA 5240 2 Montgomery, AL 0.7853 0.8475 Autauga, AL Elmore, AL Montgomery, AL 5280 Muncie, IN 0.9150 0.9410 Delaware, IN 5330 Myrtle Beach, SC 0.9141 0.9403 Horry, SC 5345 Naples, FL 0.9803 0.9865 Collier, FL 5360 1 Nashville, TN 0.9456 0.9624 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 1 Nassau-Suffolk, NY 1.3441 1.2245 Nassau, NY Suffolk, NY 5483 1 2 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 1.2520 1.1664 Fairfield, CT New Haven, CT 5523 2 New London-Norwich, CT 1.2520 1.1664 New London, CT 5560 1 New Orleans, LA 0.9050 0.9339 Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA 5600 1 New York, NY 1.4069 1.2634 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 1 Newark, NJ 1.1546 1.1035 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA 1.1434 1.0961 Orange, NY Pike, PA 5720 1 Norfolk-Virginia Beach-Newport News, VA-NC 0.8553 0.8985 Currituck, NC Chesapeake City, VA Gloucester, VA Hampton City, VA Isle of Wight, VA James City, VA Mathews, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City VA Williamsburg City, VA York, VA 5775 1 Oakland, CA 1.5324 1.3395 Alameda, CA Contra Costa, CA 5790 Ocala, FL 0.9526 0.9673 Marion, FL 5800 Odessa-Midland, TX 0.9233 0.9468 Ector, TX Midland, TX 5880 1 Oklahoma City, OK 0.8997 0.9302 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA 1.1071 1.0722 Thurston, WA 5920 Omaha, NE-IA 1.0089 1.0061 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 1 Orange County, CA 1.1726 1.1152 Orange, CA 5960 1 Orlando, FL 0.9537 0.9681 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY 0.8283 0.8790 Daviess, KY 6015 Panama City, FL 0.8926 0.9251 Bay, FL 6020 Parkersburg-Marietta, WV-OH (WV Hospitals) 0.8210 0.8737 Washington, OH Wood, WV 6020 2 Parkersburg-Marietta, WV-OH (OH Hospitals) 0.8675 0.9072 Washington, OH Wood, WV 6080 2 Pensacola, FL 0.8907 0.9238 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL 0.8854 0.9200 Peoria, IL Tazewell, IL Woodford, IL 6160 1 Philadelphia, PA-NJ 1.0675 1.0457 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 1 Phoenix-Mesa, AZ 0.9562 0.9698 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR 0.7866 0.8484 Jefferson, AR 6280 1 Pittsburgh, PA 0.9403 0.9587 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 2 Pittsfield, MA 1.1257 1.0845 Berkshire, MA 6340 Pocatello, ID 0.9013 0.9313 Bannock, ID 6360 Ponce, PR 0.5221 0.6408 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME 0.9932 0.9953 Cumberland, ME Sagadahoc, ME York, ME 6440 1 Portland-Vancouver, OR-WA 1.0792 1.0536 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 1 Providence-Warwick-Pawtucket, RI 1.0558 1.0379 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT 1.0190 1.0130 Utah, UT 6560 2 Pueblo, CO 0.9104 0.9377 Pueblo, CO 6580 2 Punta Gorda, FL 0.8907 0.9238 Charlotte, FL 6600 Racine, WI 0.9413 0.9594 Racine, WI 6640 1 Raleigh-Durham-Chapel Hill, NC 1.0083 1.0057 Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660 Rapid City, SD 0.8936 0.9259 Pennington, SD 6680 Reading, PA 0.9308 0.9521 Berks, PA 6690 Redding, CA 1.1249 1.0839 Shasta, CA 6720 Reno, NV 1.0664 1.0450 Washoe, NV 6740 Richland-Kennewick-Pasco, WA 1.1608 1.1075 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA 0.9735 0.9818 Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, VA 6780 1 Riverside-San Bernardino, CA 1.1251 1.0841 Riverside, CA San Bernardino, CA 6800 Roanoke, VA 0.8703 0.9093 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN 1.2263 1.1499 Olmsted, MN 6840 1 Rochester, NY 0.9133 0.9398 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL 0.9456 0.9624 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC 0.9322 0.9531 Edgecombe, NC Nash, NC 6920 1 Sacramento, CA 1.1636 1.1093 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI 0.9709 0.9800 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN 0.9858 0.9903 Benton, MN Stearns, MN 7000 2 St. Joseph, MO 0.8099 0.8656 Andrew, MO Buchanan, MO 7040 1 St. Louis, MO-IL 0.8907 0.9238 Clinton, IL Jersey, IL Madison, IL Monroe, IL St. Clair, IL Franklin, MO Jefferson, MO Lincoln, MO St. Charles, MO St. Louis, MO St. Louis City, MO Warren, MO 7080 Salem, OR 1.0473 1.0322 Marion, OR Polk, OR 7120 Salinas, CA 1.4772 1.3063 Monterey, CA 7160 1 Salt Lake City-Ogden, UT 1.0035 1.0024 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX 0.7956 0.8551 Tom Green, TX 7240 1 San Antonio, TX 0.8649 0.9054 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 1 San Diego, CA 1.1247 1.0838 San Diego, CA 7360 1 San Francisco, CA 1.4288 1.2768 Marin, CA San Francisco, CA San Mateo, CA 7400 1 San Jose, CA 1.4162 1.2691 Santa Clara, CA 7440 1 San Juan-Bayamon, PR 0.4706 0.5968 Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR Dorado, PR Fajardo, PR Florida, PR Guaynabo, PR Humacao, PR Juncos, PR Los Piedras, PR Loiza, PR Luguillo, PR Manati, PR Morovis, PR Naguabo, PR Naranjito, PR Rio Grande, PR San Juan, PR Toa Alta, PR Toa Baja, PR Trujillo Alto, PR Vega Alta, PR Vega Baja, PR Yabucoa, PR 7460 San Luis Obispo-Atascadero-Paso Robles, CA 1.1386 1.0930 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA 1.0588 1.0399 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA 1.3630 1.2362 Santa Cruz, CA 7490 Santa Fe, NM 1.0822 1.0556 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA 1.3179 1.2081 Sonoma, CA 7510 Sarasota-Bradenton, FL 0.9367 0.9562 Manatee, FL Sarasota, FL 7520 Savannah, GA 0.9961 0.9973 Bryan, GA Chatham, GA Effingham, GA 7560 2 Scranton--Wilkes-Barre--Hazleton, PA 0.8525 0.8965 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 1 Seattle-Bellevue-Everett, WA 1.1571 1.1051 Island, WA King, WA Snohomish, WA 7610 2 Sharon, PA 0.8525 0.8965 Mercer, PA 7620 2 Sheboygan, WI 0.9229 0.9465 Sheboygan, WI 7640 Sherman-Denison, TX 0.9334 0.9539 Grayson, TX 7680 Shreveport-Bossier City, LA 0.8813 0.9171 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE 0.9138 0.9401 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD 0.9098 0.9373 Lincoln, SD Minnehaha, SD 7800 South Bend, IN 0.9902 0.9933 St. Joseph, IN 7840 Spokane, WA 1.0961 1.0649 Spokane, WA 7880 Springfield, IL 0.8654 0.9057 Menard, IL Sangamon, IL 7920 Springfield, MO 0.8510 0.8954 Christian, MO Greene, MO Webster, MO 8003 2 Springfield, MA 1.1257 1.0845 Hampden, MA Hampshire, MA 8050 State College, PA 0.9032 0.9327 Centre, PA 8080 Steubenville-Weirton, OH-WV 0.8893 0.9228 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA 1.0630 1.0427 San Joaquin, CA 8140 2 Sumter, SC 0.8607 0.9024 Sumter, SC 8160 Syracuse, NY 0.9519 0.9668 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 Tacoma, WA 1.1052 1.0709 Pierce, WA 8240 2 Tallahassee, FL 0.8907 0.9238 Gadsden, FL Leon, FL 8280 1 Tampa-St. Petersburg-Clearwater, FL 0.9238 0.9472 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 2 Terre Haute, IN 0.8796 0.9159 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana,AR-Texarkana, TX 0.8193 0.8724 Miller, AR Bowie, TX 8400 Toledo, OH 0.9863 0.9906 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS 0.8952 0.9270 Shawnee, KS 8480 Trenton, NJ 1.0710 1.0481 Mercer, NJ 8520 Tucson, AZ 0.8993 0.9299 Pima, AZ 8560 Tulsa, OK 0.8398 0.8873 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL 0.8303 0.8804 Tuscaloosa, AL 8640 Tyler, TX 0.9650 0.9759 Smith, TX 8680 2 Utica-Rome, NY 0.8633 0.9042 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA 1.3544 1.2309 Napa, CA Solano, CA 8735 Ventura, CA 1.1209 1.0813 Ventura, CA 8750 Victoria, TX 0.8814 0.9172 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ 1.0296 1.0202 Cumberland, NJ 8780 2 Visalia-Tulare-Porterville, CA 0.9934 0.9955 Tulare, CA 8800 Waco, TX 0.8802 0.9163 McLennan, TX 8840 1 Washington, DC-MD-VA-WV 1.0852 1.0576 District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA Arlington, VA Clarke, VA Culpeper, VA Fairfax, VA Fairfax City, VA Falls Church City, VA Fauquier, VA Fredericksburg City, VA King George, VA Loudoun, VA Manassas City, VA Manassas Park City, VA Prince William, VA Spotsylvania, VA Stafford, VA Warren, VA Berkeley, WV Jefferson, WV 8920 Waterloo-Cedar Falls, IA 0.8970 0.9283 Black Hawk, IA 8940 Wausau, WI 0.9882 0.9919 Marathon, WI 8960 1 West Palm Beach-Boca Raton, FL 0.9929 0.9951 Palm Beach, FL 9000 2 Wheeling, WV-OH (WV Hospitals) 0.8053 0.8622 Belmont, OH Marshall, WV Ohio, WV 9000 2 Wheeling, WV-OH (OH Hospitals) 0.8675 0.9072 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS 0.9571 0.9704 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX 0.8023 0.8600 Archer, TX Wichita, TX 9140 Williamsport, PA 0.8624 0.9036 Lycoming, PA 9160 Wilmington-Newark, DE-MD 1.1287 1.0864 New Castle, DE Cecil, MD 9200 Wilmington, NC 0.9471 0.9635 New Hanover, NC Brunswick, NC 9260 Yakima, WA 1.0676 1.0458 Yakima, WA 9270 2 Yolo, CA 0.9934 0.9955 Yolo, CA 9280 York, PA 0.9140 0.9403 York, PA 9320 Youngstown-Warren, OH 0.9485 0.9644 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA 1.0310 1.0211 Sutter, CA Yuba, CA 9360 Yuma, AZ 0.8677 0.9074 Yuma, AZ 1 Large Urban Area 2 Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2003. Table 4B.—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Rural Areas Nonurban area Wage index GAF Alabama 0.7853 0.8475 Alaska 1.2323 1.1538 Arizona 0.8483 0.8935 Arkansas 0.7670 0.8339 California 0.9934 0.9988 Colorado 0.9104 0.9377 Connecticut 1.2520 1.1664 Delaware 0.9126 0.9393 Florida 0.8907 0.9238 Georgia 0.8254 0.8769 Hawaii 1.0342 1.0233 Idaho 0.8799 0.9161 Illinois 0.8301 0.8803 Indiana 0.8796 0.9159 Iowa 0.8395 0.8871 Kansas 0.7964 0.8556 Kentucky 0.8079 0.8641 Louisiana 0.7719 0.8375 Maine 0.8754 0.9129 Maryland 0.8855 0.9201 Massachusetts 1.1257 1.0845 Michigan 0.8961 0.9276 Minnesota 0.9249 0.9479 Mississippi 0.7759 0.8405 Missouri 0.8099 0.8656 Montana 0.8567 0.8995 Nebraska 0.8283 0.8790 Nevada 0.9519 0.9668 New Hampshire 0.9882 0.9919 New Jersey 1 New Mexico 0.8645 0.9051 New York 0.8633 0.9042 North Carolina 0.8714 0.9100 North Dakota 0.7830 0.8458 Ohio 0.8675 0.9072 Oklahoma 0.7664 0.8334 Oregon 1.0408 1.0278 Pennsylvania 0.8525 0.8965 Puerto Rico 0.4400 0.5699 Rhode Island 1 South Carolina 0.8607 0.9024 South Dakota 0.7895 0.8506 Tennessee 0.7873 0.8489 Texas 0.7759 0.8405 Utah 0.9426 0.9603 Vermont 0.9402 0.9587 Virginia 0.8494 0.8942 Washington 1.0274 1.0187 West Virginia 0.8053 0.8622 Wisconsin 0.9229 0.9465 Wyoming 0.8890 0.9226 1 All counties within the State are classified as urban. Table 4C.—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Hospitals That Are Reclassified Area Wage index GAF Abilene, TX 0.8534 0.8971 Akron, OH 0.9685 0.9783 Albany, GA 1.0658 1.0446 Albuquerque, NM 0.9372 0.9566 Alexandria, LA 0.7929 0.8531 Allentown-Bethlehem-Easton, PA 0.9833 0.9885 Altoona, PA 0.9300 0.9515 Amarillo, TX 0.8900 0.9233 Anchorage, AK 1.2610 1.1721 Ann Arbor, MI 1.1217 1.0818 Anniston, AL 0.7983 0.8570 Asheville, NC 0.9448 0.9619 Athens, GA 1.0161 1.0110 Atlanta, GA 0.9985 0.9990 Augusta-Aiken, GA-SC 0.9981 0.9987 Austin-San Marcos, TX 0.9529 0.9675 Barnstable-Yarmouth, MA 1.2894 1.1901 Baton Rouge, LA 0.8281 0.8788 Bellingham, WA 1.2139 1.1420 Benton Harbor, MI 0.9072 0.9355 Bergen-Passaic, NJ 1.2100 1.1394 Billings, MT 0.9114 0.9384 Biloxi-Gulfport-Pascagoula, MS 0.8417 0.8887 Binghamton, NY 0.8525 0.8965 Birmingham, AL 0.9301 0.9516 Bismarck, ND 0.7881 0.8495 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 1.1304 1.0876 Burlington, VT 0.9667 0.9771 Caguas, PR 0.4453 0.5746 Casper, WY 0.9655 0.9762 Champaign-Urbana, IL 0.9334 0.9539 Charleston-North Charleston, SC 0.8607 0.9024 Charleston, WV 0.8602 0.9020 Charlotte-Gastonia-Rock Hill, NC-SC 0.9839 0.9889 Charlottesville, VA 1.0252 1.0172 Chattanooga, TN-GA 0.8878 0.9217 Chicago, IL 1.0953 1.0643 Cincinnati, OH-KY-IN 0.9354 0.9553 Clarksville-Hopkinsville, TN-KY 0.8239 0.8758 Cleveland-Lorain-Elyria, OH 0.9295 0.9512 Columbia, MO 0.8737 0.9117 Columbia, SC 0.8990 0.9297 Columbus, GA-AL (GA Hospitals) 0.8254 0.8769 Columbus, GA-AL (AL Hospitals) 0.8041 0.8613 Columbus, OH 0.9521 0.9669 Corpus Christi, TX 0.8154 0.8696 Dallas, TX 0.9831 0.9884 Danville, VA 0.8530 0.8968 Davenport-Moline-Rock Island, IA-IL 0.8872 0.9213 Dayton-Springfield, OH 0.9378 0.9570 Denver, CO 1.0401 1.0273 Des Moines, IA 0.8908 0.9239 Detroit, MI 1.0506 1.0344 Dothan, AL 0.8028 0.8603 Dover, DE 0.9274 0.9497 Duluth-Superior, MN-WI 1.0462 1.0314 Eau Claire, WI 0.9229 0.9465 Elkhart-Goshen, IN 0.9484 0.9643 Erie, PA 0.8850 0.9197 Eugene-Springfield, OR 1.1077 1.0726 Fargo-Moorhead, ND-MN 0.9564 0.9699 Fayetteville, NC 0.9055 0.9343 Flagstaff, AZ-UT 1.0234 1.0160 Flint, MI 1.1041 1.0702 Florence, AL 0.7960 0.8554 Florence, SC 0.8869 0.9211 Fort Collins-Loveland, CO 0.9923 0.9947 Ft. Lauderdale, FL 1.0792 1.0536 Fort Pierce-Port St. Lucie, FL 0.9959 0.9972 Fort Smith, AR-OK 0.7681 0.8347 Fort Walton Beach, FL 0.9365 0.9561 Forth Worth-Arlington, TX 0.9620 0.9738 Gadsden, AL 0.8684 0.9079 Grand Forks, ND-MN 0.9338 0.9542 Grand Junction, CO 0.9824 0.9879 Grand Rapids-Muskegon-Holland, MI 0.9664 0.9769 Great Falls, MT 0.9057 0.9344 Greeley, CO 0.9219 0.9458 Green Bay, WI 0.9347 0.9548 Greensboro-Winston-Salem-High Point, NC 0.9131 0.9396 Greenville, NC 0.9257 0.9485 Harrisburg-Lebanon-Carlisle, PA 0.9315 0.9526 Hartford, CT 1.1550 1.1037 Hattiesburg, MS 0.7759 0.8405 Hickory-Morganton-Lenoir, NC 0.8958 0.9274 Houston, TX 0.9746 0.9825 Huntington-Ashland, WV-KY-OH 0.9251 0.9481 Huntsville, AL 0.8901 0.9234 Indianapolis, IN 0.9828 0.9882 Iowa City, IA 0.9828 0.9882 Jackson, MS 0.8587 0.9009 Jackson, TN 0.9032 0.9327 Jacksonville, FL 0.9225 0.9463 Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals) 0.8494 0.8942 Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals) 0.8384 0.8863 Jonesboro, AR (AR Hospitals) 0.7906 0.8514 Jonesboro, AR (MO Hospitals) 0.8099 0.8656 Joplin, MO 0.8700 0.9090 Kalamazoo-Battlecreek, MI 1.0490 1.0333 Kansas City, KS-MO 0.9809 0.9869 Knoxville, TN 0.9090 0.9368 Kokomo, IN 0.9031 0.9326 Lafayette, LA 0.8392 0.8869 Lakeland-Winter Haven, FL 0.9170 0.9424 Las Vegas, NV-AZ 1.1018 1.0686 Lawton, OK 0.8073 0.8636 Lexington, KY 0.8629 0.9040 Lima, OH 0.9515 0.9665 Lincoln, NE 0.9133 0.9398 Little Rock-North Little Rock, AR 0.8926 0.9251 Longview-Marshall, TX 0.8588 0.9010 Los Angeles-Long Beach, CA 1.2044 1.1358 Louisville, KY-IN 0.9382 0.9573 Lubbock, TX 0.7809 0.8442 Lynchburg, VA 0.9114 0.9384 Macon, GA 0.9296 0.9512 Madison, WI 1.0188 1.0128 Mansfield, OH 0.8989 0.9296 Medford-Ashland, OR 1.0408 1.0278 Memphis, TN-AR-MS 0.8667 0.9067 Miami, FL 0.9878 0.9916 Milwaukee-Waukesha, WI 0.9901 0.9932 Minneapolis-St. Paul, MN-WI 1.0969 1.0654 Missoula, MT 0.9139 0.9402 Mobile, AL 0.8181 0.8715 Modesto, CA 1.0606 1.0411 Monmouth-Ocean, NJ 1.1290 1.0866 Monroe, LA 0.8191 0.8723 Montgomery, AL 0.7853 0.8475 Nashville, TN 0.9283 0.9503 New Haven-Bridgeport-Stamford-Waterbury- Danbury, CT 1.2520 1.1664 New London-Norwich, CT 1.1683 1.1124 New Orleans, LA 0.9050 0.9339 New York, NY 1.3936 1.2552 Newark, NJ 1.1546 1.1035 Newburgh, NY-PA 1.0820 1.0555 Norfolk-Virginia Beach-Newport News, VA-NC 0.8714 0.9100 Oakland, CA 1.5324 1.3395 Ocala, FL 0.9343 0.9545 Odessa-Midland, TX 0.8910 0.9240 Oklahoma City, OK 0.8997 0.9302 Omaha, NE-IA 1.0089 1.0061 Orange County, CA 1.1726 1.1152 Orlando, FL 0.9537 0.9681 Peoria-Pekin, IL 0.8854 0.9200 Philadelphia, PA-NJ 1.0675 1.0457 Phoenix-Mesa, AZ 0.9562 0.9698 Pine Bluff, AR 0.7760 0.8406 Pittsburgh, PA 0.9268 0.9493 Pittsfield, MA 0.9869 0.9910 Pocatello, ID 0.9013 0.9313 Portland, ME 0.9698 0.9792 Portland-Vancouver, OR-WA 1.0792 1.0536 Provo-Orem, UT 1.0088 1.0060 Raleigh-Durham-Chapel Hill, NC 0.9978 0.9985 Rapid City, SD 0.8936 0.9259 Reading, PA 0.9126 0.9393 Redding, CA 1.1249 1.0839 Reno, NV 1.0445 1.0303 Richland-Kennewick-Pasco, WA 1.1209 1.0813 Richmond-Petersburg, VA 0.9735 0.9818 Roanoke, VA 0.8703 0.9093 Rochester, MN 1.2263 1.1499 Rockford, IL 0.9456 0.9624 Sacramento, CA 1.1636 1.1093 Saginaw-Bay City-Midland, MI 0.9709 0.9800 St. Cloud, MN 0.9858 0.9903 St. Joseph, MO 0.8300 0.8802 St. Louis, MO-IL 0.8907 0.9238 Salinas, CA 1.4772 1.3063 Salt Lake City-Ogden, UT 1.0035 1.0024 San Antonio, TX 0.8649 0.9054 San Diego, CA 1.1247 1.0838 Santa Fe, NM 0.9927 0.9950 Santa Rosa, CA 1.2891 1.1899 Sarasota-Bradenton, FL 0.9367 0.9562 Savannah, GA 0.9841 0.9891 Seattle-Bellevue-Everett, WA 1.1571 1.1051 Sherman-Denison, TX 0.9090 0.9368 Shreveport-Bossier City, LA 0.8813 0.9171 Sioux City, IA-NE 0.8736 0.9116 Sioux Falls, SD 0.8950 0.9268 South Bend, IN 0.9902 0.9933 Spokane, WA 1.0770 1.0521 Springfield, IL 0.8654 0.9057 Springfield, MO 0.8236 0.8756 Stockton-Lodi, CA 1.0630 1.0427 Syracuse, NY 0.9519 0.9668 Tampa-St. Petersburg-Clearwater, FL 0.9238 0.9472 Texarkana,AR-Texarkana, TX 0.8193 0.8724 Toledo, OH 0.9863 0.9906 Topeka, KS 0.8840 0.9190 Tucson, AZ 0.8993 0.9299 Tulsa, OK 0.8398 0.8873 Tuscaloosa, AL 0.8303 0.8804 Tyler, TX 0.9249 0.9479 Vallejo-Fairfield-Napa, CA 1.3544 1.2309 Victoria, TX 0.8668 0.9067 Waco, TX 0.8671 0.9070 Washington, DC-MD-VA-WV 1.0852 1.0576 Waterloo-Cedar Falls, IA 0.8970 0.9283 Wausau, WI 0.9710 0.9800 West Palm Beach-Boca Raton, FL 0.9929 0.9951 Wichita, KS 0.9235 0.9470 Wichita Falls, TX 0.7918 0.8523 Wilmington-Newark, DE-MD 1.0973 1.0657 Wilmington, NC 0.9336 0.9540 York, PA 0.9140 0.9403 Youngstown-Warren, OH 0.9485 0.9644 Rural Alabama 0.7853 0.8475 Rural Florida 0.8907 0.9238 Rural Illinois (IA Hospitals) 0.8395 0.8871 Rural Illinois (MO Hospitals) 0.8301 0.8803 Rural Kentucky 0.8079 0.8641 Rural Louisiana 0.7719 0.8375 Rural Massachusetts 1.0417 1.0284 Rural Michigan 0.8961 0.9276 Rural Minnesota 0.9249 0.9479 Rural Mississippi 0.7759 0.8405 Rural Missouri 0.8099 0.8656 Rural Montana 0.8567 0.8995 Rural Nebraska 0.8283 0.8790 Rural Nevada 0.9097 0.9372 Rural Texas 0.7759 0.8405 Rural Washington 1.0274 1.0187 Rural Wyoming 0.8890 0.9226 Table 4F.—Puerto Rico Wage Index and Capital Geographic Adjustment Factor
(GAF)Area Wage index GAF Wage index— reclass. hospitals GAF— reclass. hospitals Aguadilla, PR 0.9781 0.9850 1 Arecibo, PR 0.9289 0.9507 Caguas, PR 0.9400 0.9585 0.9400 0.9585 Mayaguez, PR 1.0388 1.0264 Ponce, PR 1.1021 1.0688 San Juan-Bayamon, PR 0.9935 0.9955 Rural Puerto Rico 0.9289 0.9507 1 Hospitals geographically located in the area are assigned the Rural Puerto Rico wage index for FY 2003. Table 4G.—Pre-Reclassified Wage Index for Urban Areas Urban area (constituent counties) Wage index 0040 Abilene, TX 0.9268 Taylor, TX 0060 Aguadilla, PR 0.4634 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH 0.9685 Portage, OH Summit, OH 0120 Albany, GA 1.0835 Dougherty, GA Lee, GA 0160 Albany-Schenectady-Troy, NY 0.8633 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM 0.9279 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA 0.7903 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA 0.9833 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA 0.9300 Blair, PA 0320 Amarillo, TX 0.9051 Potter, TX Randall, TX 0380 Anchorage, AK 1.2477 Anchorage, AK 0440 Ann Arbor, MI 1.1217 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL 0.8126 Calhoun, AL 0460 Appleton-Oshkosh-Neenah, WI 0.9229 Calumet, WI Outagamie, WI Winnebago, WI 0470 Arecibo, PR 0.4400 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC 0.9682 Buncombe, NC Madison, NC 0500 Athens, GA 1.0308 Clarke, GA Madison, GA Oconee, GA 0520 Atlanta, GA 1.0091 Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Pickens, GA Rockdale, GA Spalding, GA Walton, GA 0560 Atlantic-Cape May, NJ 1.1058 Atlantic, NJ Cape May, NJ 0580 Auburn-Opelika, AL 0.8306 Lee, AL 0600 Augusta-Aiken, GA-SC 1.0364 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 Austin-San Marcos, TX 0.9529 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 Bakersfield, CA 1.0186 Kern, CA 0720 Baltimore, MD 0.9757 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME 0.9791 Penobscot, ME 0743 Barnstable-Yarmouth, MA 1.3127 Barnstable, MA 0760 Baton Rouge, LA 0.8388 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX 0.8389 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA 1.2407 Whatcom, WA 0870 Benton Harbor, MI 0.8992 Berrien, MI 0875 Bergen-Passaic, NJ 1.2100 Bergen, NJ Passaic, NJ 0880 Billings, MT 0.9114 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS 0.8830 Hancock, MS Harrison, MS Jackson, MS 0960 Binghamton, NY 0.8633 Broome, NY Tioga, NY 1000 Birmingham, AL 0.9301 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND 0.7848 Burleigh, ND Morton, ND 1020 Bloomington, IN 0.8997 Monroe, IN 1040 Bloomington-Normal, IL 0.9202 McLean, IL 1080 Boise City, ID 0.9403 Ada, ID Canyon, ID 1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH Hospitals) 1.1304 Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1125 Boulder-Longmont, CO 0.9688 Boulder, CO 1145 Brazoria, TX 0.8617 Brazoria, TX 1150 Bremerton, WA 1.1056 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX 0.8992 Cameron, TX 1260 Bryan-College Station, TX 0.8410 Brazos, TX 1280 Buffalo-Niagara Falls, NY 0.9464 Erie, NY Niagara, NY 1303 Burlington, VT 1.0176 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR 0.4415 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320 Canton-Massillon, OH 0.9026 Carroll, OH Stark, OH 1350 Casper, WY 0.9788 Natrona, WY 1360 Cedar Rapids, IA 0.9149 Linn, IA 1400 Champaign-Urbana, IL 0.9983 Champaign, IL 1440 Charleston-North Charleston, SC 0.8607 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV 0.8765 Kanawha, WV Putnam, WV 1520 Charlotte-Gastonia-Rock Hill, NC-SC 0.9839 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 1540 Charlottesville, VA 1.0583 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA 0.9069 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 Cheyenne, WY 0.8890 Laramie, WY 1600 Chicago, IL 1.1088 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 Chico-Paradise, CA 0.9934 Butte, CA 1640 Cincinnati, OH-KY-IN 0.9323 Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 1660 Clarksville-Hopkinsville, TN-KY 0.8386 Christian, KY Montgomery, TN 1680 Cleveland-Lorain-Elyria, OH 0.9295 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 Colorado Springs, CO 0.9968 El Paso, CO 1740 Columbia, MO 0.8737 Boone, MO 1760 Columbia, SC 0.8990 Lexington, SC Richland, SC 1800 Columbus, GA-AL 0.8450 Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 1840 Columbus, OH 0.9705 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX 0.8154 Nueces, TX San Patricio, TX 1890 Corvallis, OR 1.1569 Benton, OR 1900 Cumberland, MD-WV (WV Hospital) 0.8053 Allegany, MD Mineral, WV 1920 Dallas, TX 0.9831 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA 0.8785 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL 0.8872 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH 0.9378 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL 0.9133 Flagler, FL Volusia, FL 2030 Decatur, AL 0.9066 Lawrence, AL Morgan, AL 2040 Decatur, IL 0.8301 Macon, IL 2080 Denver, CO 1.0401 Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA 0.8867 Dallas, IA Polk, IA Warren, IA 2160 Detroit, MI 1.0506 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL 0.7990 Dale, AL Houston, AL 2190 Dover, DE 0.9452 Kent, DE 2200 Dubuque, IA 0.8801 Dubuque, IA 2240 Duluth-Superior, MN-WI 1.0462 St. Louis, MN Douglas, WI 2281 Dutchess County, NY 1.0793 Dutchess, NY 2290 Eau Claire, WI 0.9229 Chippewa, WI Eau Claire, WI 2320 El Paso, TX 0.9137 El Paso, TX 2330 Elkhart-Goshen, IN 0.9851 Elkhart, IN 2335 Elmira, NY 0.8633 Chemung, NY 2340 Enid, OK 0.8387 Garfield, OK 2360 Erie, PA 0.9016 Erie, PA 2400 Eugene-Springfield, OR 1.1077 Lane, OR 2440 Evansville-Henderson, IN-KY (IN Hospitals) 0.8796 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN 0.9783 Clay, MN Cass, ND 2560 Fayetteville, NC 0.8980 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR 0.8182 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT 1.0791 Coconino, AZ Kane, UT 2640 Flint, MI 1.1233 Genesee, MI 2650 Florence, AL 0.7927 Colbert, AL Lauderdale, AL 2655 Florence, SC 0.8869 Florence, SC 2670 Fort Collins-Loveland, CO 0.9923 Larimer, CO 2680 Ft. Lauderdale, FL 1.0368 Broward, FL 2700 Fort Myers-Cape Coral, FL 0.9456 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL 0.9802 Martin, FL St. Lucie, FL 2720 Fort Smith, AR-OK 0.7811 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL 0.9651 Okaloosa, FL 2760 Fort Wayne, IN 0.9499 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800 Forth Worth-Arlington, TX 0.9620 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA 1.0340 Fresno, CA Madera, CA 2880 Gadsden, AL 0.8580 Etowah, AL 2900 Gainesville, FL 0.9730 Alachua, FL 2920 Galveston-Texas City, TX 0.9603 Galveston, TX 2960 Gary, IN 0.9676 Lake, IN Porter, IN 2975 Glens Falls, NY 0.8633 Warren, NY Washington, NY 2980 Goldsboro, NC 0.8982 Wayne, NC 2985 Grand Forks, ND-MN 0.8988 Polk, MN Grand Forks, ND 2995 Grand Junction, CO 0.9615 Mesa, CO 3000 Grand Rapids- Muskegon-Holland, MI 0.9645 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT 0.9042 Cascade, MT 3060 Greeley, CO 0.9104 Weld, CO 3080 Green Bay, WI 0.9599 Brown, WI 3120 Greensboro-Winston-Salem-High Point, NC 0.9270 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC 0.9177 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC 0.9177 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD 0.9362 Washington, MD 3200 Hamilton-Middletown, OH 0.9484 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA 0.9315 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 Hartford, CT 1.2520 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 2 Hattiesburg, MS 0.7746 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC 0.8958 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI 1.1121 Honolulu, HI 3350 Houma, LA 0.8470 Lafourche, LA Terrebonne, LA 3360 Houston, TX 0.9746 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH 0.9744 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL 0.8901 Limestone, AL Madison, AL 3480 Indianapolis, IN 0.9828 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA 1.0025 Johnson, IA 3520 Jackson, MI 0.9591 Jackson, MI 3560 Jackson, MS 0.8713 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN 0.9370 Madison, TN Chester, TN 3600 Jacksonville, FL 0.9341 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 Jacksonville, NC 0.8714 Onslow, NC 3610 Jamestown, NY 0.8633 Chautauqua, NY 3620 Janesville-Beloit, WI 0.9696 Rock, WI 3640 Jersey City, NJ 1.1200 Hudson, NJ 3660 Johnson City- Kingsport-Bristol, TN-VA 0.8307 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680 Johnstown, PA 0.8525 Cambria, PA Somerset, PA 3700 Jonesboro, AR 0.7828 Craighead, AR 3710 Joplin, MO 0.8700 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI 1.0689 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL 0.9591 Kankakee, IL 3760 Kansas City, KS-MO 0.9809 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800 Kenosha, WI 0.9741 Kenosha, WI 3810 Killeen-Temple, TX 0.8447 Bell, TX Coryell, TX 3840 Knoxville, TN 0.9090 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN 0.8950 Howard, IN Tipton, IN 3870 La Crosse, WI-MN 0.9229 Houston, MN La Crosse, WI 3880 Lafayette, LA 0.8550 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN 0.9515 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA 0.8030 Calcasieu, LA 3980 Lakeland-Winter Haven, FL 0.9162 Polk, FL 4000 Lancaster, PA 0.9171 Lancaster, PA 4040 Lansing-East Lansing, MI 0.9827 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX 0.8504 Webb, TX 4100 Las Cruces, NM 0.8888 Dona Ana, NM 4120 Las Vegas, NV-AZ 1.1018 Mohave, AZ Clark, NV Nye, NV 4150 Lawrence, KS 0.7964 Douglas, KS 4200 Lawton, OK 0.8251 Comanche, OK 4243 Lewiston-Auburn, ME 0.9249 Androscoggin, ME 4280 Lexington, KY 0.8629 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH 0.9515 Allen, OH Auglaize, OH 4360 Lincoln, NE 0.8928 Lancaster, NE 4400 Little Rock-North Little Rock, AR 0.9045 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX 0.8588 Gregg, TX Harrison, TX Upshur, TX 4480 Los Angeles-Long Beach, CA 1.2027 Los Angeles, CA 4520 1 Louisville, KY-IN 0.9517 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX 0.7752 Lubbock, TX 4640 Lynchburg, VA 0.9311 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA 0.9259 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI 1.0188 Dane, WI 4800 Mansfield, OH 0.8989 Crawford, OH Richland, OH 4840 Mayaguez, PR 0.4921 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX 0.8419 Hidalgo, TX 4890 Medford-Ashland, OR 1.0605 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL 1.0782 Brevard, Fl 4920 Memphis, TN-AR-MS 0.8839 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 Merced, CA 0.9937 Merced, CA 5000 Miami, FL 0.9864 Dade, FL 5015 Middlesex-Somerset-Hunterdon, NJ 1.1454 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 Milwaukee-Waukesha, WI 0.9901 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 Minneapolis-St. Paul, MN-WI 1.0969 Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Sherburne, MN Washington, MN Wright, MN Pierce, WI St. Croix, WI 5140 Missoula, MT 0.9250 Missoula, MT 5160 Mobile, AL 0.8179 Baldwin, AL Mobile, AL 5170 Modesto, CA 1.0606 Stanislaus, CA 5190 Monmouth-Ocean, NJ 1.1270 Monmouth, NJ Ocean, NJ 5200 Monroe, LA 0.8191 Ouachita, LA 5240 Montgomery, AL 0.7786 Autauga, AL Elmore, AL Montgomery, AL 5280 Muncie, IN 0.9150 Delaware, IN 5330 Myrtle Beach, SC 0.9141 Horry, SC 5345 Naples, FL 0.9803 Collier, FL 5360 Nashville, TN 0.9456 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 Nassau-Suffolk, NY 1.3441 Nassau, NY Suffolk, NY 5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 1.2520 Fairfield, CT New Haven, CT 5523 New London-Norwich, CT 1.2520 New London, CT 5560 New Orleans, LA 0.9050 Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA 5600 New York, NY 1.4069 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 Newark, NJ 1.1504 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA 1.1434 Orange, NY Pike, PA 5720 Norfolk-Virginia Beach-Newport News, VA-NC 0.8553 Currituck, NC Chesapeake City, VA Gloucester, VA Hampton City, VA Isle of Wight, VA James City, VA Mathews, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City VA Williamsburg City, VA York, VA 5775 Oakland, CA 1.5222 Alameda, CA Contra Costa, CA 5790 Ocala, FL 0.9526 Marion, FL 5800 Odessa-Midland, TX 0.9233 Ector, TX Midland, TX 5880 Oklahoma City, OK 0.8997 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA 1.1071 Thurston, WA 5920 Omaha, NE-IA 1.0089 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 Orange County, CA 1.1604 Orange, CA 5960 Orlando, FL 0.9537 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY 0.8283 Daviess, KY 6015 Panama City, FL 0.8926 Bay, FL 6020 Parkersburg-Marietta, WV-OH 0.8210 Washington, OH Wood, WV 6080 Pensacola, FL 0.8907 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL 0.8854 Peoria, IL Tazewell, IL Woodford, IL 6160 Philadelphia, PA-NJ 1.0675 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 Phoenix-Mesa, AZ 0.9562 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR 0.7866 Jefferson, AR 6280 Pittsburgh, PA 0.9403 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 Pittsfield, MA 1.1257 Berkshire, MA 6340 Pocatello, ID 0.8799 Bannock, ID 6360 Ponce, PR 0.5221 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME 0.9932 Cumberland, ME Sagadahoc, ME York, ME 6440 Portland-Vancouver, OR-WA 1.0774 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 Providence-Warwick-Pawtucket, RI 1.0558 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT 1.0190 Utah, UT 6560 Pueblo, CO 0.9104 Pueblo, CO 6580 Punta Gorda, FL 0.8907 Charlotte, FL 6600 Racine, WI 0.9413 Racine, WI 6640 Raleigh-Durham-Chapel Hill, NC 1.0083 Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660 Rapid City, SD 0.8936 Pennington, SD 6680 Reading, PA 0.9308 Berks, PA 6690 Redding, CA 1.1249 Shasta, CA 6720 Reno, NV 1.0664 Washoe, NV 6740 Richland-Kennewick-Pasco, WA 1.1608 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA 0.9735 Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, VA 6780 Riverside-San Bernardino, CA 1.1251 Riverside, CA San Bernardino, CA 6800 Roanoke, VA 0.8703 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN 1.2263 Olmsted, MN 6840 Rochester, NY 0.9133 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL 0.9456 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC 0.9322 Edgecombe, NC Nash, NC 6920 Sacramento, CA 1.1622 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI 0.9709 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN 0.9757 Benton, MN Stearns, MN 7000 St. Joseph, MO 0.8093 Andrew, MO Buchanan, MO 7040 St. Louis, MO-IL 0.8907 Clinton, IL Jersey, IL Madison, IL Monroe, IL St. Clair, IL Franklin, MO Jefferson, MO Lincoln, MO St. Charles, MO St. Louis, MO St. Louis City, MO Warren, MO 7080 Salem, OR 1.0473 Marion, OR Polk, OR 7120 Salinas, CA 1.4772 Monterey, CA 7160 Salt Lake City-Ogden, UT 1.0035 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX 0.7956 Tom Green, TX 7240 San Antonio, TX 0.8649 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 San Diego, CA 1.1243 San Diego, CA 7360 San Francisco, CA 1.4288 Marin, CA San Francisco, CA San Mateo, CA 7400 San Jose, CA 1.4162 Santa Clara, CA 7440 San Juan-Bayamon, PR 0.4706 Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR Dorado, PR Fajardo, PR Florida, PR Guaynabo, PR Humacao, PR Juncos, PR Los Piedras, PR Loiza, PR Luguillo, PR Manati, PR Morovis, PR Naguabo, PR Naranjito, PR Rio Grande, PR San Juan, PR Toa Alta, PR Toa Baja, PR Trujillo Alto, PR Vega Alta, PR Vega Baja, PR Yabucoa, PR 7460 San Luis Obispo- Atascadero-Paso Robles, CA 1.1386 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA 1.0588 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA 1.3630 Santa Cruz, CA 7490 Santa Fe, NM 1.0822 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA 1.3179 Sonoma, CA 7510 Sarasota-Bradenton, FL 0.9339 Manatee, FL Sarasota, FL 7520 Savannah, GA 0.9961 Bryan, GA Chatham, GA Effingham, GA 7560 Scranton--Wilkes-Barre--Hazleton, PA 0.8525 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 Seattle-Bellevue-Everett, WA 1.1571 Island, WA King, WA Snohomish, WA 7610 Sharon, PA 0.8525 Mercer, PA 7620 Sheboygan, WI 0.9229 Sheboygan, WI 7640 Sherman-Denison, TX 0.9334 Grayson, TX 7680 Shreveport-Bossier City, LA 0.8813 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE 0.9138 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD 0.9098 Lincoln, SD Minnehaha, SD 7800 South Bend, IN 0.9902 St. Joseph, IN 7840 Spokane, WA 1.0961 Spokane, WA 7880 Springfield, IL 0.8654 Menard, IL Sangamon, IL 7920 Springfield, MO 0.8510 Christian, MO Greene, MO Webster, MO 8003 Springfield, MA 1.1257 Hampden, MA Hampshire, MA 8050 State College, PA 0.9032 Centre, PA 8080 Steubenville-Weirton, OH-WV (WV Hospitals) 0.8893 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA 1.0445 San Joaquin, CA 8140 Sumter, SC 0.8607 Sumter, SC 8160 Syracuse, NY 0.9519 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 Tacoma, WA 1.1052 Pierce, WA 8240 Tallahassee, FL 0.8907 Gadsden, FL Leon, FL 8280 Tampa-St. Petersburg-Clearwater, FL 0.9127 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 Terre Haute, IN 0.8796 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana,AR-Texarkana, TX 0.8150 Miller, AR Bowie, TX 8400 Toledo, OH 0.9863 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS 0.8952 Shawnee, KS 8480 Trenton, NJ 1.0710 Mercer, NJ 8520 Tucson, AZ 0.8993 Pima, AZ 8560 Tulsa, OK 0.8398 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL 0.8221 Tuscaloosa, AL 8640 Tyler, TX 0.9650 Smith, TX 8680 Utica-Rome, NY 0.8633 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA 1.3472 Napa, CA Solano, CA 8735 Ventura, CA 1.1209 Ventura, CA 8750 Victoria, TX 0.8814 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ 1.0296 Cumberland, NJ 8780 Visalia-Tulare-Porterville, CA 0.9934 Tulare, CA 8800 Waco, TX 0.8802 McLennan, TX 8840 Washington, DC-MD- VA-WV 1.0852 District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA Arlington, VA Clarke, VA Culpeper, VA Fairfax, VA Fairfax City, VA Falls Church City, VA Fauquier, VA Fredericksburg City, VA King George, VA Loudoun, VA Manassas City, VA Manassas Park City, VA Prince William, VA Spotsylvania, VA Stafford, VA Warren, VA Berkeley, WV Jefferson, WV 8920 Waterloo-Cedar Falls, IA 0.8395 Black Hawk, IA 8940 Wausau, WI 0.9882 Marathon, WI 8960 West Palm Beach- Boca Raton, FL 0.9929 Palm Beach, FL 9000 Wheeling, WV-OH 0.8053 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS 0.9571 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX 0.8023 Archer, TX Wichita, TX 9140 Williamsport, PA 0.8624 Lycoming, PA 9160 Wilmington-Newark, DE-MD 1.1287 New Castle, DE Cecil, MD 9200 Wilmington, NC 0.9471 New Hanover, NC Brunswick, NC 9260 Yakima, WA 1.0676 Yakima, WA 9270 Yolo, CA 0.9934 Yolo, CA 9280 York, PA 0.9140 York, PA 9320 Youngstown-Warren, OH 0.9485 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA 1.0310 Sutter, CA Yuba, CA 9360 Yuma, AZ 0.8677 Yuma, AZ Table 4H.—Pre-Reclassified Wage Index for Rural Areas Nonurban area Wage index Alabama 0.7786 Alaska 1.2323 Arizona 0.8483 Arkansas 0.7670 California 0.9934 Colorado 0.9104 Connecticut 1.2520 Delaware 0.9126 Florida 0.8907 Georgia 0.8254 Hawaii 1.0342 Idaho 0.8799 Illinois 0.8301 Indiana 0.8796 Iowa 0.8395 Kansas 0.7964 Kentucky 0.8079 Louisiana 0.7637 Maine 0.8754 Maryland 0.8855 Massachusetts 1.1257 Michigan 0.8944 Minnesota 0.9249 Mississippi 0.7746 Missouri 0.8093 Montana 0.8567 Nebraska 0.8283 Nevada 0.9519 New Hampshire 0.9882 New Jersey 1 New Mexico 0.8645 New York 0.8633 North Carolina 0.8714 North Dakota 0.7830 Ohio 0.8675 Oklahoma 0.7664 Oregon 1.0408 Pennsylvania 0.8525 Puerto Rico 0.4400 Rhode Island 1 South Carolina 0.8607 South Dakota 0.7895 Tennessee 0.7873 Texas 0.7752 Utah 0.9426 Vermont 0.9402 Virginia 0.8494 Washington 1.0274 West Virginia 0.8053 Wisconsin 0.9229 Wyoming 0.8890 1 All counties within the State are classified as urban. —————————— * MEDICARE DATA HAVE BEEN SUPPLEMENTED BY DATA FROM 19 STATES FOR LOW VOLUME DRGS. ** DRGS 469 AND 470 CONTAIN CASES WHICH COULD NOT BE ASSIGNED TO VALID DRGS. GEOMETRIC MEAN IS USED ONLY TO DETERMINE PAYMENT FOR TRANSFER CASES. ARITHMETIC MEAN IS PRESENTED FOR INFORMATIONAL PURPOSES ONLY. NOTE: RELATIVE WEIGHTS ARE BASED ON MEDICARE PATIENT DATA AND MAY NOT BE APPROPRIATE FOR OTHER PATIENTS. Table 5.—List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean Length of Stay DRG MDC Type DRG Title Relative weights Geometric mean LOS Arithmetic mean LOS 1 01 SURG CRANIOTOMY AGE >17 W CC 3.7174 8.1 11.2 2 01 SURG CRANIOTOMY AGE >17 W/O CC 1.9613 4.0 5.2 3 01 SURG * CRANIOTOMY AGE 0-17 1.9441 12.7 12.7 4 01 SURG SPINAL PROCEDURES 2.2960 4.5 7.2 5 01 SURG EXTRACRANIAL VASCULAR PROCEDURES 1.3846 2.1 3.1 6 01 SURG CARPAL TUNNEL RELEASE .8237 2.1 2.9 7 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC 2.5718 6.5 9.8 8 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC 1.4925 1.9 2.8 9 01 MED SPINAL DISORDERS & INJURIES 1.3592 4.6 6.6 10 01 MED NERVOUS SYSTEM NEOPLASMS W CC 1.2507 4.9 6.6 11 01 MED NERVOUS SYSTEM NEOPLASMS W/O CC .8629 3.0 4.0 12 01 MED DEGENERATIVE NERVOUS SYSTEM DISORDERS .8881 4.4 5.9 13 01 MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA .7928 4.1 5.0 14 01 MED INTRACRANIAL HEMORRHAGE & STROKE W INFARCT 1.2742 4.8 6.2 15 01 MED NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT .9844 4.0 5.0 16 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 1.2389 4.7 6.2 17 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC .6651 2.5 3.1 18 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W CC .9712 4.2 5.4 19 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC .6939 2.8 3.5 20 01 MED NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS 2.7921 8.0 10.8 21 01 MED VIRAL MENINGITIS 1.5323 5.0 6.6 22 01 MED HYPERTENSIVE ENCEPHALOPATHY 1.0334 3.9 5.0 23 01 MED NONTRAUMATIC STUPOR & COMA .8214 3.1 4.3 24 01 MED SEIZURE & HEADACHE AGE >17 W CC .9953 3.6 4.9 25 01 MED SEIZURE & HEADACHE AGE >17 W/O CC .6061 2.5 3.2 26 01 MED SEIZURE & HEADACHE AGE 0-17 .7854 2.5 4.7 27 01 MED TRAUMATIC STUPOR & COMA, COMA >1 HR 1.3045 3.2 5.0 28 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC 1.3318 4.5 6.3 29 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC .7069 2.7 3.6 30 01 MED * TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 .3288 2.0 2.0 31 01 MED CONCUSSION AGE >17 W CC .8787 3.0 4.1 32 01 MED CONCUSSION AGE >17 W/O CC .5318 1.9 2.4 33 01 MED * CONCUSSION AGE 0-17 .2066 1.6 1.6 34 01 MED OTHER DISORDERS OF NERVOUS SYSTEM W CC .9962 3.7 5.1 35 01 MED OTHER DISORDERS OF NERVOUS SYSTEM W/O CC .6353 2.5 3.2 36 02 SURG RETINAL PROCEDURES .6814 1.2 1.5 37 02 SURG ORBITAL PROCEDURES 1.0534 2.6 3.8 38 02 SURG PRIMARY IRIS PROCEDURES .5412 1.9 2.5 39 02 SURG LENS PROCEDURES WITH OR WITHOUT VITRECTOMY .5924 1.5 1.9 40 02 SURG EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 .8647 2.5 3.6 41 02 SURG * EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 .3348 1.6 1.6 42 02 SURG INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS .6552 1.7 2.4 43 02 MED HYPHEMA .4951 2.4 3.0 44 02 MED ACUTE MAJOR EYE INFECTIONS .6374 4.1 5.1 45 02 MED NEUROLOGICAL EYE DISORDERS .7064 2.6 3.2 46 02 MED OTHER DISORDERS OF THE EYE AGE >17 W CC .7810 3.4 4.6 47 02 MED OTHER DISORDERS OF THE EYE AGE >17 W/O CC .5193 2.5 3.2 48 02 MED * OTHER DISORDERS OF THE EYE AGE 0-17 .2949 2.9 2.9 49 03 SURG MAJOR HEAD & NECK PROCEDURES 1.7706 3.3 4.6 50 03 SURG SIALOADENECTOMY .8318 1.5 1.8 51 03 SURG SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY .9325 1.9 3.1 52 03 SURG CLEFT LIP & PALATE REPAIR .8003 1.5 1.9 53 03 SURG SINUS & MASTOID PROCEDURES AGE >17 1.1968 2.1 3.4 54 03 SURG * SINUS & MASTOID PROCEDURES AGE 0-17 .4779 3.2 3.2 55 03 SURG MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES .9492 1.9 3.0 56 03 SURG RHINOPLASTY .9678 2.0 3.0 57 03 SURG T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 .9849 2.4 3.7 58 03 SURG * T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 .2714 1.5 1.5 59 03 SURG TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 .7530 1.8 2.6 60 03 SURG * TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 .2067 1.5 1.5 61 03 SURG MYRINGOTOMY W TUBE INSERTION AGE >17 1.3030 2.9 4.8 62 03 SURG * MYRINGOTOMY W TUBE INSERTION AGE 0-17 .2927 1.3 1.3 63 03 SURG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES 1.4279 3.0 4.5 64 03 MED EAR, NOSE, MOUTH & THROAT MALIGNANCY 1.3100 4.4 6.6 65 03 MED DYSEQUILIBRIUM .5487 2.3 2.8 66 03 MED EPISTAXIS .5626 2.4 3.1 67 03 MED EPIGLOTTITIS .7763 2.8 3.6 68 03 MED OTITIS MEDIA & URI AGE >17 W CC .6690 3.1 3.8 69 03 MED OTITIS MEDIA & URI AGE >17 W/O CC .5033 2.4 3.0 70 03 MED OTITIS MEDIA & URI AGE 0-17 .4570 2.8 3.5 71 03 MED LARYNGOTRACHEITIS .6933 2.8 3.4 72 03 MED NASAL TRAUMA & DEFORMITY .7159 2.6 3.6 73 03 MED OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 .7961 3.2 4.4 74 03 MED * OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 .3326 2.1 2.1 75 04 SURG MAJOR CHEST PROCEDURES 3.0978 7.7 10.1 76 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W CC 2.8553 8.5 11.4 77 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 1.2070 3.5 4.9 78 04 MED PULMONARY EMBOLISM 1.2980 5.7 6.7 79 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC 1.6199 6.7 8.5 80 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC .8747 4.4 5.5 81 04 MED * RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 1.5059 6.1 6.1 82 04 MED RESPIRATORY NEOPLASMS 1.3926 5.2 7.0 83 04 MED MAJOR CHEST TRAUMA W CC .9653 4.3 5.5 84 04 MED MAJOR CHEST TRAUMA W/O CC .5109 2.6 3.2 85 04 MED PLEURAL EFFUSION W CC 1.2119 4.8 6.4 86 04 MED PLEURAL EFFUSION W/O CC .6963 2.9 3.8 87 04 MED PULMONARY EDEMA & RESPIRATORY FAILURE 1.3625 4.8 6.3 88 04 MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE .9039 4.1 5.1 89 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC 1.0431 4.8 5.9 90 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC .6270 3.4 4.0 91 04 MED SIMPLE PNEUMONIA & PLEURISY AGE 0-17 .6854 3.2 4.0 92 04 MED INTERSTITIAL LUNG DISEASE W CC 1.2255 5.0 6.4 93 04 MED INTERSTITIAL LUNG DISEASE W/O CC .7331 3.3 4.1 94 04 MED PNEUMOTHORAX W CC 1.1575 4.7 6.4 95 04 MED PNEUMOTHORAX W/O CC .5895 2.9 3.7 96 04 MED BRONCHITIS & ASTHMA AGE >17 W CC .7541 3.7 4.6 97 04 MED BRONCHITIS & ASTHMA AGE >17 W/O CC .5602 2.9 3.5 98 04 MED BRONCHITIS & ASTHMA AGE 0-17 .9319 3.7 5.1 99 04 MED RESPIRATORY SIGNS & SYMPTOMS W CC .7022 2.4 3.2 100 04 MED RESPIRATORY SIGNS & SYMPTOMS W/O CC .5347 1.7 2.1 101 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W CC .8567 3.3 4.4 102 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC .5447 2.0 2.6 103 PRE SURG HEART TRANSPLANT 19.5361 29.7 49.4 104 05 SURG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W CARD CATH 7.9615 12.3 14.4 105 05 SURG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH 5.7856 8.3 10.0 106 05 SURG CORONARY BYPASS W PTCA 7.4493 9.6 11.4 107 05 SURG CORONARY BYPASS W CARDIAC CATH 5.3894 9.2 10.5 108 05 SURG OTHER CARDIOTHORACIC PROCEDURES 5.4585 7.8 10.3 109 05 SURG CORONARY BYPASS W/O PTCA OR CARDIAC CATH 3.9756 6.8 7.7 110 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W CC 4.0985 6.5 9.1 111 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W/O CC 2.4445 3.5 4.4 112 05 SURG NO LONGER VALID .0000 .0 .0 113 05 SURG AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE 2.9028 10.4 13.4 114 05 SURG UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS 1.6530 6.2 8.5 115 05 SURG PRM CARD PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GN 3.4452 5.9 8.3 116 05 SURG OTHER PERMANENT CARDIAC PACEMAKER IMPLANT 2.3075 3.2 4.5 117 05 SURG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT 1.3312 2.6 4.2 118 05 SURG CARDIAC PACEMAKER DEVICE REPLACEMENT 1.5696 1.9 2.9 119 05 SURG VEIN LIGATION & STRIPPING 1.3027 3.0 5.1 120 05 SURG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 2.2337 5.3 8.8 121 05 MED CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE 1.5813 5.3 6.6 122 05 MED CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE 1.0393 3.0 3.8 123 05 MED CIRCULATORY DISORDERS W AMI, EXPIRED 1.5526 2.8 4.7 124 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG 1.4301 3.3 4.4 125 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG 1.0846 2.1 2.7 126 05 MED ACUTE & SUBACUTE ENDOCARDITIS 2.6971 9.5 12.2 127 05 MED HEART FAILURE & SHOCK 1.0027 4.1 5.3 128 05 MED DEEP VEIN THROMBOPHLEBITIS .7241 4.7 5.5 129 05 MED CARDIAC ARREST, UNEXPLAINED 1.0803 1.8 2.8 130 05 MED PERIPHERAL VASCULAR DISORDERS W CC .9384 4.5 5.7 131 05 MED PERIPHERAL VASCULAR DISORDERS W/O CC .5683 3.3 4.1 132 05 MED ATHEROSCLEROSIS W CC .6540 2.3 3.0 133 05 MED ATHEROSCLEROSIS W/O CC .5359 1.8 2.3 134 05 MED HYPERTENSION .5884 2.5 3.2 135 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC .8961 3.3 4.5 136 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC .5709 2.1 2.6 137 05 MED * CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 .8113 3.3 3.3 138 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC .8249 3.1 4.0 139 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC .5128 2.0 2.5 140 05 MED ANGINA PECTORIS .5384 2.1 2.6 141 05 MED SYNCOPE & COLLAPSE W CC .7284 2.8 3.6 142 05 MED SYNCOPE & COLLAPSE W/O CC .5605 2.1 2.6 143 05 MED CHEST PAIN .5394 1.7 2.1 144 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W CC 1.1931 3.8 5.5 145 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC .5881 2.1 2.7 146 06 SURG RECTAL RESECTION W CC 2.7193 8.8 10.2 147 06 SURG RECTAL RESECTION W/O CC 1.5566 5.8 6.4 148 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 3.4444 10.2 12.3 149 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC 1.5247 5.9 6.5 150 06 SURG PERITONEAL ADHESIOLYSIS W CC 2.8477 9.1 11.2 151 06 SURG PERITONEAL ADHESIOLYSIS W/O CC 1.3334 4.5 5.7 152 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W CC 1.9467 6.9 8.3 153 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC 1.1736 4.8 5.4 154 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC 4.1397 9.8 13.2 155 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC 1.3054 3.0 4.0 156 06 SURG * STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 .8355 6.0 6.0 157 06 SURG ANAL & STOMAL PROCEDURES W CC 1.2618 3.9 5.6 158 06 SURG ANAL & STOMAL PROCEDURES W/O CC .6504 2.0 2.5 159 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC 1.3593 3.7 5.1 160 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC .8070 2.2 2.7 161 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC 1.1278 2.8 4.2 162 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC .6337 1.6 1.9 163 06 SURG * HERNIA PROCEDURES AGE 0-17 .6855 2.1 2.1 164 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 2.2964 7.0 8.3 165 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC 1.2622 4.0 4.7 166 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 1.4680 3.7 4.9 167 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC .9104 2.1 2.5 168 03 SURG MOUTH PROCEDURES W CC 1.2974 3.3 4.9 169 03 SURG MOUTH PROCEDURES W/O CC .7397 1.8 2.3 170 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 2.8017 7.4 11.0 171 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC 1.1651 3.1 4.3 172 06 MED DIGESTIVE MALIGNANCY W CC 1.3567 5.1 7.0 173 06 MED DIGESTIVE MALIGNANCY W/O CC .7531 2.7 3.8 174 06 MED G.I. HEMORRHAGE W CC .9937 3.9 4.8 175 06 MED G.I. HEMORRHAGE W/O CC .5553 2.5 2.9 176 06 MED COMPLICATED PEPTIC ULCER 1.0832 4.1 5.3 177 06 MED UNCOMPLICATED PEPTIC ULCER W CC .9193 3.7 4.5 178 06 MED UNCOMPLICATED PEPTIC ULCER W/O CC .6843 2.6 3.1 179 06 MED INFLAMMATORY BOWEL DISEASE 1.0778 4.6 6.0 180 06 MED G.I. OBSTRUCTION W CC .9429 4.2 5.4 181 06 MED G.I. OBSTRUCTION W/O CC .5322 2.8 3.4 182 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC .7982 3.3 4.4 183 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC .5722 2.3 2.9 184 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 .4806 2.3 2.8 185 03 MED DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17 .8998 3.3 4.7 186 03 MED * DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17 .3185 2.9 2.9 187 03 MED DENTAL EXTRACTIONS & RESTORATIONS .8564 3.0 4.1 188 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC 1.0955 4.1 5.6 189 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC .5821 2.4 3.1 190 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 .6986 3.3 4.8 191 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W CC 4.2962 9.8 13.8 192 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W/O CC 1.6932 4.7 6.1 193 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC 3.4015 10.4 12.8 194 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC 1.6023 5.5 6.9 195 07 SURG CHOLECYSTECTOMY W C.D.E. W CC 3.0046 8.6 10.4 196 07 SURG CHOLECYSTECTOMY W C.D.E. W/O CC 1.6036 4.6 5.4 197 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 2.4858 7.3 9.0 198 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC 1.2276 3.8 4.4 199 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY 2.4260 7.0 9.9 200 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY 2.9570 6.5 10.5 201 07 SURG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES 3.7421 10.3 14.5 202 07 MED CIRRHOSIS & ALCOHOLIC HEPATITIS 1.2879 4.8 6.4 203 07 MED MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS 1.3499 5.0 6.8 204 07 MED DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1.1826 4.4 5.8 205 07 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC 1.1933 4.6 6.2 206 07 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC .7038 3.0 3.9 207 07 MED DISORDERS OF THE BILIARY TRACT W CC 1.1338 4.0 5.3 208 07 MED DISORDERS OF THE BILIARY TRACT W/O CC .6526 2.3 2.9 209 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF LOWER EXTREMITY 2.0531 4.5 5.0 210 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 1.8289 6.1 7.0 211 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC 1.2715 4.6 5.0 212 08 SURG * HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 .8391 11.1 11.1 213 08 SURG AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS 1.8664 6.6 9.2 214 08 SURG NO LONGER VALID .0000 .0 .0 215 08 SURG NO LONGER VALID .0000 .0 .0 216 08 SURG BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 2.2151 6.6 9.6 217 08 SURG WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS 3.0062 9.1 13.4 218 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC 1.5404 4.3 5.4 219 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC 1.0244 2.7 3.2 220 08 SURG * LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17 .5789 5.3 5.3 221 08 SURG NO LONGER VALID .0000 .0 .0 222 08 SURG NO LONGER VALID .0000 .0 .0 223 08 SURG MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC 1.0248 2.1 2.9 224 08 SURG SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC .7868 1.6 1.9 225 08 SURG FOOT PROCEDURES 1.1460 3.4 5.0 226 08 SURG SOFT TISSUE PROCEDURES W CC 1.5663 4.6 6.7 227 08 SURG SOFT TISSUE PROCEDURES W/O CC .8129 2.1 2.7 228 08 SURG MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC 1.1339 2.6 4.1 229 08 SURG HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC .6984 1.7 2.2 230 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR 1.2657 3.3 5.1 231 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES EXCEPT HIP & FEMUR 1.3977 3.1 4.9 232 08 SURG ARTHROSCOPY 1.0021 1.8 2.7 233 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC 1.9862 4.8 7.2 234 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC 1.2329 2.3 3.2 235 08 MED FRACTURES OF FEMUR .7648 3.8 5.1 236 08 MED FRACTURES OF HIP & PELVIS .7233 4.0 4.9 237 08 MED SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH .5797 2.9 3.6 238 08 MED OSTEOMYELITIS 1.3934 6.6 8.9 239 08 MED PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY 1.0031 4.9 6.3 240 08 MED CONNECTIVE TISSUE DISORDERS W CC 1.3301 5.0 6.7 241 08 MED CONNECTIVE TISSUE DISORDERS W/O CC .6493 3.1 3.9 242 08 MED SEPTIC ARTHRITIS 1.1093 5.1 6.7 243 08 MED MEDICAL BACK PROBLEMS .7407 3.7 4.7 244 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W CC .7056 3.7 4.7 245 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC .4686 2.7 3.4 246 08 MED NON-SPECIFIC ARTHROPATHIES .5658 2.9 3.8 247 08 MED SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE .5725 2.6 3.4 248 08 MED TENDONITIS, MYOSITIS & BURSITIS .8317 3.8 4.9 249 08 MED AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE .6895 2.5 3.7 250 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC .6886 3.3 4.2 251 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC .4624 2.2 2.8 252 08 MED * FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 .2513 1.8 1.8 253 08 MED FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC .7384 3.7 4.7 254 08 MED FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/O CC .4433 2.6 3.1 255 08 MED * FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 .2928 2.9 2.9 256 08 MED OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES .8038 3.8 5.1 257 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W CC .8995 2.1 2.7 258 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W/O CC .7107 1.6 1.8 259 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC .9130 1.7 2.7 260 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC .6821 1.2 1.4 261 09 SURG BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION .9773 1.6 2.2 262 09 SURG BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY .9324 2.9 4.3 263 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC 2.2113 9.3 12.5 264 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC 1.1350 5.5 7.1 265 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC 1.5906 4.2 6.7 266 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC .8540 2.2 3.1 267 09 SURG PERIANAL & PILONIDAL PROCEDURES .9343 2.5 4.3 268 09 SURG SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES 1.1068 2.4 3.6 269 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W CC 1.6798 5.7 8.2 270 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC .7495 2.3 3.3 271 09 MED SKIN ULCERS 1.0266 5.6 7.3 272 09 MED MAJOR SKIN DISORDERS W CC 1.0013 4.6 6.1 273 09 MED MAJOR SKIN DISORDERS W/O CC .5578 3.0 3.9 274 09 MED MALIGNANT BREAST DISORDERS W CC 1.1936 4.8 6.8 275 09 MED MALIGNANT BREAST DISORDERS W/O CC .5469 2.2 3.0 276 09 MED NON-MALIGANT BREAST DISORDERS .6781 3.5 4.5 277 09 MED CELLULITIS AGE >17 W CC .8580 4.7 5.8 278 09 MED CELLULITIS AGE >17 W/O CC .5497 3.6 4.3 279 09 MED * CELLULITIS AGE 0-17 .6580 4.2 4.2 280 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC .6972 3.2 4.2 281 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC .4634 2.3 2.9 282 09 MED * TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 .2545 2.2 2.2 283 09 MED MINOR SKIN DISORDERS W CC .7211 3.5 4.7 284 09 MED MINOR SKIN DISORDERS W/O CC .4300 2.4 3.1 285 10 SURG AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DISORDERS 2.0391 8.0 10.6 286 10 SURG ADRENAL & PITUITARY PROCEDURES 2.0831 4.5 5.9 287 10 SURG SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS 1.8701 7.7 10.6 288 10 SURG O.R. PROCEDURES FOR OBESITY 2.2124 4.3 5.4 289 10 SURG PARATHYROID PROCEDURES .9697 1.8 2.8 290 10 SURG THYROID PROCEDURES .8955 1.7 2.2 291 10 SURG THYROGLOSSAL PROCEDURES .6333 1.4 1.6 292 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC 2.4623 6.8 10.0 293 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC 1.2998 3.3 4.9 294 10 MED DIABETES AGE >35 .7573 3.4 4.5 295 10 MED DIABETES AGE 0-35 .7854 3.0 4.0 296 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC .8469 3.9 5.1 297 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC .5046 2.7 3.4 298 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 .5879 2.9 4.4 299 10 MED INBORN ERRORS OF METABOLISM .9367 3.8 5.4 300 10 MED ENDOCRINE DISORDERS W CC 1.0930 4.7 6.2 301 10 MED ENDOCRINE DISORDERS W/O CC .6308 2.8 3.7 302 11 SURG KIDNEY TRANSPLANT 3.2671 7.4 8.7 303 11 SURG KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM 2.4195 6.7 8.3 304 11 SURG KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC 2.3243 6.2 8.7 305 11 SURG KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC 1.1946 2.9 3.6 306 11 SURG PROSTATECTOMY W CC 1.2725 3.6 5.5 307 11 SURG PROSTATECTOMY W/O CC .6329 1.8 2.2 308 11 SURG MINOR BLADDER PROCEDURES W CC 1.6399 4.0 6.3 309 11 SURG MINOR BLADDER PROCEDURES W/O CC .8980 1.7 2.2 310 11 SURG TRANSURETHRAL PROCEDURES W CC 1.1281 2.9 4.3 311 11 SURG TRANSURETHRAL PROCEDURES W/O CC .6270 1.5 1.8 312 11 SURG URETHRAL PROCEDURES, AGE >17 W CC 1.0583 3.0 4.5 313 11 SURG URETHRAL PROCEDURES, AGE >17 W/O CC .6693 1.7 2.1 314 11 SURG * URETHRAL PROCEDURES, AGE 0-17 .4905 2.3 2.3 315 11 SURG OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES 2.0954 3.8 7.2 316 11 MED RENAL FAILURE 1.3241 4.9 6.6 317 11 MED ADMIT FOR RENAL DIALYSIS .6603 2.0 3.1 318 11 MED KIDNEY & URINARY TRACT NEOPLASMS W CC 1.1819 4.4 6.1 319 11 MED KIDNEY & URINARY TRACT NEOPLASMS W/O CC .6051 2.1 2.9 320 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC .8555 4.3 5.3 321 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC .5645 3.1 3.8 322 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 .4769 3.1 3.7 323 11 MED URINARY STONES W CC, &/OR ESW LITHOTRIPSY .8049 2.4 3.1 324 11 MED URINARY STONES W/O CC .4643 1.5 1.8 325 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC .6508 2.9 3.8 326 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC .4441 2.2 2.7 327 11 MED * KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0-17 .3668 3.1 3.1 328 11 MED URETHRAL STRICTURE AGE >17 W CC .7339 2.8 3.8 329 11 MED URETHRAL STRICTURE AGE >17 W/O CC .4891 1.7 2.2 330 11 MED * URETHRAL STRICTURE AGE 0-17 .3160 1.6 1.6 331 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC 1.0553 4.2 5.6 332 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC .5998 2.4 3.2 333 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 .7662 3.3 4.7 334 12 SURG MAJOR MALE PELVIC PROCEDURES W CC 1.5217 4.0 4.8 335 12 SURG MAJOR MALE PELVIC PROCEDURES W/O CC 1.1249 2.9 3.2 336 12 SURG TRANSURETHRAL PROSTATECTOMY W CC .8721 2.6 3.4 337 12 SURG TRANSURETHRAL PROSTATECTOMY W/O CC .6046 1.8 2.1 338 12 SURG TESTES PROCEDURES, FOR MALIGNANCY 1.2297 3.5 5.6 339 12 SURG TESTES PROCEDURES, NON-MALIGNANCY AGE >17 1.1006 2.9 4.6 340 12 SURG * TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 .2808 2.4 2.4 341 12 SURG PENIS PROCEDURES 1.2148 1.9 3.1 342 12 SURG CIRCUMCISION AGE >17 .7897 2.3 3.1 343 12 SURG * CIRCUMCISION AGE 0-17 .1526 1.7 1.7 344 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY 1.2631 1.6 2.4 345 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY 1.1839 2.9 4.8 346 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC 1.0453 4.5 6.0 347 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC .5654 2.0 2.7 348 12 MED BENIGN PROSTATIC HYPERTROPHY W CC .7111 3.2 4.2 349 12 MED BENIGN PROSTATIC HYPERTROPHY W/O CC .3943 1.9 2.5 350 12 MED INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM .7192 3.6 4.5 351 12 MED * STERILIZATION, MALE .2342 1.3 1.3 352 12 MED OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES .7227 2.8 4.0 353 13 SURG PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY 1.8746 5.0 6.5 354 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC 1.5439 4.8 5.8 355 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC .9119 3.0 3.2 356 13 SURG FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES .7675 1.9 2.2 357 13 SURG UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY 2.3212 6.7 8.4 358 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 1.2295 3.5 4.3 359 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC .8356 2.4 2.6 360 13 SURG VAGINA, CERVIX & VULVA PROCEDURES .8857 2.3 2.8 361 13 SURG LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 1.1215 2.3 3.7 362 13 SURG * ENDOSCOPIC TUBAL INTERRUPTION .2993 1.4 1.4 363 13 SURG D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY .8801 2.6 3.6 364 13 SURG D&C, CONIZATION EXCEPT FOR MALIGNANCY .8399 2.7 3.9 365 13 SURG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES 1.9401 5.2 7.7 366 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC 1.2804 4.9 6.9 367 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC .5388 2.3 3.0 368 13 MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM 1.2019 5.2 6.7 369 13 MED MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS .5941 2.4 3.2 370 14 SURG CESAREAN SECTION W CC .9721 4.4 5.7 371 14 SURG CESAREAN SECTION W/O CC .6742 3.3 3.6 372 14 MED VAGINAL DELIVERY W COMPLICATING DIAGNOSES .6053 2.6 3.7 373 14 MED VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES .3931 2.0 2.3 374 14 SURG VAGINAL DELIVERY W STERILIZATION &/OR D&C .7855 2.5 2.9 375 14 SURG * VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C .5714 4.4 4.4 376 14 MED POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE .4827 2.6 3.5 377 14 SURG POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE 1.4673 3.2 4.4 378 14 MED ECTOPIC PREGNANCY .8385 2.0 2.5 379 14 MED THREATENED ABORTION .3944 2.1 3.0 380 14 MED ABORTION W/O D&C .3662 1.6 2.0 381 14 SURG ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY .5859 1.6 2.1 382 14 MED FALSE LABOR .1588 1.2 1.4 383 14 MED OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS .5475 2.7 4.0 384 14 MED OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS .4188 1.8 2.7 385 15 MED * NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 1.3636 1.8 1.8 386 15 MED * EXTREME IMMATURITY 4.4966 17.9 17.9 387 15 MED * PREMATURITY W MAJOR PROBLEMS 3.0711 13.3 13.3 388 15 MED * PREMATURITY W/O MAJOR PROBLEMS 1.8531 8.6 8.6 389 15 MED * FULL TERM NEONATE W MAJOR PROBLEMS 3.1546 4.7 4.7 390 15 MED * NEONATE W OTHER SIGNIFICANT PROBLEMS 1.1165 3.4 3.4 391 15 MED * NORMAL NEWBORN .1512 3.1 3.1 392 16 SURG SPLENECTOMY AGE >17 3.1530 6.9 9.5 393 16 SURG * SPLENECTOMY AGE 0-17 1.3357 9.1 9.1 394 16 SURG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS 1.7961 4.3 7.0 395 16 MED RED BLOOD CELL DISORDERS AGE >17 .8141 3.2 4.4 396 16 MED RED BLOOD CELL DISORDERS AGE 0-17 .6515 2.4 3.8 397 16 MED COAGULATION DISORDERS 1.2348 3.7 5.2 398 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC 1.2646 4.6 5.9 399 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC .6883 2.8 3.6 400 17 SURG LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE 2.6627 5.5 9.0 401 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 2.7815 8.0 11.3 402 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC 1.1184 2.7 3.9 403 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W CC 1.7630 5.7 8.0 404 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC .8543 3.0 4.2 405 17 MED * ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 1.8937 4.9 4.9 406 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC 2.7896 6.9 9.7 407 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC 1.2754 3.3 4.1 408 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC 2.0472 4.7 7.9 409 17 MED RADIOTHERAPY 1.2026 4.5 6.1 410 17 MED CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 1.0423 3.1 4.0 411 17 MED HISTORY OF MALIGNANCY W/O ENDOSCOPY .3885 2.2 2.9 412 17 MED HISTORY OF MALIGNANCY W ENDOSCOPY .2791 1.6 2.0 413 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC 1.3594 5.3 7.3 414 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC .6897 3.0 4.0 415 18 SURG O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES 3.6521 10.4 14.5 416 18 MED SEPTICEMIA AGE >17 1.5936 5.6 7.5 417 18 MED SEPTICEMIA AGE 0-17 1.1657 4.5 6.1 418 18 MED POSTOPERATIVE & POST-TRAUMATIC INFECTIONS 1.0377 4.8 6.2 419 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W CC .8636 3.6 4.7 420 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC .5907 2.8 3.4 421 18 MED VIRAL ILLNESS AGE >17 .7028 2.9 3.8 422 18 MED VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 .4351 2.3 2.9 423 18 MED OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES 1.7883 5.9 8.3 424 19 SURG O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS 2.2964 8.1 13.0 425 19 MED ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION .6796 2.9 3.9 426 19 MED DEPRESSIVE NEUROSES .5177 3.2 4.5 427 19 MED NEUROSES EXCEPT DEPRESSIVE .5199 3.1 4.4 428 19 MED DISORDERS OF PERSONALITY & IMPULSE CONTROL .7376 4.4 7.4 429 19 MED ORGANIC DISTURBANCES & MENTAL RETARDATION .8268 4.7 6.3 430 19 MED PSYCHOSES .7128 5.7 8.0 431 19 MED CHILDHOOD MENTAL DISORDERS .5925 4.2 5.9 432 19 MED OTHER MENTAL DISORDER DIAGNOSES .6333 2.9 4.6 433 20 MED ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA .2752 2.2 3.0 434 20 MED NO LONGER VALID .0000 .0 .0 435 20 MED NO LONGER VALID .0000 .0 .0 436 20 MED NO LONGER VALID .0000 .0 .0 437 20 MED NO LONGER VALID .0000 .0 .0 438 20 NO LONGER VALID .0000 .0 .0 439 21 SURG SKIN GRAFTS FOR INJURIES 1.6840 5.4 8.5 440 21 SURG WOUND DEBRIDEMENTS FOR INJURIES 1.9031 5.7 9.0 441 21 SURG HAND PROCEDURES FOR INJURIES .9231 2.1 3.1 442 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W CC 2.4078 5.6 8.6 443 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W/O CC 1.0670 2.6 3.5 444 21 MED TRAUMATIC INJURY AGE >17 W CC .7577 3.2 4.3 445 21 MED TRAUMATIC INJURY AGE >17 W/O CC .4857 2.3 2.9 446 21 MED * TRAUMATIC INJURY AGE 0-17 .2936 2.4 2.4 447 21 MED ALLERGIC REACTIONS AGE >17 .5000 1.8 2.4 448 21 MED * ALLERGIC REACTIONS AGE 0-17 .0965 2.9 2.9 449 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC .8233 2.6 3.7 450 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC .4272 1.6 2.0 451 21 MED * POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 .2607 2.1 2.1 452 21 MED COMPLICATIONS OF TREATMENT W CC 1.0378 3.5 5.0 453 21 MED COMPLICATIONS OF TREATMENT W/O CC .5133 2.1 2.8 454 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC .8272 3.0 4.4 455 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC .4542 1.8 2.4 456 22 NO LONGER VALID .0000 .0 .0 457 22 MED NO LONGER VALID .0000 .0 .0 458 22 SURG NO LONGER VALID .0000 .0 .0 459 22 SURG NO LONGER VALID .0000 .0 .0 460 22 MED NO LONGER VALID .0000 .0 .0 461 23 SURG O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES 1.1927 2.2 4.1 462 23 MED REHABILITATION 1.1251 9.3 11.5 463 23 MED SIGNS & SYMPTOMS W CC .6930 3.2 4.2 464 23 MED SIGNS & SYMPTOMS W/O CC .4957 2.4 3.0 465 23 MED AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS .6785 1.8 2.9 466 23 MED AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS .7305 2.1 3.9 467 23 MED OTHER FACTORS INFLUENCING HEALTH STATUS .6095 2.1 8.4 468 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 3.6658 9.2 13.0 469 ** PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS .0000 .0 .0 470 ** UNGROUPABLE .0000 .0 .0 471 08 SURG BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY 3.0990 4.8 5.5 472 22 SURG NO LONGER VALID .0000 .0 .0 473 17 SURG ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 3.5075 7.3 12.6 474 04 SURG NO LONGER VALID .0000 .0 .0 475 04 MED RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT 3.6408 8.0 11.3 476 SURG PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.2587 8.0 11.3 477 SURG NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.8605 5.3 8.2 478 05 SURG OTHER VASCULAR PROCEDURES W CC 2.3660 4.9 7.4 479 05 SURG OTHER VASCULAR PROCEDURES W/O CC 1.4314 2.5 3.3 480 PRE SURG LIVER TRANSPLANT 10.1911 15.7 21.5 481 PRE SURG BONE MARROW TRANSPLANT 6.9570 19.3 22.0 482 PRE SURG TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES 3.4938 9.7 12.5 483 PRE SURG TRACHEOSTOMY/MECH VENT 96+HRS EXCEPT FACE,MOUTH & NECK DIAGNOSES 16.2670 34.6 42.0 484 24 SURG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 5.5512 8.9 13.2 485 24 SURG LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRA 2.9897 7.6 9.5 486 24 SURG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 4.8066 8.4 12.4 487 24 MED OTHER MULTIPLE SIGNIFICANT TRAUMA 1.9538 5.5 7.8 488 25 SURG HIV W EXTENSIVE O.R. PROCEDURE 4.6394 11.5 16.9 489 25 MED HIV W MAJOR RELATED CONDITION 1.7885 6.0 8.6 490 25 MED HIV W OR W/O OTHER RELATED CONDITION 1.0200 3.7 5.3 491 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY 1.7021 2.9 3.5 492 17 MED CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 3.9117 9.2 15.0 493 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 1.8188 4.3 5.9 494 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC 1.0128 1.9 2.5 495 PRE SURG LUNG TRANSPLANT 8.9713 14.3 17.2 496 08 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 5.7699 7.1 9.5 497 08 SURG SPINAL FUSION EXCEPT CERVICAL W CC 3.3834 5.4 6.5 498 08 SURG SPINAL FUSION EXCEPT CERVICAL W/O CC 2.4714 3.7 4.1 499 08 SURG BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 1.4381 3.4 4.6 500 08 SURG BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC .9487 2.0 2.5 501 08 SURG KNEE PROCEDURES W PDX OF INFECTION W CC 2.5940 8.4 10.7 502 08 SURG KNEE PROCEDURES W PDX OF INFECTION W/O CC 1.5391 5.3 6.4 503 08 SURG KNEE PROCEDURES W/O PDX OF INFECTION 1.2111 2.9 3.9 504 22 SURG EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 14.4707 26.9 35.1 505 22 MED EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT 1.9872 2.2 3.7 506 22 SURG FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA 4.6264 12.7 17.3 507 22 SURG FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 1.7118 6.5 9.0 508 22 MED FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA 1.4160 5.8 8.4 509 22 MED FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA .9410 4.1 5.5 510 22 MED NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA 1.2161 4.6 6.7 511 22 MED NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA .6968 3.0 4.4 512 PRE SURG SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT 5.7000 11.7 14.2 513 PRE SURG PANCREAS TRANSPLANT 6.1951 9.4 10.7 514 05 SURG CARDIAC DEFIBRILLATOR IMPLANT W CARDIAC CATH 6.3288 5.0 7.3 515 05 SURG CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH 5.0380 3.3 5.5 516 05 SURG PERCUTANEOUS CARDIOVASC PROC W AMI 2.7295 3.7 4.7 517 05 SURG PERC CARDIO PROC W CORONARY ARTERY STENT W/O AMI 2.1793 1.9 2.6 518 05 SURG PERC CARDIO PROC W/O CORONARY ARTERY STENT OR AMI 1.7267 2.3 3.4 519 08 SURG CERVICAL SPINAL FUSION W CC 2.3467 3.2 5.2 520 08 SURG CERVICAL SPINAL FUSION W/O CC 1.5390 1.7 2.1 521 20 MED ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC .7267 4.3 5.8 522 20 MED ALC/DRUG ABUSE OR DEPEND W REHABILITATION THERAPY W/O CC .5829 7.5 9.5 523 20 MED ALC/DRUG ABUSE OR DEPEND W/O REHABILITATION THERAPY W/O CC .4007 3.3 4.1 524 01 MED TRANSIENT ISCHEMIA .7236 2.7 3.4 525 05 SURG HEART ASSIST SYSTEM IMPLANT 11.3787 9.3 16.2 * MEDICARE DATA HAVE BEEN SUPPLEMENTED BY DATA FROM 19 STATES FOR LOW VOLUME DRGS. ** DRGS 469 AND 470 CONTAIN CASES WHICH COULD NOT BE ASSIGNED TO VALID DRGS. GEOMETRIC MEAN IS USED ONLY TO DETERMINE PAYMENT FOR TRANSFER CASES. ARITHMETIC MEAN IS PRESENTED FOR INFORMATIONAL PURPOSES ONLY. NOTE: RELATIVE WEIGHTS ARE BASED ON MEDICARE PATIENT DATA AND MAY NOT BE APPROPRIATE FOR OTHER PATIENTS. Table 6A.—New Diagnosis Codes Diagnosis code Description CC MDC DRG 040.82 Toxic shock syndrome Y 18 423 066.4 West Nile fever N 18 421, 422 277.02 Cystic fibrosis with pulmonary manifestations Y 4 79, 80, 81 277.03 Cystic fibrosis with gastrointestinal manifestations Y 6 188, 189, 190 277.09 Cystic fibrosis with other manifestations Y 10 296, 297, 298 357.81 Chronic inflammatory demyelinating polyneuritis N 1 18, 19 357.82 Critical illness polyneuropathy N 1 18, 19 357.89 Other inflammatory and toxic neuropathy N 1 18, 19 359.81 Critical illness myopathy N 1 34, 35 359.89 Other myopathies N 1 34, 35 365.83 Aqueous misdirection N 2 46, 47, 48 414.06 Coronary atherosclerosis of coronary artery of transplanted heart N 5 132, 133 414.12 Dissection of coronary artery N 5 121, 144, 145 428.20 Unspecified systolic heart failure Y 5 115, 121, 124, 127 428.21 Acute systolic heart failure Y 5 115, 121, 124, 127 428.22 Chronic systolic heart failure Y 5 115, 121, 124, 127 428.23 Acute on chronic systolic heart failure Y 5 115, 121, 124, 127 428.30 Unspecified diastolic heart failure Y 5 115, 121, 124, 127 428.31 Acute diastolic heart failure Y 5 115, 121, 124, 127 428.32 Chronic diastolic heart failure Y 5 115, 121, 124, 127 428.33 Acute on chronic diastolic heart failure Y 5 115, 121, 124, 127 428.40 Unspecified combined systolic and diastolic heart failure Y 5 115, 121, 124, 127 428.41 Acute combined systolic and diastolic heart failure Y 5 115, 121, 124, 127 428.42 Chronic combined systolic and diastolic heart failure Y 5 115, 121, 124, 127 428.43 Acute on chronic combined systolic and diastolic heart failure Y 5 115, 121, 124, 127 438.6 Alterations of sensations N 1 12 438.7 Disturbances of vision N 1 12 438.83 Facial weakness N 1 12 438.84 Ataxia N 1 12 438.85 Vertigo N 1 12 443.21 Dissection of carotid artery N 5 130, 131 443.22 Dissection of iliac artery N 5 130, 131 443.23 Dissection of renal artery N 11 331, 332, 333 443.24 Dissection of vertebral artery N 5 130, 131 443.29 Dissection of other artery N 5 130, 131 445.01 Atheroembolism, upper extremity Y 5 130, 131 445.02 Atheroembolism, lower extremity Y 5 130, 131 445.81 Atheroembolism, kidney Y 11 331, 332, 333 445.89 Atheroembolism, other site Y 5 130, 131 454.8 Varicose veins of the lower extremities, with other complications N 5 130, 131 459.10 Postphlebetic syndrome without complications N 5 130, 131 459.11 Postphlebetic syndrome with ulcer N 5 130, 131 459.12 Postphlebetic syndrome with inflammation N 5 130, 131 459.13 Postphlebetic syndrome with ulcer and inflammation N 5 130, 131 459.19 Postphlebetic syndrome with other complication N 5 130, 131 459.30 Chronic venous hypertension without complications N 5 130, 131 459.31 Chronic venous hypertension with ulcer N 5 130, 131 459.32 Chronic venous hypertension with inflammation N 5 130, 131 459.33 Chronic venous hypertension with ulcer and inflammation N 5 130, 131 459.39 Chronic venous hypertension with other complication N 5 130, 131 537.84 Dieulafoy lesion (hemorrhagic) of stomach and duodenum Y 6 174, 175 569.86 Dieulafoy lesion (hemorrhagic) of intestine Y 6 188, 189, 190 633.00 Abdominal pregnancy without intrauterine pregnancy N 14 378 633.01 Abdominal pregnancy with intrauterine pregnancy N 14 378 633.10 Tubal pregnancy without intrauterine pregnancy N 14 378 633.11 Tubal pregnancy with intrauterine pregnancy N 14 378 633.20 Ovarian pregnancy without intrauterine pregnancy N 14 378 633.21 Ovarian pregnancy with intrauterine pregnancy N 14 378 633.80 Other ectopic pregnancy without intrauterine pregnancy N 14 378 633.81 Other ectopic pregnancy with intrauterine pregnancy N 14 378 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy N 14 378 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy N 14 378 747.83 Persistent fetal circulation N 15 387, 389 765.20 Unspecified weeks of gestation N 15 391 765.21 Less than 24 completed weeks of gestation N 15 386 765.22 24 completed weeks of gestation N 15 386 765.23 25-26 completed weeks of gestation N 15 386 765.24 27-28 completed weeks of gestation N 15 387, 388 765.25 29-30 completed weeks of gestation N 15 387, 388 765.26 31-32 completed weeks of gestation N 15 387, 388 765.27 33-34 completed weeks of gestation N 15 387, 388 765.28 35-36 completed weeks of gestation N 15 387, 388 765.29 37 or more completed weeks of gestation N 15 391 770.81 Primary apnea of newborn N 15 390 770.82 Other apnea of newborn N 15 390 770.83 Cyanotic attacks of newborn N 15 390 770.84 Respiratory failure of newborn Y 15 387, 389 770.89 Other respiratory problems after birth N 15 390 771.81 Septicemia [sepsis] of newborn Y 15 387, 389 771.82 Urinary tract infection of newborn N 15 387, 389 771.83 Bacteremia of newborn Y 15 387, 389 771.89 Other infections specific to the perinatal period N 15 387, 389 779.81 Neonatal bradycardia N 15 390 779.82 Neonatal tachycardia N 15 390 779.89 Other specified conditions originating in the perinatal period N 15 390 780.91 Fussy infant
(baby)N 23 463,464 780.92 Excessive crying of infant
(baby)N 23 463,464 780.99 Other general symptoms N 23 463,464 781.93 Ocular torticollis N 8 243 795.00 Nonspecific abnormal Papanicolaou smear of cervix, unspecified N 13 358, 359, 369 795.01 Atypical squamous cell changes of undetermined significance favor benign (ASCUS favor benign) N 13 358, 359, 369 795.02 Atypical squamous cell changes of undetermined significance favor dysplasia (ASCUS favor dysplasia) N 13 358, 359, 369 795.09 Other nonspecific abnormal Papanicolaou smear of cervix N 13 358, 359, 369 795.31 Nonspecific positive findings for anthrax N 18 423 795.39 Other nonspecific positive culture findings N 18 423 813.45 Torus fracture of radius N 8 24 250, 251, 252 487 823.40 Torus fracture, tibia alone N 8 24 253, 254, 255 487 823.41 Torus fracture, fibula alone N 8 24 253, 254, 255 487 823.42 Torus fracture, fibula with tibia N 8 24 253, 254, 255 487 995.90 Systemic inflammatory response syndrome, unspecified Y 18 416, 417 995.91 Systemic inflammatory response syndrome due to infectious process without organ dysfunction Y 18 416, 417 995.92 Systemic inflammatory response syndrome due to infectious process with organ dysfunction Y 18 416, 417 995.93 Systemic inflammatory response syndrome due to non-infectious process without organ dysfunction Y 18 416, 417 995.94 Systemic inflammatory response syndrome due to non-infectious process with organ dysfunction Y 18 416, 417 998.31 Disruption of internal operation wound Y 21 452, 453 998.32 Disruption of external operation wound Y 21 452, 453 V01.81 Contact with or exposure to communicable diseases, anthrax N 15 23 391 1 467 V01.89 Contact with or exposure to communicable diseases, other communicable diseases N 15 23 391 1 467 V13.21 Personal history of pre-term labor N 23 467 V13.29 Personal history of other genital system and obstetric disorders N 23 467 V23.41 Pregnancy with history of pre-term labor N 14 469 V23.49 Pregnancy with other poor obstetric history N 14 469 V46.2 Other dependence on machines, supplemental oxygen N 23 467 V54.10 Aftercare for healing traumatic fracture of arm, unspecified N 8 249 V54.11 Aftercare for healing traumatic fracture of upper arm N 8 249 V54.12 Aftercare for healing traumatic fracture of lower arm N 8 249 V54.13 Aftercare for healing traumatic fracture of hip N 8 249 V54.14 Aftercare for healing traumatic fracture of leg, unspecified N 8 249 V54.15 Aftercare for healing traumatic fracture of upper leg N 8 249 V54.16 Aftercare for healing traumatic fracture of lower leg N 8 249 V54.17 Aftercare for healing traumatic fracture of vertebrae N 8 249 V54.19 Aftercare for healing traumatic fracture of other bone N 8 249 V54.20 Aftercare for healing pathologic fracture of arm, unspecified N 8 249 V54.21 Aftercare for healing pathologic fracture of upper arm N 8 249 V54.22 Aftercare for healing pathologic fracture of lower arm N 8 249 V54.23 Aftercare for healing pathologic fracture of hip N 8 249 V54.24 Aftercare for healing pathologic fracture of leg, unspecified N 8 249 V54.25 Aftercare for healing pathologic fracture of upper leg N 8 249 V54.26 Aftercare for healing pathologic fracture of lower leg N 8 249 V54.27 Aftercare for healing pathologic fracture of vertebrae N 8 249 V54.29 Aftercare for healing pathologic fracture of other bone N 8 249 V54.81 Aftercare following joint replacement N 8 249 V54.89 Other orthopedic aftercare N 8 249 V58.42 Aftercare following surgery for neoplasm N 23 465,466 V58.43 Aftercare following surgery for injury and trauma N 23 465,466 V58.71 Aftercare following surgery of the sense organs, NEC N 23 465,466 V58.72 Aftercare following surgery of the nervous system, NEC N 23 465,466 V58.73 Aftercare following surgery of the circulatory system, NEC N 23 465,466 V58.74 Aftercare following surgery of the respiratory system, NEC N 23 465,466 V58.75 Aftercare following surgery of the teeth, oral cavity and digestive system, NEC N 23 465,466 V58.76 Aftercare following surgery of the genitourinary system, NEC N 23 465,466 V58.77 Aftercare following surgery of the skin and subcutaneous tissue, NEC N 23 465,466 V58.78 Aftercare following surgery of the musculoskeletal system, NEC N 23 465,466 V71.82 Observation and evaluation for suspected exposure to anthrax N 23 467 V71.83 Observation and evaluation for suspected exposure to other biological agent N 23 467 V83.81 Cystic fibrosis gene carrier N 23 467 V83.89 Other genetic carrier status N 23 467 1 Classified as an “only secondary diagnosis” in this DRG. Table 6B.—New Procedure Codes Procedure code Description OR MDC DRG 00.01 Therapeutic ultrasound of vessels of head and neck N 00.02 Therapeutic ultrasound of heart N 00.03 Therapeutic ultrasound of peripheral vascular vessels N 00.09 Other therapeutic ultrasound N 00.10 Implantation of chemotherapeutic agent N 00.11 Infusion of drotrecogin alfa (activated) N 00.12 Administration of inhaled nitric oxide N 00.13 Injection or infusion of nesiritide N 00.14 Injection or infusion of oxazolidinone class of antibiotics N 00.50 Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P] Y 5 115 1 , 116 1 00.51 Implantation of cardiac resynchronization defibrillator, total system [CRT-D] Y 5 514 1 , 515 1 00.52 Implantation or replacement of transvenous lead (electrode) into left ventricular coronary venous system Y 5 115 2 , 116 3 , 514 4 , 515 4 00.53 Implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P] Y 5 115 2 , 116 3 , 118 00.54 Implantation or replacement of cardiac resynchronization defibrillator pulse generator only [CRT-D] Y 5 115 1 , 514 4 , 515 4 00.55 Insertion of drug-eluting noncoronary artery stent(s) N 36.07 Insertion of drug-eluting coronary artery stents(s) N* 5 517 39.72 Endovascular repair or occlusion of head and neck vessels Y 1 5 11 21 24 1,2,3 110, 111 315 442, 443 486 49.75 Implantation or revision of artificial anal sphincter Y 6 9 21 24 157, 158 267 442, 443 486 49.76 Removal of artificial anal sphincter Y 6 9 21 24 157, 158 267 442, 443 486 81.61 360 degree spinal fusion, single incision approach Y 1 8 21 24 4 496 442, 443 486 84.51 Insertion of interbody spinal fusion device N 84.52 Insertion of recombinant bone morphogenetic protein N 88.96 Other intraoperative magnetic resonance imaging N 99.76 Extracorporeal immunoadsorption N 99.77 Application or administration of an adhesion barrier substance N *Non-operating room procedure, but affects DRG. 1 Classified under “operating room procedures”. 2 Classified under “operating room procedure” and under “as any of the following procedure combinations” as 00.52 and 00.53. 3 Classified under “any of the following procedure combinations” as 00.52 and 00.53. 4 Classified under “any of the following procedure combinations” as 00.52 and 00.54. Table 6C.—Invalid Diagnosis Codes Diagnosis code Description CC MDC DRG 357.8 Other inflammatory and toxic neuropathy N 1 18, 19 359.8 Other myopathies N 1 34, 35 459.1 Postphlebetic syndrome N 5 130, 131 633.0 Abdominal pregnancy N 14 378 633.1 Tubal pregnancy N 14 378 633.2 Ovarian pregnancy N 14 378 633.8 Other ectopic pregnancy N 14 378 633.9 Unspecified ectopic pregnancy N 14 378 770.8 Other respiratory problems after birth N 15 387, 389 771.8 Other infections specific to the perinatal period Y 15 387, 389 779.8 Other specified conditions originating in the perinatal period N 15 390 780.9 Other general symptoms N 23 463, 464 795.0 Nonspecific abnormal Papanicolaou smear of cervix N 13 358, 359, 369 795.3 Nonspecific positive culture findings N 18 423 998.3 Disruption of operation wound Y 21 452, 453 V01.8 Other communicable diseases N 23 467 V13.2 Other genital system and obstetric disorders N 23 467 V23.4 Pregnancy with other poor obstetric history N 14 469 V54.8 Other orthopedic aftercare N 8 249 Table 6D.—Invalid Procedure Codes Note: There are no invalid procedure codes for FY 2003. Table 6E.—Revised Diagnosis Code Titles Diagnosis code Description CC MDC DRG 402.00 Hypertensive heart disease, malignant, without heart failure Y 5 134 402.01 Hypertensive heart disease, malignant, with heart failure Y 5 115, 121, 124, 127 402.10 Hypertensive heart disease, benign, without heart failure N 5 134 402.11 Hypertensive heart disease, benign, with heart failure Y 5 115, 121, 124, 127 402.90 Hypertensive heart disease, unspecified, without heart failure N 5 134 402.91 Hypertensive heart disease, unspecified, with heart failure Y 5 115, 121, 124, 127 404.00 Hypertensive heart and renal disease, malignant, without mention of heart failure or renal failure Y 5 134 404.01 Hypertensive heart and renal disease, malignant, with heart failure Y 5 115, 121, 124, 127 404.03 Hypertensive heart and renal disease, malignant, with heart failure and renal failure Y 5 115, 121, 124, 127 404.10 Hypertensive heart and renal disease, benign, without mention of heart failure or renal failure N 5 134 404.11 Hypertensive heart and renal disease, benign, with heart failure Y 5 115, 121, 124, 127 404.13 Hypertensive heart and renal disease, benign, with heart failure and renal failure Y 5 115, 121, 124, 127 404.90 Hypertensive heart and renal disease, unspecified, without mention of heart failure or renal failure N 5 134 404.91 Hypertensive heart and renal disease, unspecified, with heart failure Y 5 115, 121, 124, 127 404.93 Hypertensive heart and renal disease, unspecified, with heart failure and renal failure Y 5 115, 121, 124, 127 414.10 Aneurysm of heart N 5 121, 144, 145 414.11 Aneurysm of coronary vessels N 5 121, 144, 145 414.19 Other aneurysm of heart N 5 121, 144, 145 428.0 Congestive heart failure, unspecified Y 5 115, 121, 124, 127 454.9 Asymptomatic varicose veins N 5 130, 131 627.2 Symptomatic menopausal or female climacteric states N 13 358, 359, 369 627.4 Symptomatic states associated with artificial menopause N 13 358, 359, 369 V49.81 Asymptomatic postmenopausal status (age-related) (natural) N 23 467 Table 6F.—Revised Procedure Code Titles Procedure code Description OR MDC DRG 36.06 Insertion of nondrug-eluting coronary artery stents(s) N* 5 517 39.79 Other endovascular repair of aneurysm of other vessels Y 1 5 11 21 1, 2, 3 110, 111 315 442, 443 39.90 Insertion of nondrug-eluting, noncoronary artery stent(s) N 24 486 *Nonoperating room procedure, but affects DRG. Table 6G.—Additions to the CC Exclusions List [CCs that are added to the list are in Table 6G-Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.] *0031 99591 6829 99591 99593 44501 42821 4280 99590 99592 99590 99592 99594 44502 42822 4281 99591 99593 99591 99593 *04186 44581 42823 42820 99592 99594 99592 99594 99590 44589 42830 42821 99593 *03843 99593 *0412 99591 *25090 42831 42822 99594 99590 99594 99590 99592 44501 42832 42823 *0202 99591 *04089 99591 99593 44502 42833 42830 99590 99592 99590 99592 99594 44581 42840 42831 99591 99593 99591 99593 *04189 44589 42841 42832 99592 99594 99592 99594 99590 *25091 42842 42833 99593 *03844 99593 *0413 99591 44501 42843 42840 99594 99590 99594 99590 99592 44502 *40211 42841 *0362 99591 *04100 99591 99593 44581 42820 42842 99590 99592 99590 99592 99594 44589 42821 42843 99591 99593 99591 99593 *0419 *25092 42822 4289 99592 99594 99592 99594 99590 44501 42823 5184 99593 *03849 99593 *0414 99591 44502 42830 *42821 99594 99590 99594 99590 99592 44581 42831 39891 *0380 99591 *04101 99591 99593 44589 42832 40201 99590 99592 99590 99592 99594 *25093 42833 40211 99591 99593 99591 99593 *0545 44501 42840 40291 99592 99594 99592 99594 99590 44502 42841 4280 99593 *0388 99593 *0415 99591 44581 42842 4281 99594 99590 99594 99590 99592 44589 42843 42820 *03810 99591 *04102 99591 99593 *2515 *40291 42821 99590 99592 99590 99592 99594 53784 42820 42822 99591 99593 99591 99593 *1398 56986 42821 42823 99592 99594 99592 99594 99590 *27700 42822 42830 99593 *0389 99593 *0416 99591 27702 42823 42831 99594 99590 99594 99590 99592 27703 42830 42832 *03811 99591 *04103 99591 99593 27709 42831 42833 99590 99592 99590 99592 99594 *27701 42832 42840 99591 99593 99591 99593 *25070 27702 42833 42841 99592 99594 99592 99594 44501 27703 42840 42842 99593 *04082 99593 *0417 44502 27709 42841 42843 99594 0380 99594 99590 44581 *27702 42842 4289 *03819 03810 *04104 99591 44589 27700 42843 5184 99590 03811 99590 99592 *25071 27701 *4280 *42822 99591 03819 99591 99593 44501 27702 42820 39891 99592 0382 99592 99594 44502 27703 42821 40201 99593 0383 99593 *04181 44581 27709 42822 40211 99594 03840 99594 99590 44589 *27703 42823 40291 *0382 03841 *04105 99591 *25072 27700 42830 4280 99590 03842 99590 99592 44501 27701 42831 4281 99591 03843 99591 99593 44502 27702 42832 42820 99592 03844 99592 99594 44581 27703 42833 42821 99593 03849 99593 *04182 44589 27709 42840 42822 99594 0388 99594 99590 *25073 *27709 42841 42823 *0383 0389 *04109 99591 44501 27700 42842 42830 99590 04082 99590 99592 44502 27701 42843 42831 99591 6800 99591 99593 44581 27702 *4281 42832 99592 6801 99592 99594 44589 27703 42820 42833 99593 6802 99593 *04183 *25080 27709 42821 42840 99594 6803 99594 99590 44501 *39891 42822 42841 *03840 6804 *04110 99591 44502 42820 42823 42842 99590 6805 99590 99592 44581 42821 42830 42843 99591 6806 99591 99593 44589 42822 42831 4289 99592 6807 99592 99594 *25081 42823 42832 5184 99593 6808 99593 *04184 44501 42830 42833 *42823 99594 6809 99594 99590 44502 42831 42840 39891 *03841 6820 *04111 99591 44581 42832 42841 40201 99590 6821 99590 99592 44589 42833 42842 40211 99591 6822 99591 99593 *25082 42840 42843 40291 99592 6823 99592 99594 44501 42841 *42820 4280 99593 6825 99593 *04185 44502 42842 39891 4281 99594 6826 99594 99590 44581 42843 40201 42820 *03842 6827 *04119 99591 44589 *40201 40211 42821 99590 6828 99590 99592 *25083 42820 40291 42822 Table 6G.—Additions to the CC Exclusions List —Continued [CCs that are added to the list are in Table 6G-Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.] 42823 5184 42822 42831 56986 *53270 53784 *56202 42830 *42833 42823 42832 *53140 53784 56986 53784 42831 39891 42830 42833 53784 56986 *53411 56986 42832 40201 42831 42840 56986 *53271 53784 *56203 42833 40211 42832 42841 *53141 53784 56986 53784 42840 40291 42833 42842 53784 56986 *53420 56986 42841 4280 42840 42843 56986 *53290 53784 *56212 42842 4281 42841 44501 *53150 53784 56986 53784 42843 42820 42842 44502 53784 56986 *53421 56986 4289 42821 42843 44581 56986 *53291 53784 *56213 5184 42822 4289 44589 *53151 53784 56986 53784 *42830 42823 5184 *4599 53784 56986 *53430 56986 39891 42830 *42843 42820 56986 *53300 53784 *5693 40201 42831 39891 42821 *53160 53784 56986 53784 40211 42832 40201 42822 53784 56986 *53431 56986 40291 42833 40211 42823 56986 *53301 53784 *56985 4280 42840 40291 42830 *53161 53784 56986 53784 4281 42841 4280 42831 53784 56986 *53440 56986 42820 42842 4281 42832 56986 *53310 53784 *56986 42821 42843 42820 42833 *53170 53784 56986 56986 42822 4289 42821 42840 53784 56986 *53441 *5780 42823 5184 42822 42841 56986 *53311 53784 53784 42830 *42840 42823 42842 *53171 53784 56986 56986 42831 39891 42830 42843 53784 56986 *53450 *5781 42832 40201 42831 44501 56986 *53320 53784 53784 42833 40211 42832 44502 *53190 53784 56986 56986 42840 40291 42833 44581 53784 56986 *53451 *5789 42841 4280 42840 44589 56986 *53321 53784 53784 42842 4281 42841 *5184 *53191 53784 56986 56986 42843 42820 42842 42820 53784 56986 *53460 *74783 4289 42821 42843 42821 56986 *53330 53784 42971 5184 42822 4289 42822 *53200 53784 56986 42979 *42831 42823 5184 42823 53784 56986 *53461 7450 39891 42830 *4289 42830 56986 *53331 53784 74510 40201 42831 42820 42831 *53201 53784 56986 74511 40211 42832 42821 42832 53784 56986 *53470 74512 40291 42833 42822 42833 56986 *53340 53784 74519 4280 42840 42823 42840 *53210 53784 56986 7452 4281 42841 42830 42841 53784 56986 *53471 7453 42820 42842 42831 42842 56986 *53341 53784 7454 42821 42843 42832 42843 *53211 53784 56986 74560 42822 4289 42833 *5302 53784 56986 *53490 74569 42823 5184 42840 53784 56986 *53350 53784 7457 42830 *42841 42841 56986 *53220 53784 56986 74601 42831 39891 42842 *5307 53784 56986 *53491 74602 42832 40201 42843 53784 56986 *53351 53784 7461 42833 40211 *44489 56986 *53221 53784 56986 7462 42840 40291 44501 *53082 53784 56986 *53501 7463 42841 4280 44502 53784 56986 *53360 53784 7464 42842 4281 44581 56986 *53230 53784 56986 7465 42843 42820 44589 *53100 53784 56986 *53511 7466 4289 42821 *4449 53784 56986 *53361 53784 7467 5184 42822 44501 56986 *53231 53784 56986 74681 *42832 42823 44502 *53101 53784 56986 *53521 74682 39891 42830 44581 53784 56986 *53370 53784 74683 40201 42831 44589 56986 *53240 53784 56986 74684 40211 42832 *44501 *53110 53784 56986 *53531 74686 40291 42833 44501 53784 56986 *53371 53784 74711 4280 42840 *44502 56986 *53241 53784 56986 74722 4281 42841 44502 *53111 53784 56986 *53541 *76520 42820 42842 *44581 53784 56986 *53390 53784 76501 42821 42843 44581 56986 *53250 53784 56986 76502 42822 4289 *44589 *53120 53784 56986 *53551 76503 42823 5184 44589 53784 56986 *53391 53784 76504 42830 *42842 *4560 56986 *53251 53784 56986 76505 42831 39891 53784 *53121 53784 56986 *53561 76506 42832 40201 56986 53784 56986 *53400 53784 76507 42833 40211 *45989 56986 *53260 53784 56986 76508 42840 40291 42820 *53130 53784 56986 *53783 *76521 42841 4280 42821 53784 56986 *53401 53784 76501 42842 4281 42822 56986 *53261 53784 56986 76502 42843 42820 42823 *53131 53784 56986 *53784 76503 4289 42821 42830 53784 56986 *53410 53784 76504 Table 6G.—Additions to the CC Exclusions List —Continued [CCs that are added to the list are in Table 6G-Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.] 76505 76506 769 76508 7703 7713 78039 03811 76506 76507 7700 7670 7704 77181 7817 03819 76507 76508 7701 7685 7705 77183 7854 0382 76508 *7685 7702 769 7707 77210 78550 0383 *76522 77084 7703 7700 77084 77211 78551 03840 76501 *7686 7704 7701 7710 77212 78559 03841 76502 77084 7705 7702 7711 77213 7863 03842 76503 *7689 7707 7703 7713 77214 78820 03843 76504 77084 77084 7704 77181 7722 78829 03844 76505 *769 *7709 7705 77183 7724 7895 03849 76506 77084 77084 7707 77210 7725 7907 0388 76507 *7700 *7714 77084 77211 7730 7911 0389 76508 77084 77181 7710 77212 7731 7913 0545 *76523 *7701 77183 7711 77213 7732 7991 99590 76501 77084 *7715 7713 77214 7733 7994 99591 76502 *7702 77181 77181 7722 7734 *78099 99592 76503 77084 77183 77183 7724 7740 04082 99593 76504 *7703 *7716 77210 7725 7741 44024 99594 76505 77084 77181 77211 7730 7742 78001 *99592 76506 *7704 77183 77212 7731 77430 78003 0362 76507 77084 *7717 77213 7732 77431 7801 0380 76508 *7705 77181 77214 7733 77439 78031 03810 *76524 77084 77183 7722 7734 7744 78039 03811 76501 *7706 *77181 7724 7740 7745 7817 03819 76502 77084 77181 7725 7741 7747 7854 0382 76503 *7707 77183 7730 7742 7751 78550 0383 76504 77084 *77182 7731 77430 7752 78551 03840 76505 *77081 77181 7732 77431 7753 78559 03841 76506 7685 77183 7733 77439 7754 7863 03842 76507 769 *77183 7734 7744 7755 78820 03843 76508 7700 77181 7740 7745 7756 78829 03844 *76525 7701 77183 7741 7747 7757 7895 03849 76501 7702 *77189 7742 7751 7760 7907 0388 76502 7703 77181 77430 7752 7761 7911 0389 76503 7704 77183 77431 7753 7762 7913 0545 76504 7705 *7760 77439 7754 7763 7991 99590 76505 7707 77181 7744 7755 7771 7994 99591 76506 77084 77183 7745 7756 7772 *78550 99592 76507 *77082 *7761 7747 7757 7775 04082 99593 76508 7685 77181 7751 7760 7776 *78551 99594 *76526 769 77183 7752 7761 7780 04082 *99593 76501 7700 *7762 7753 7762 7790 *78559 0362 76502 7701 77181 7754 7763 7791 04082 0380 76503 7702 77183 7755 7771 7797 *7859 03810 76504 7703 *7763 7756 7772 *78091 04082 03811 76505 7704 77181 7757 7775 04082 *7998 03819 76506 7705 77183 7760 7776 44024 04082 0382 76507 7707 *7764 7761 7780 78001 *99590 0383 76508 77084 77181 7762 7790 78003 0362 03840 *76527 *77083 77183 7763 7791 7801 0380 03841 76501 7685 *7765 7771 7797 78031 03810 03842 76502 769 77181 7772 *77989 78039 03811 03843 76503 7700 77183 7775 76501 7817 03819 03844 76504 7701 *7766 7776 76502 7854 0382 03849 76505 7702 77181 7780 76503 78550 0383 0388 76506 7703 77183 7790 76504 78551 03840 0389 76507 7704 *7767 7791 76505 78559 03841 0545 76508 7705 77181 7797 76506 7863 03842 99590 *76528 7707 77183 *77982 76507 78820 03843 99591 76501 77084 *7768 76501 76508 78829 03844 99592 76502 *77084 77181 76502 7670 7895 03849 99593 76503 7685 77183 76503 7685 7907 0388 99594 76504 769 *7769 76504 769 7911 0389 *99594 76505 7700 77181 76505 7700 7913 0545 0362 76506 7701 77183 76506 7701 7991 99590 0380 76507 7702 *77981 76507 7702 7994 99591 03810 76508 7703 76501 76508 7703 *78092 99592 03811 *76529 7704 76502 7670 7704 04082 99593 03819 76501 7705 76503 7685 7705 44024 99594 0382 76502 7707 76504 769 7707 78001 *99591 0383 76503 77084 76505 7700 77084 78003 0362 03840 76504 *77089 76506 7701 7710 7801 0380 03841 76505 7685 76507 7702 7711 78031 03810 03842 Table 6G.—Additions to the CC Exclusions List —Continued [CCs that are added to the list are in Table 6G-Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.] 03843 99591 03844 99592 03849 99593 0388 99594 0389 *V096 0545 99590 99590 99591 99591 99592 99592 99593 99593 99594 99594 *V0970 *99791 99590 99831 99591 99832 99592 *99799 99593 99831 99594 99832 *V0971 *99831 99590 99831 99591 99832 99592 *99832 99593 99831 99594 99832 *V0980 *99881 99590 99831 99591 99832 99592 *99883 99593 99831 99594 99832 *V0981 *99889 99590 99831 99591 99832 99592 *9989 99593 99831 99594 99832 *V0990 *V090 99590 99590 99591 99591 99592 99592 99593 99593 99594 99594 *V0991 *V091 99590 99590 99591 99591 99592 99592 99593 99593 99594 99594 *V2341 *V092 V237 99590 V2381 99591 V2382 99592 V2383 99593 V2384 99594 V2389 *V093 V239 99590 *V2349 99591 V237 99592 V2381 99593 V2382 99594 V2383 *V094 V2384 99590 V2389 99591 V239 99592 *V462 99593 V461 99594 *V0950 99590 99591 99592 99593 99594 *V0951 99590 Table 6H.—Deletions to the CC Exclusions List [CCs that are deleted from the list are in Table 6H-Deletions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.] *7708 7722 9983 7685 7724 *9989 769 7725 9983 7700 7730 *V234 7701 7731 V237 7702 7732 V2381 7703 7733 V2382 7704 7734 V2383 7705 7740 V2384 7707 7741 V2389 *7714 7742 V239 7718 77430 *7715 77431 7718 77439 *7716 7744 7718 7745 *7717 7747 7718 7751 *7718 7752 7718 7753 *7760 7754 7718 7755 *7761 7756 7718 7757 *7762 7760 7718 7761 *7763 7762 7718 7763 *7764 7771 7718 7772 *7765 7775 7718 7776 *7766 7780 7718 7790 *7767 7791 7718 7797 *7768 *7809 7718 44024 *7769 78001 7718 78003 *7798 7801 76501 78031 76502 78039 76503 7817 76504 7854 76505 78550 76506 78551 76507 78559 76508 7863 7670 78820 7685 78829 769 7895 7700 7907 7701 7911 7702 7913 7703 7991 7704 7994 7705 *99791 7707 9983 7710 *99799 7711 9983 7713 *9983 7718 9983 77210 *99881 77211 9983 77212 *99883 77213 9983 77214 *99889 Table 7A.—Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2001 MEDPAR Update 12/01 Grouper V19.0] DRG Number discharges Arithmetic mean LOS 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile 1 34667 8.9765 2 3 6 12 19 2 7122 9.9083 3 5 8 13 20 3 7 7.4286 1 1 3 4 10 4 6414 7.1743 1 2 5 9 16 5 93169 3.0674 1 1 2 3 7 6 398 2.9196 1 1 2 4 6 7 14187 9.7565 1 4 7 12 20 8 4350 2.7572 1 1 1 3 6 9 1738 6.4689 1 3 5 8 13 10 18019 6.5224 2 3 5 8 13 11 3400 4.0044 1 2 3 5 8 12 49655 5.8699 2 3 4 7 11 13 6646 5.0141 2 3 4 6 9 14 320358 5.8150 2 3 5 7 11 15 152285 3.4737 1 2 3 4 6 16 11455 6.0111 2 3 5 7 12 17 3729 3.2773 1 2 3 4 6 18 28016 5.4234 2 3 4 7 10 19 8679 3.5369 1 2 3 5 7 20 5618 10.4676 3 5 8 13 20 21 1429 6.5850 2 3 5 8 13 22 2723 5.0165 2 2 4 6 10 23 11192 4.2429 1 2 3 5 8 24 55364 4.8878 1 2 4 6 10 25 27208 3.2250 1 2 3 4 6 26 34 4.6765 1 1 2 4 6 27 3839 5.0253 1 1 3 6 11 28 12344 6.2286 1 3 5 8 13 29 4930 3.5613 1 2 3 5 7 31 3815 4.0765 1 2 3 5 8 32 1893 2.4464 1 1 2 3 5 34 21788 5.0453 1 2 4 6 9 35 6839 3.2388 1 1 3 4 6 36 2493 1.4705 1 1 1 1 2 37 1419 3.8182 1 1 2 4 9 38 93 2.4946 1 1 1 3 6 39 667 1.9340 1 1 1 2 4 40 1524 3.6037 1 1 2 5 8 42 1938 2.3710 1 1 1 3 5 43 110 3.0455 1 1 2 4 6 44 1295 5.0347 2 3 4 6 9 45 2600 3.2423 1 2 3 4 6 46 3374 4.5871 1 2 4 6 9 47 1350 3.1719 1 1 3 4 6 48 1 2.0000 2 2 2 2 2 49 2335 4.6188 1 2 3 5 9 50 2483 1.8212 1 1 1 2 3 51 251 3.1195 1 1 1 3 7 52 239 1.9205 1 1 1 2 3 53 2516 3.3792 1 1 2 4 8 54 1 4.0000 4 4 4 4 4 55 1566 3.0556 1 1 1 3 6 56 528 2.9848 1 1 2 3 6 57 692 3.6893 1 1 2 4 8 59 128 2.6641 1 1 1 3 6 60 6 3.3333 1 1 2 5 5 61 243 4.8354 1 1 3 7 10 62 3 1.6667 1 1 1 3 3 63 2887 4.4891 1 1 3 6 9 64 3132 6.6028 1 2 4 8 14 65 39024 2.7977 1 1 2 3 5 66 7671 3.1068 1 1 2 4 6 67 440 3.5955 1 2 3 4 6 68 8648 3.8274 1 2 3 5 7 69 2973 3.0054 1 2 2 4 6 70 25 3.4800 1 2 3 4 8 71 87 3.4368 1 2 3 4 6 72 926 3.5659 1 1 3 4 7 73 7073 4.3867 1 2 3 6 9 75 39878 10.0489 3 5 7 12 20 76 41691 11.4166 3 5 9 14 22 77 2445 4.8634 1 2 4 7 10 78 35316 6.6636 3 4 6 8 11 79 166404 8.5040 3 4 7 11 16 80 8320 5.4954 2 3 5 7 10 81 2 8.0000 3 3 13 13 13 82 63426 6.9938 2 3 6 9 14 83 6394 5.4759 2 3 4 7 10 84 1559 3.2290 1 2 3 4 6 85 21268 6.3168 2 3 5 8 12 86 2180 3.8138 1 2 3 5 8 87 59482 6.3070 1 3 5 8 12 88 396842 5.1059 2 3 4 6 9 89 502709 5.8920 2 3 5 7 11 90 46817 4.0322 2 2 3 5 7 91 57 4.0000 2 2 3 5 8 92 14816 6.3579 2 3 5 8 12 93 1710 4.1076 1 2 3 5 8 94 12574 6.3304 2 3 5 8 13 95 1679 3.7123 1 2 3 5 7 96 53729 4.5526 2 2 4 6 8 97 28601 3.5208 1 2 3 4 6 98 15 5.0000 1 2 3 4 13 99 21279 3.1677 1 1 2 4 6 100 8950 2.1349 1 1 2 3 4 101 21127 4.3832 1 2 3 6 9 102 5559 2.5690 1 1 2 3 5 103 428 49.2103 9 14 26 61 116 104 19836 14.4245 6 8 12 17 25 105 27462 9.9935 5 6 8 11 18 106 3308 11.3987 5 7 10 14 20 107 85791 10.4560 5 7 9 12 17 108 6205 10.2743 3 5 8 13 20 109 59572 7.7288 4 5 6 9 13 110 53172 9.0340 2 4 7 11 18 111 9394 4.4159 1 2 4 6 8 113 41424 12.4557 4 6 9 15 24 114 8852 8.5204 2 4 7 11 17 115 15271 8.2839 1 4 7 11 16 116 109277 4.4721 1 2 3 6 9 117 4177 4.1611 1 1 2 5 9 118 8112 2.8930 1 1 1 3 7 119 1316 5.1117 1 1 3 6 12 120 37220 8.7981 1 2 6 12 20 121 167308 6.3297 2 3 5 8 12 122 81710 3.6163 1 2 3 5 7 123 41163 4.7016 1 1 3 6 11 124 137232 4.3524 1 2 3 5 8 125 91133 2.7831 1 1 2 4 5 126 5016 11.8909 4 6 9 15 22 127 682134 5.2700 2 3 4 7 10 128 8254 5.4723 2 3 5 7 9 129 4105 2.8378 1 1 1 3 6 130 88700 5.6615 2 3 5 7 10 131 27798 4.0539 1 2 4 5 7 132 152312 2.9301 1 1 2 4 5 133 8929 2.2655 1 1 2 3 4 134 39623 3.1770 1 2 2 4 6 135 7554 4.4298 1 2 3 5 8 136 1237 2.5594 1 1 2 3 5 138 203378 3.9834 1 2 3 5 8 139 90000 2.4829 1 1 2 3 5 140 66435 2.5585 1 1 2 3 5 141 102391 3.5917 1 2 3 4 7 142 51719 2.5539 1 1 2 3 5 143 250133 2.0827 1 1 2 3 4 144 88510 5.4530 1 2 4 7 11 145 7598 2.6481 1 1 2 3 5 146 10799 10.2146 5 7 8 12 17 147 2798 6.4010 3 5 6 8 10 148 129350 12.2861 5 7 10 15 22 149 19313 6.4669 4 5 6 8 10 150 20328 11.2319 4 7 10 14 20 151 4963 5.6756 1 3 5 8 10 152 4425 8.3250 3 5 7 10 14 153 2014 5.3803 3 4 5 7 8 154 29001 13.2057 3 7 10 16 26 155 7262 3.9898 1 2 3 6 8 156 3 15.0000 11 11 13 21 21 157 8154 5.5581 1 2 4 7 11 158 4562 2.5184 1 1 2 3 5 159 17114 5.0598 1 2 4 6 10 160 12169 2.6492 1 1 2 3 5 161 11152 4.1588 1 1 3 5 9 162 7288 1.9175 1 1 1 2 4 163 3 3.0000 1 1 3 5 5 164 5118 8.2651 3 5 7 10 14 165 2185 4.6499 2 3 4 6 8 166 3903 4.8737 1 2 4 6 9 167 3800 2.5132 1 1 2 3 4 168 1279 5.0023 1 2 3 6 11 169 827 2.2866 1 1 2 3 5 170 12108 10.9853 2 4 8 14 22 171 1355 4.3107 1 2 3 6 9 172 30622 6.9624 2 3 5 9 14 173 2711 3.7444 1 1 3 5 8 174 247222 4.8059 2 3 4 6 9 175 35165 2.9201 1 2 3 4 5 176 15219 5.2481 2 3 4 6 10 177 9429 4.5038 2 2 4 6 8 178 3758 3.0780 1 2 3 4 6 179 12541 5.9632 2 3 5 7 11 180 88300 5.3709 2 3 4 7 10 181 27097 3.3767 1 2 3 4 6 182 248889 4.4042 1 2 3 5 8 183 87342 2.8973 1 1 2 4 5 184 90 2.9000 1 1 2 4 6 185 5021 4.7104 1 2 3 6 9 186 3 4.6667 2 2 3 9 9 187 446 4.3565 1 2 3 6 8 188 79403 5.5558 1 2 4 7 11 189 13113 3.0563 1 1 2 4 6 190 74 4.7838 1 2 3 5 9 191 9222 13.7304 3 6 10 17 28 192 1257 6.0963 1 3 5 8 11 193 4865 12.7394 5 7 10 16 23 194 733 6.8759 2 4 6 8 12 195 4157 10.3560 4 6 9 12 18 196 1051 5.4186 2 3 5 7 9 197 18569 8.9827 3 5 7 11 16 198 5672 4.4381 2 3 4 6 8 199 1644 9.9179 2 4 7 13 21 200 1042 10.4539 1 3 7 14 22 201 1466 14.4734 3 6 11 18 29 202 26156 6.3731 2 3 5 8 13 203 29310 6.7403 2 3 5 9 13 204 61544 5.8119 2 3 4 7 11 205 24459 6.1537 2 3 5 8 12 206 2049 3.9204 1 2 3 5 8 207 32107 5.1834 1 2 4 7 10 208 10745 2.8598 1 1 2 4 5 209 371105 4.9903 3 3 4 6 8 210 121541 6.8894 3 4 6 8 11 211 32567 4.9284 3 4 5 6 7 212 7 3.2857 1 2 2 2 4 213 9878 9.1432 2 4 7 11 18 216 6916 9.5448 2 4 7 12 19 217 17029 13.4060 3 5 9 16 28 218 22745 5.4427 2 3 4 7 10 219 20867 3.2086 1 2 3 4 5 220 1 2.0000 2 2 2 2 2 223 13667 2.8776 1 1 2 3 6 224 12467 1.8627 1 1 1 2 3 225 6124 5.0144 1 2 3 7 11 226 5702 6.6733 1 3 5 8 14 227 4923 2.6669 1 1 2 3 5 228 2481 4.0806 1 1 2 5 9 229 1176 2.2168 1 1 2 3 4 230 2407 5.0586 1 2 3 6 11 231 13540 4.8875 1 1 3 6 10 232 882 2.7426 1 1 1 3 7 233 7199 7.2148 1 3 5 9 15 234 4623 3.1573 1 1 2 4 7 235 5091 5.0304 1 2 4 6 9 236 39785 4.7450 1 3 4 6 9 237 1744 3.5740 1 2 3 4 7 238 8625 8.8420 3 4 7 11 17 239 48235 6.2846 2 3 5 8 12 240 11808 6.7199 2 3 5 8 13 241 3223 3.8849 1 2 3 5 7 242 2516 6.5568 2 3 5 8 13 243 93807 4.6804 1 2 4 6 9 244 13584 4.7331 1 2 4 6 9 245 5733 3.3630 1 2 3 4 6 246 1347 3.7647 1 2 3 5 7 247 19620 3.3687 1 1 3 4 6 248 12067 4.8652 1 2 4 6 9 249 12912 3.6678 1 1 2 4 8 250 3795 4.1686 1 2 3 5 7 251 2489 2.7814 1 1 2 4 5 253 20861 4.6779 1 3 4 6 9 254 10809 3.1314 1 2 3 4 6 255 1 2.0000 2 2 2 2 2 256 6422 5.1110 1 2 4 6 10 257 16706 2.6651 1 1 2 3 5 258 16972 1.8186 1 1 2 2 3 259 3813 2.6693 1 1 1 2 6 260 5087 1.3666 1 1 1 1 2 261 1889 2.1615 1 1 1 2 4 262 683 4.2958 1 1 3 5 10 263 24569 11.8050 3 5 8 14 23 264 3982 6.9006 2 3 5 8 14 265 4052 6.7347 1 2 4 8 14 266 2676 3.1371 1 1 2 4 6 267 267 4.2584 1 1 2 4 8 268 899 3.6274 1 1 2 4 8 269 9064 8.2177 2 3 6 10 17 270 2746 3.2618 1 1 2 4 7 271 19612 7.2767 2 4 6 9 13 272 5471 6.1349 2 3 5 7 12 273 1387 3.9250 1 2 3 5 7 274 2344 6.7675 1 3 5 8 14 275 247 3.0202 1 1 2 4 6 276 1315 4.5384 1 2 4 6 8 277 93957 5.7577 2 3 5 7 10 278 31764 4.2755 2 3 4 5 7 279 3 7.0000 3 3 8 10 10 280 17047 4.1686 1 2 3 5 8 281 7834 2.9183 1 1 2 4 5 283 5638 4.6568 1 2 4 6 9 284 1950 3.0569 1 1 2 4 6 285 6574 10.6492 3 5 8 13 20 286 2183 5.9464 2 3 4 7 11 287 6460 10.5718 3 5 8 12 20 288 3675 5.3897 2 3 4 6 8 289 6423 2.8026 1 1 1 3 6 290 9500 2.2281 1 1 1 2 4 291 78 1.6026 1 1 1 2 3 292 5423 9.9458 2 4 8 13 20 293 345 4.9246 1 2 3 7 10 294 95391 4.5356 1 2 3 6 9 295 3359 3.9690 1 2 3 5 7 296 250941 5.1144 1 2 4 6 10 297 47743 3.3559 1 2 3 4 6 298 103 4.3495 1 2 3 5 8 299 1218 5.3760 1 2 4 6 10 300 17546 6.1581 2 3 5 8 12 301 3644 3.6509 1 2 3 5 7 302 7896 8.6990 4 5 7 10 15 303 20694 8.2722 3 4 6 9 15 304 11944 8.6761 2 4 6 11 18 305 2972 3.5697 1 2 3 4 6 306 7213 5.4883 1 2 3 7 13 307 2168 2.2002 1 1 2 3 4 308 7359 6.3367 1 2 4 8 14 309 4375 2.1913 1 1 2 3 4 310 24597 4.3470 1 1 3 5 9 311 8323 1.8264 1 1 1 2 3 312 1547 4.4945 1 1 3 6 10 313 644 2.1289 1 1 1 2 4 314 1 5.0000 5 5 5 5 5 315 31230 6.8866 1 1 4 9 16 316 116645 6.6308 2 3 5 8 13 317 1890 3.0899 1 1 2 3 7 318 5739 6.0294 1 3 4 8 12 319 494 2.8543 1 1 2 4 6 320 193283 5.3020 2 3 4 7 10 321 30745 3.7500 1 2 3 5 7 322 64 3.6563 1 2 3 4 7 323 18622 3.1423 1 1 2 4 6 324 7455 1.8437 1 1 1 2 3 325 8938 3.7880 1 2 3 5 7 326 2803 2.6718 1 1 2 3 5 327 2 2.5000 1 1 4 4 4 328 685 3.7883 1 1 3 5 7 329 105 2.2000 1 1 1 2 5 331 49140 5.5819 1 3 4 7 11 332 5119 3.1686 1 1 2 4 6 333 311 4.6849 1 2 3 6 10 334 10271 4.7684 2 3 4 5 8 335 12383 3.1779 2 2 3 4 5 336 36334 3.4249 1 2 2 4 7 337 29524 2.0688 1 1 2 2 3 338 1055 5.5526 1 2 3 8 13 339 1505 4.6186 1 1 3 6 10 340 1 1.0000 1 1 1 1 1 341 3670 3.0695 1 1 2 3 6 342 723 3.1355 1 1 2 4 6 343 1 5.0000 5 5 5 5 5 344 3810 2.2850 1 1 1 2 4 345 1180 3.8542 1 1 2 4 8 346 4562 6.0342 1 3 5 8 12 347 373 2.6971 1 1 2 3 6 348 3281 4.1591 1 2 3 5 8 349 597 2.4623 1 1 2 3 5 350 6497 4.5045 2 2 4 6 8 351 1 1.0000 1 1 1 1 1 352 768 3.9557 1 2 3 5 8 353 2659 6.4772 2 3 5 7 12 354 7491 5.8265 3 3 4 7 10 355 5680 3.2347 2 2 3 4 5 356 25943 2.1725 1 1 2 3 4 357 5715 8.4126 3 4 6 10 16 358 20616 4.3038 2 3 3 5 7 359 31095 2.6372 1 2 3 3 4 360 15579 2.8185 1 2 2 3 5 361 369 3.6694 1 1 2 4 8 362 2 1.0000 1 1 1 1 1 363 2684 3.6256 1 2 2 4 7 364 1632 3.8762 1 1 3 5 8 365 1770 7.3989 1 3 5 9 16 366 4436 6.8537 2 3 5 9 14 367 521 3.0115 1 1 2 4 6 368 3288 6.7318 2 3 5 8 13 369 3280 3.1976 1 1 2 4 6 370 1244 5.6937 3 3 4 5 9 371 1416 3.6031 2 3 3 4 5 372 919 3.6529 1 2 2 3 5 373 3878 2.2935 1 2 2 3 3 374 116 2.8793 1 2 2 3 5 375 8 5.2500 1 3 5 5 9 376 263 3.5095 1 2 2 4 6 377 29 4.3793 1 2 3 4 7 378 169 2.4615 1 1 2 3 4 379 408 3.0000 1 1 2 3 6 380 76 1.9605 1 1 1 2 4 381 181 2.0829 1 1 1 2 4 382 25 1.3600 1 1 1 1 3 383 1841 3.9620 1 1 3 4 8 384 149 2.7315 1 1 1 3 6 389 5 3.4000 1 1 2 4 8 390 8 2.7500 1 1 1 4 5 392 2247 9.5167 2 4 7 12 19 393 1 2.0000 2 2 2 2 2 394 1959 6.2950 1 2 4 8 14 395 100668 4.3478 1 2 3 5 9 396 11 3.8182 1 1 2 4 6 397 17952 5.1683 1 2 4 7 10 398 17121 5.8897 2 3 5 7 11 399 1788 3.5520 1 2 3 5 7 400 6488 8.9578 1 3 6 11 20 401 5837 11.2479 2 5 9 15 23 402 1598 3.8899 1 1 3 5 8 403 32013 8.0033 2 3 6 10 17 404 4593 4.1916 1 2 3 5 9 406 2495 9.6970 2 4 7 12 20 407 702 4.1140 1 2 3 5 8 408 2122 7.8591 1 2 5 10 18 409 2517 6.1339 2 3 4 6 13 410 30770 4.0138 1 2 4 5 6 411 14 2.9286 1 1 2 4 6 412 18 2.0000 1 1 1 2 4 413 5767 7.2917 2 3 6 9 14 414 763 4.0170 1 2 3 5 8 415 39920 14.4391 4 6 11 18 29 416 181162 7.4625 2 4 6 9 14 417 37 6.1351 2 2 4 8 13 418 23410 6.1742 2 3 5 8 12 419 15730 4.6490 1 2 4 6 9 420 2958 3.4324 1 2 3 4 6 421 9274 3.7804 1 2 3 4 7 422 69 2.9130 1 1 2 3 6 423 7273 8.2391 2 3 6 10 17 424 1292 12.9690 2 5 9 16 26 425 16309 3.8956 1 2 3 5 8 426 4483 4.4716 1 2 3 5 9 427 1576 4.4143 1 2 3 5 9 428 745 7.3732 1 2 4 8 15 429 27035 6.1425 2 3 4 7 12 430 63072 7.9697 2 3 6 10 16 431 321 5.9470 1 2 4 7 13 432 411 4.5645 1 1 3 5 9 433 5523 2.9714 1 1 2 3 6 439 1457 8.5003 1 3 6 10 17 440 5440 9.0241 2 3 6 11 20 441 612 3.0735 1 1 2 4 7 442 16697 8.5604 1 3 6 10 18 443 3806 3.5365 1 1 3 4 7 444 5676 4.3175 1 2 3 5 8 445 2726 2.8995 1 1 2 4 5 447 6278 2.4462 1 1 2 3 5 448 1 1.0000 1 1 1 1 1 449 30479 3.6797 1 1 3 4 8 450 7369 1.9900 1 1 1 2 4 451 5 1.6000 1 1 2 2 2 452 25229 5.0164 1 2 3 6 10 453 5648 2.7665 1 1 2 3 5 454 4624 4.3575 1 2 3 5 9 455 1098 2.3752 1 1 2 3 5 461 4563 4.0690 1 1 2 4 10 462 11994 11.3643 4 6 10 14 21 463 25215 4.1639 1 2 3 5 8 464 7115 3.0145 1 1 2 4 6 465 224 2.8973 1 1 1 3 5 466 1797 3.9321 1 1 2 4 7 467 1043 8.3931 1 1 2 3 6 468 57090 12.8803 3 6 10 16 25 471 12468 5.4931 3 3 4 6 9 473 8236 12.3409 1 3 7 17 32 475 104072 11.1941 2 5 9 15 22 476 3803 11.2611 2 5 10 15 21 477 25564 8.1456 1 3 6 11 17 478 108638 7.3817 1 3 5 9 16 479 24179 3.3012 1 1 3 4 7 480 622 21.5354 7 9 14 28 49 481 726 21.9353 13 17 20 25 33 482 5562 13.2251 4 7 10 16 25 483 43028 39.7169 15 22 33 49 71 484 317 13.0820 2 5 10 18 27 485 3029 9.4262 4 5 7 11 18 486 1867 12.3214 1 5 10 16 25 487 3536 7.6683 1 3 6 10 16 488 776 16.9162 3 6 13 22 35 489 13557 8.5376 2 3 6 10 18 490 5252 5.2582 1 2 4 6 10 491 13607 3.4664 1 2 3 4 6 492 2875 15.0104 2 5 7 25 34 493 58106 5.8777 1 3 5 7 11 494 30972 2.4751 1 1 2 3 5 495 211 17.1659 8 10 13 20 31 496 1842 9.4870 3 4 7 11 19 497 18414 6.5560 3 4 5 7 11 498 13584 4.1477 2 3 4 5 6 499 33300 4.6629 1 2 3 6 9 500 49827 2.4760 1 1 2 3 5 501 2356 10.6341 4 5 8 13 20 502 637 6.4066 2 4 5 8 11 503 5894 3.8884 1 2 3 5 7 504 123 34.9756 9 15 27 44 66 505 147 3.6667 1 1 1 5 9 506 937 17.2604 4 8 14 22 36 507 288 8.9549 2 4 7 12 18 508 667 8.2219 2 3 6 10 17 509 177 5.4350 1 2 4 7 10 510 1671 6.6092 1 3 5 8 13 511 616 4.3766 1 1 3 5 9 512 450 14.2244 6 8 11 15 24 513 142 10.7042 5 7 9 11 20 514 19261 7.2615 1 3 6 9 15 515 4570 5.4897 1 1 3 7 13 516 76256 4.7308 2 2 4 6 9 517 191586 2.6138 1 1 2 3 6 518 51638 3.3905 1 1 2 4 7 519 7316 5.1875 1 2 3 6 12 520 11118 2.1205 1 1 2 2 4 521 28568 5.7752 2 3 4 7 12 522 6141 9.4402 3 4 8 12 20 523 14812 4.0927 1 2 3 5 7 11403341 Table 7B.—Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2001 MEDPAR Update 12/01 Grouper V20.0] DRG Number discharges Arithmetic mean LOS 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile 1 27708 11.1212 3 5 8 14 22 2 14081 5.2277 1 3 4 7 10 3 7 7.4286 1 1 3 4 10 4 6426 7.1748 1 2 5 9 16 5 93169 3.0674 1 1 2 3 7 6 398 2.9196 1 1 2 4 6 7 14187 9.7565 1 4 7 12 20 8 4350 2.7572 1 1 1 3 6 9 1737 6.4669 1 3 5 8 13 10 18019 6.5224 2 3 5 8 13 11 3400 4.0044 1 2 3 5 8 12 49655 5.8699 2 3 4 7 11 13 6646 5.0141 2 3 4 6 9 14 236067 6.0768 2 3 5 7 12 15 101726 4.9503 2 3 4 6 9 16 9257 6.1391 2 3 5 8 12 17 2871 3.1379 1 1 2 4 6 18 28016 5.4234 2 3 4 7 10 19 8679 3.5369 1 2 3 5 7 20 5618 10.4676 3 5 8 13 20 21 1429 6.5850 2 3 5 8 13 22 2723 5.0165 2 2 4 6 10 23 11192 4.2429 1 2 3 5 8 24 55364 4.8878 1 2 4 6 10 25 27208 3.2250 1 2 3 4 6 26 34 4.6765 1 1 2 4 6 27 3839 5.0253 1 1 3 6 11 28 12344 6.2286 1 3 5 8 13 29 4930 3.5613 1 2 3 5 7 31 3815 4.0765 1 2 3 5 8 32 1893 2.4464 1 1 2 3 5 34 22342 5.0412 1 2 4 6 9 35 7331 3.2195 1 1 3 4 6 36 2493 1.4705 1 1 1 1 2 37 1419 3.8182 1 1 2 4 9 38 93 2.4946 1 1 1 3 6 39 667 1.9340 1 1 1 2 4 40 1524 3.6037 1 1 2 5 8 42 1938 2.3710 1 1 1 3 5 43 110 3.0455 1 1 2 4 6 44 1295 5.0347 2 3 4 6 9 45 2600 3.2423 1 2 3 4 6 46 3374 4.5871 1 2 4 6 9 47 1350 3.1719 1 1 3 4 6 48 1 2.0000 2 2 2 2 2 49 2337 4.6166 1 2 3 5 9 50 2483 1.8212 1 1 1 2 3 51 251 3.1195 1 1 1 3 7 52 239 1.9205 1 1 1 2 3 53 2518 3.3777 1 1 2 4 8 54 1 4.0000 4 4 4 4 4 55 1566 3.0556 1 1 1 3 6 56 528 2.9848 1 1 2 3 6 57 692 3.6893 1 1 2 4 8 59 128 2.6641 1 1 1 3 6 60 6 3.3333 1 1 2 5 5 61 243 4.8354 1 1 3 7 10 62 3 1.6667 1 1 1 3 3 63 2900 4.4831 1 1 3 6 9 64 3132 6.6028 1 2 4 8 14 65 39024 2.7977 1 1 2 3 5 66 7671 3.1068 1 1 2 4 6 67 440 3.5955 1 2 3 4 6 68 8754 3.8284 1 2 3 5 7 69 3035 2.9997 1 2 2 4 5 70 25 3.4800 1 2 3 4 8 71 87 3.4368 1 2 3 4 6 72 926 3.5659 1 1 3 4 7 73 7073 4.3867 1 2 3 6 9 75 39878 10.0489 3 5 7 12 20 76 41691 11.4166 3 5 9 14 22 77 2445 4.8634 1 2 4 7 10 78 35316 6.6636 3 4 6 8 11 79 166404 8.5040 3 4 7 11 16 80 8320 5.4954 2 3 5 7 10 81 2 8.0000 3 3 13 13 13 82 63426 6.9938 2 3 6 9 14 83 6394 5.4759 2 3 4 7 10 84 1559 3.2290 1 2 3 4 6 85 21268 6.3168 2 3 5 8 12 86 2180 3.8138 1 2 3 5 8 87 59482 6.3070 1 3 5 8 12 88 396842 5.1059 2 3 4 6 9 89 502709 5.8920 2 3 5 7 11 90 46817 4.0322 2 2 3 5 7 91 57 4.0000 2 2 3 5 8 92 14816 6.3579 2 3 5 8 12 93 1710 4.1076 1 2 3 5 8 94 12574 6.3304 2 3 5 8 13 95 1679 3.7123 1 2 3 5 7 96 53729 4.5526 2 2 4 6 8 97 28601 3.5208 1 2 3 4 6 98 15 5.0000 1 2 3 4 13 99 21279 3.1677 1 1 2 4 6 100 8950 2.1349 1 1 2 3 4 101 21127 4.3832 1 2 3 6 9 102 5559 2.5690 1 1 2 3 5 103 428 49.2103 9 14 26 61 116 104 19517 14.4041 6 8 12 17 25 105 27289 9.9529 5 6 8 11 18 106 3308 11.3987 5 7 10 14 20 107 85791 10.4560 5 7 9 12 17 108 6205 10.2743 3 5 8 13 20 109 59572 7.7288 4 5 6 9 13 110 53172 9.0340 2 4 7 11 18 111 9394 4.4159 1 2 4 6 8 113 41424 12.4557 4 6 9 15 24 114 8852 8.5204 2 4 7 11 17 115 15271 8.2839 1 4 7 11 16 116 109277 4.4721 1 2 3 6 9 117 4177 4.1611 1 1 2 5 9 118 8112 2.8930 1 1 1 3 7 119 1316 5.1117 1 1 3 6 12 120 37308 8.7872 1 2 6 12 20 121 167308 6.3297 2 3 5 8 12 122 81710 3.6163 1 2 3 5 7 123 41163 4.7016 1 1 3 6 11 124 138287 4.3673 1 2 3 6 8 125 90077 2.7417 1 1 2 4 5 126 5016 11.8909 4 6 9 15 22 127 682134 5.2700 2 3 4 7 10 128 8254 5.4723 2 3 5 7 9 129 4105 2.8378 1 1 1 3 6 130 88700 5.6615 2 3 5 7 10 131 27798 4.0539 1 2 4 5 7 132 152311 2.9301 1 1 2 4 5 133 8929 2.2655 1 1 2 3 4 134 39623 3.1770 1 2 2 4 6 135 7554 4.4298 1 2 3 5 8 136 1237 2.5594 1 1 2 3 5 138 203378 3.9834 1 2 3 5 8 139 90000 2.4829 1 1 2 3 5 140 66435 2.5585 1 1 2 3 5 141 102391 3.5917 1 2 3 4 7 142 51719 2.5539 1 1 2 3 5 143 250133 2.0827 1 1 2 3 4 144 88510 5.4530 1 2 4 7 11 145 7598 2.6481 1 1 2 3 5 146 10800 10.2147 5 7 8 12 17 147 2799 6.4012 3 5 6 8 10 148 129450 12.2855 5 7 10 15 22 149 19342 6.4670 4 5 6 8 10 150 20334 11.2329 4 7 10 14 20 151 4963 5.6756 1 3 5 8 10 152 4425 8.3250 3 5 7 10 14 153 2015 5.3782 3 4 5 7 8 154 29004 13.2062 3 7 10 16 26 155 7262 3.9898 1 2 3 6 8 156 3 15.0000 11 11 13 21 21 157 8155 5.5579 1 2 4 7 11 158 4564 2.5184 1 1 2 3 5 159 17115 5.0602 1 2 4 6 10 160 12172 2.6489 1 1 2 3 5 161 11155 4.1600 1 1 3 5 9 162 7290 1.9177 1 1 1 2 4 163 3 3.0000 1 1 3 5 5 164 5118 8.2651 3 5 7 10 14 165 2185 4.6499 2 3 4 6 8 166 3903 4.8737 1 2 4 6 9 167 3800 2.5132 1 1 2 3 4 168 1382 4.8705 1 2 3 6 10 169 869 2.2842 1 1 2 3 5 170 12156 10.9845 2 4 8 14 22 171 1359 4.3061 1 2 3 6 9 172 30622 6.9624 2 3 5 9 14 173 2711 3.7444 1 1 3 5 8 174 247222 4.8059 2 3 4 6 9 175 35165 2.9201 1 2 3 4 5 176 15219 5.2481 2 3 4 6 10 177 9429 4.5038 2 2 4 6 8 178 3758 3.0780 1 2 3 4 6 179 12541 5.9632 2 3 5 7 11 180 88300 5.3709 2 3 4 7 10 181 27097 3.3767 1 2 3 4 6 182 260686 4.3600 1 2 3 5 8 183 91243 2.8817 1 1 2 4 5 184 93 2.8387 1 1 2 4 6 185 5070 4.6984 1 2 3 6 9 186 3 4.6667 2 2 3 9 9 187 668 4.1153 1 2 3 6 8 188 79403 5.5558 1 2 4 7 11 189 13113 3.0563 1 1 2 4 6 190 74 4.7838 1 2 3 5 9 191 9222 13.7304 3 6 10 17 28 192 1257 6.0963 1 3 5 8 11 193 4865 12.7394 5 7 10 16 23 194 733 6.8759 2 4 6 8 12 195 4157 10.3560 4 6 9 12 18 196 1051 5.4186 2 3 5 7 9 197 18569 8.9827 3 5 7 11 16 198 5672 4.4381 2 3 4 6 8 199 1644 9.9179 2 4 7 13 21 200 1042 10.4539 1 3 7 14 22 201 2013 14.4287 4 6 11 18 28 202 26156 6.3731 2 3 5 8 13 203 29310 6.7403 2 3 5 9 13 204 61544 5.8119 2 3 4 7 11 205 24459 6.1537 2 3 5 8 12 206 2049 3.9204 1 2 3 5 8 207 32107 5.1834 1 2 4 7 10 208 10745 2.8598 1 1 2 4 5 209 371105 4.9903 3 3 4 6 8 210 121541 6.8894 3 4 6 8 11 211 32567 4.9284 3 4 5 6 7 212 7 3.2857 1 2 2 2 4 213 9878 9.1432 2 4 7 11 18 216 6916 9.5448 2 4 7 12 19 217 17029 13.4060 3 5 9 16 28 218 22744 5.4422 2 3 4 7 10 219 20866 3.2085 1 2 3 4 5 220 1 2.0000 2 2 2 2 2 223 13666 2.8724 1 1 2 3 6 224 12467 1.8627 1 1 1 2 3 225 6124 5.0144 1 2 3 7 11 226 5699 6.6699 1 3 5 8 14 227 4921 2.6651 1 1 2 3 5 228 2481 4.0806 1 1 2 5 9 229 1175 2.2179 1 1 2 3 4 230 2406 5.0590 1 2 3 6 11 231 12533 4.8810 1 1 3 6 11 232 882 2.7426 1 1 1 3 7 233 7179 7.2117 1 3 5 9 15 234 4607 3.1532 1 1 2 4 7 235 5091 5.0304 1 2 4 6 9 236 39785 4.7450 1 3 4 6 9 237 1744 3.5740 1 2 3 4 7 238 8625 8.8420 3 4 7 11 17 239 48230 6.2846 2 3 5 8 12 240 11807 6.7199 2 3 5 8 13 241 3223 3.8849 1 2 3 5 7 242 2516 6.5568 2 3 5 8 13 243 93654 4.6808 1 2 4 6 9 244 13584 4.7331 1 2 4 6 9 245 5732 3.3627 1 2 3 4 6 246 1346 3.7645 1 2 3 5 7 247 19620 3.3687 1 1 3 4 6 248 12067 4.8652 1 2 4 6 9 249 12651 3.6505 1 1 2 4 7 250 3795 4.1686 1 2 3 5 7 251 2489 2.7814 1 1 2 4 5 253 20861 4.6779 1 3 4 6 9 254 10809 3.1314 1 2 3 4 6 255 1 2.0000 2 2 2 2 2 256 6404 5.1084 1 2 4 6 10 257 16706 2.6651 1 1 2 3 5 258 16974 1.8185 1 1 2 2 3 259 3813 2.6693 1 1 1 2 6 260 5087 1.3666 1 1 1 1 2 261 1893 2.1590 1 1 1 2 4 262 686 4.2886 1 1 3 5 10 263 24569 11.8050 3 5 8 14 23 264 3982 6.9006 2 3 5 8 14 265 4052 6.7347 1 2 4 8 14 266 2676 3.1371 1 1 2 4 6 267 267 4.2584 1 1 2 4 8 268 899 3.6274 1 1 2 4 8 269 9064 8.2177 2 3 6 10 17 270 2746 3.2618 1 1 2 4 7 271 19612 7.2767 2 4 6 9 13 272 5471 6.1349 2 3 5 7 12 273 1387 3.9250 1 2 3 5 7 274 2344 6.7675 1 3 5 8 14 275 247 3.0202 1 1 2 4 6 276 1326 4.5181 1 2 4 6 8 277 93957 5.7577 2 3 5 7 10 278 31764 4.2755 2 3 4 5 7 279 3 7.0000 3 3 8 10 10 280 17047 4.1686 1 2 3 5 8 281 7834 2.9183 1 1 2 4 5 283 5638 4.6568 1 2 4 6 9 284 1950 3.0569 1 1 2 4 6 285 6574 10.6492 3 5 8 13 20 286 2183 5.9464 2 3 4 7 11 287 6460 10.5718 3 5 8 12 20 288 3675 5.3897 2 3 4 6 8 289 6423 2.8026 1 1 1 3 6 290 9500 2.2281 1 1 1 2 4 291 78 1.6026 1 1 1 2 3 292 5423 9.9458 2 4 8 13 20 293 345 4.9246 1 2 3 7 10 294 95391 4.5356 1 2 3 6 9 295 3359 3.9690 1 2 3 5 7 296 250941 5.1144 1 2 4 6 10 297 47743 3.3559 1 2 3 4 6 298 103 4.3495 1 2 3 5 8 299 1218 5.3760 1 2 4 6 10 300 17546 6.1581 2 3 5 8 12 301 3643 3.6508 1 2 3 5 7 302 7896 8.6990 4 5 7 10 15 303 20709 8.2736 3 4 6 9 15 304 12044 8.6857 2 4 6 11 18 305 3008 3.6051 1 2 3 5 6 306 7213 5.4883 1 2 3 7 13 307 2168 2.2002 1 1 2 3 4 308 7245 6.2803 1 2 4 8 14 309 4338 2.1547 1 1 2 3 4 310 24597 4.3470 1 1 3 5 9 311 8323 1.8264 1 1 1 2 3 312 1547 4.4945 1 1 3 6 10 313 644 2.1289 1 1 1 2 4 314 1 5.0000 5 5 5 5 5 315 33711 7.1835 1 1 4 9 17 316 115329 6.5892 2 3 5 8 13 317 1890 3.0899 1 1 2 3 7 318 5739 6.0294 1 3 4 8 12 319 494 2.8543 1 1 2 4 6 320 193283 5.3020 2 3 4 7 10 321 30745 3.7500 1 2 3 5 7 322 64 3.6563 1 2 3 4 7 323 18622 3.1423 1 1 2 4 6 324 7455 1.8437 1 1 1 2 3 325 8938 3.7880 1 2 3 5 7 326 2803 2.6718 1 1 2 3 5 327 2 2.5000 1 1 4 4 4 328 685 3.7883 1 1 3 5 7 329 105 2.2000 1 1 1 2 5 331 49140 5.5819 1 3 4 7 11 332 5119 3.1686 1 1 2 4 6 333 311 4.6849 1 2 3 6 10 334 10271 4.7684 2 3 4 5 8 335 12383 3.1779 2 2 3 4 5 336 36334 3.4249 1 2 2 4 7 337 29524 2.0688 1 1 2 2 3 338 1055 5.5526 1 2 3 8 13 339 1505 4.6186 1 1 3 6 10 340 1 1.0000 1 1 1 1 1 341 3670 3.0695 1 1 2 3 6 342 723 3.1355 1 1 2 4 6 343 1 5.0000 5 5 5 5 5 344 3840 2.3802 1 1 1 2 5 345 1336 4.7859 1 1 3 6 10 346 4562 6.0342 1 3 5 8 12 347 373 2.6971 1 1 2 3 6 348 3281 4.1591 1 2 3 5 8 349 597 2.4623 1 1 2 3 5 350 6497 4.5045 2 2 4 6 8 351 1 1.0000 1 1 1 1 1 352 768 3.9557 1 2 3 5 8 353 2659 6.4772 2 3 5 7 12 354 7491 5.8265 3 3 4 7 10 355 5680 3.2347 2 2 3 4 5 356 25943 2.1725 1 1 2 3 4 357 5715 8.4126 3 4 6 10 16 358 20617 4.3038 2 3 3 5 7 359 31095 2.6372 1 2 3 3 4 360 15583 2.8183 1 2 2 3 5 361 369 3.6694 1 1 2 4 8 362 2 1.0000 1 1 1 1 1 363 2683 3.6254 1 2 2 4 7 364 1631 3.8780 1 1 3 5 8 365 1834 7.6930 2 3 5 10 17 366 4436 6.8537 2 3 5 9 14 367 521 3.0115 1 1 2 4 6 368 3288 6.7318 2 3 5 8 13 369 3281 3.1987 1 1 2 4 6 370 1244 5.6937 3 3 4 5 9 371 1416 3.6031 2 3 3 4 5 372 919 3.6529 1 2 2 3 5 373 3878 2.2935 1 2 2 3 3 374 116 2.8793 1 2 2 3 5 375 8 5.2500 1 3 5 5 9 376 263 3.5095 1 2 2 4 6 377 29 4.3793 1 2 3 4 7 378 169 2.4615 1 1 2 3 4 379 408 3.0000 1 1 2 3 6 380 76 1.9605 1 1 1 2 4 381 181 2.0829 1 1 1 2 4 382 25 1.3600 1 1 1 1 3 383 1841 3.9620 1 1 3 4 8 384 149 2.7315 1 1 1 3 6 389 5 3.4000 1 1 2 4 8 390 1 4.0000 4 4 4 4 4 392 2247 9.5167 2 4 7 12 19 393 1 2.0000 2 2 2 2 2 394 2329 7.0575 1 2 5 9 15 395 100668 4.3478 1 2 3 5 9 396 11 3.8182 1 1 2 4 6 397 17952 5.1683 1 2 4 7 10 398 17121 5.8897 2 3 5 7 11 399 1788 3.5520 1 2 3 5 7 400 6488 8.9578 1 3 6 11 20 401 5837 11.2479 2 5 9 15 23 402 1599 3.8899 1 1 3 5 8 403 32013 8.0033 2 3 6 10 17 404 4592 4.1916 1 2 3 5 9 406 2495 9.6970 2 4 7 12 20 407 702 4.1140 1 2 3 5 8 408 2122 7.8591 1 2 5 10 18 409 2517 6.1339 2 3 4 6 13 410 30770 4.0138 1 2 4 5 6 411 14 2.9286 1 1 2 4 6 412 18 2.0000 1 1 1 2 4 413 5767 7.2917 2 3 6 9 14 414 763 4.0170 1 2 3 5 8 415 39922 14.4392 4 6 11 18 29 416 181162 7.4625 2 4 6 9 14 417 37 6.1351 2 2 4 8 13 418 23408 6.1732 2 3 5 8 12 419 15730 4.6490 1 2 4 6 9 420 2958 3.4324 1 2 3 4 6 421 9274 3.7804 1 2 3 4 7 422 69 2.9130 1 1 2 3 6 423 7273 8.2391 2 3 6 10 17 424 1292 12.9690 2 5 9 16 26 425 16309 3.8956 1 2 3 5 8 426 4483 4.4716 1 2 3 5 9 427 1576 4.4143 1 2 3 5 9 428 745 7.3732 1 2 4 8 15 429 27035 6.1425 2 3 4 7 12 430 63072 7.9697 2 3 6 10 16 431 321 5.9470 1 2 4 7 13 432 411 4.5645 1 1 3 5 9 433 5523 2.9714 1 1 2 3 6 439 1457 8.5003 1 3 6 10 17 440 5440 9.0241 2 3 6 11 20 441 612 3.0735 1 1 2 4 7 442 16700 8.5598 1 3 6 10 18 443 3808 3.5355 1 1 3 4 7 444 5676 4.3175 1 2 3 5 8 445 2726 2.8995 1 1 2 4 5 447 6278 2.4462 1 1 2 3 5 448 1 1.0000 1 1 1 1 1 449 30478 3.6796 1 1 3 4 8 450 7369 1.9900 1 1 1 2 4 451 5 1.6000 1 1 2 2 2 452 25229 5.0164 1 2 3 6 10 453 5646 2.7669 1 1 2 3 5 454 4624 4.3575 1 2 3 5 9 455 1098 2.3752 1 1 2 3 5 461 4563 4.0690 1 1 2 4 10 462 11994 11.3643 4 6 10 14 21 463 25215 4.1639 1 2 3 5 8 464 7115 3.0145 1 1 2 4 6 465 224 2.8973 1 1 1 3 5 466 1797 3.9321 1 1 2 4 7 467 1043 8.3931 1 1 2 3 6 468 54726 12.9153 3 6 10 16 25 471 12468 5.4931 3 3 4 6 9 473 8236 12.3409 1 3 7 17 32 475 104072 11.1941 2 5 9 15 22 476 3814 11.2651 2 5 10 15 21 477 25602 8.1413 1 3 6 11 17 478 108638 7.3817 1 3 5 9 16 479 24179 3.3012 1 1 3 4 7 480 622 21.5354 7 9 14 28 49 481 726 21.9353 13 17 20 25 33 482 5300 12.4930 4 7 9 15 23 483 43301 39.6393 14 22 33 49 71 484 317 13.0820 2 5 10 18 27 485 3029 9.4262 4 5 7 11 18 486 1867 12.3214 1 5 10 16 25 487 3536 7.6683 1 3 6 10 16 488 776 16.9162 3 6 13 22 35 489 13557 8.5376 2 3 6 10 18 490 5252 5.2582 1 2 4 6 10 491 13607 3.4664 1 2 3 4 6 492 2875 15.0104 2 5 7 25 34 493 58106 5.8777 1 3 5 7 11 494 30972 2.4751 1 1 2 3 5 495 211 17.1659 8 10 13 20 31 496 1842 9.4870 3 4 7 11 19 497 19927 6.5368 3 4 5 7 11 498 14665 4.1305 2 3 4 5 6 499 32668 4.6299 1 2 3 6 9 500 49512 2.4657 1 1 2 3 5 501 2356 10.6341 4 5 8 13 20 502 637 6.4066 2 4 5 8 11 503 5894 3.8884 1 2 3 5 7 504 123 34.9756 9 15 27 44 66 505 147 3.6667 1 1 1 5 9 506 937 17.2604 4 8 14 22 36 507 288 8.9549 2 4 7 12 18 508 667 8.2219 2 3 6 10 17 509 177 5.4350 1 2 4 7 10 510 1671 6.6092 1 3 5 8 13 511 616 4.3766 1 1 3 5 9 512 450 14.2244 6 8 11 15 24 513 142 10.7042 5 7 9 11 20 514 19261 7.2615 1 3 6 9 15 515 4570 5.4897 1 1 3 7 13 516 76256 4.7308 2 2 4 6 9 517 191586 2.6138 1 1 2 3 6 518 51638 3.3905 1 1 2 4 7 519 7220 5.1497 1 2 3 6 12 520 11073 2.1137 1 1 2 2 4 521 28568 5.7752 2 3 4 7 12 522 6141 9.4402 3 4 8 12 20 523 14812 4.0927 1 2 3 5 7 524 136857 3.3964 1 2 3 4 6 525 492 15.9309 2 5 9 18 35 11420001 Table 8A.—Statewide Average Operating Cost-To-Charge Ratios for Urban and Rural Hospitals (Case Weighted) March 2002 State Urban Rural ALABAMA 0.337 0.394 ALASKA 0.407 0.675 ARIZONA 0.349 0.478 ARKANSAS 0.456 0.438 CALIFORNIA 0.335 0.419 COLORADO 0.463 0.538 CONNECTICUT 0.494 0.509 DELAWARE 0.516 0.484 DISTRICT OF COLUMBIA 0.413 FLORIDA 0.349 0.365 GEORGIA 0.446 0.456 HAWAII 0.403 0.519 IDAHO 0.558 0.599 ILLINOIS 0.398 0.492 INDIANA 0.522 0.529 IOWA 0.484 0.594 KANSAS 0.380 0.591 KENTUCKY 0.478 0.490 LOUISIANA 0.390 0.482 MAINE 0.585 0.523 MARYLAND 0.759 0.821 MASSACHUSETTS 0.550 0.568 MICHIGAN 0.460 0.562 MINNESOTA 0.470 0.581 MISSISSIPPI 0.444 0.434 MISSOURI 0.399 0.473 MONTANA 0.504 0.544 NEBRASKA 0.428 0.550 NEVADA 0.284 0.473 NEW HAMPSHIRE 0.524 0.579 NEW JERSEY 0.393 NEW MEXICO 0.471 0.516 NEW YORK 0.500 0.595 NORTH CAROLINA 0.511 0.465 NORTH DAKOTA 0.611 0.611 OHIO 0.492 0.568 OKLAHOMA 0.405 0.485 OREGON 0.545 0.579 PENNSYLVANIA 0.376 0.500 PUERTO RICO 0.467 0.561 RHODE ISLAND 0.486 SOUTH CAROLINA 0.438 0.455 SOUTH DAKOTA 0.498 0.546 TENNESSEE 0.432 0.457 TEXAS 0.380 0.484 UTAH 0.495 0.570 VERMONT 0.572 0.595 VIRGINIA 0.452 0.546 WASHINGTON 0.580 0.598 WEST VIRGINIA 0.563 0.534 WISCONSIN 0.524 0.599 WYOMING 0.524 0.707 Table 8B.—Statewide Average Capital Cost-To-Charge Ratios (Case Weighted) March 2002 State Ratio ALABAMA 0.041 ALASKA 0.053 ARIZONA 0.038 ARKANSAS 0.049 CALIFORNIA 0.033 COLORADO 0.045 CONNECTICUT 0.036 DELAWARE 0.048 DISTRICT OF COLUMBIA 0.032 FLORIDA 0.043 GEORGIA 0.049 HAWAII 0.038 IDAHO 0.048 ILLINOIS 0.039 INDIANA 0.056 IOWA 0.049 KANSAS 0.047 KENTUCKY 0.046 LOUISIANA 0.046 MAINE 0.038 MARYLAND 0.013 MASSACHUSETTS 0.050 MICHIGAN 0.044 MINNESOTA 0.043 MISSISSIPPI 0.043 MISSOURI 0.043 MONTANA 0.051 NEBRASKA 0.047 NEVADA 0.032 NEW HAMPSHIRE 0.058 NEW JERSEY 0.035 NEW MEXICO 0.045 NEW YORK 0.049 NORTH CAROLINA 0.047 NORTH DAKOTA 0.073 OHIO 0.047 OKLAHOMA 0.045 OREGON 0.042 PENNSYLVANIA 0.037 PUERTO RICO 0.041 RHODE ISLAND 0.031 SOUTH CAROLINA 0.046 SOUTH DAKOTA 0.050 TENNESSEE 0.049 TEXAS 0.043 UTAH 0.045 VERMONT 0.049 VIRGINIA 0.057 WASHINGTON 0.068 WEST VIRGINIA 0.044 WISCONSIN 0.050 WYOMING 0.062 Table 9.—Hospital Reclassifications and Redesignations by Individual Hospital—FY—2003 Provider number Actual MSA or rural area Wage index MSA reclassification Standardized amount MSA reclassification 010005 01 3440 3440 010008 01 5240 010010 01 3440 3440 010012 01 2880 010022 01 2880 010029 0580 1800 010035 01 1000 010036 01 2750 010043 01 1000 1000 010044 01 25 010072 01 0450 0450 010101 01 0450 0450 010118 01 5240 010120 01 5160 010121 01 5240 010126 01 2180 010150 01 5240 010158 01 2650 020008 02 0380 030007 03 2620 030012 03 6200 030033 03 2620 030043 03 8520 040014 04 4400 040017 04 7920 040019 04 4920 040020 3700 4920 040026 04 4400 040027 04 7920 040041 04 4400 040045 04 26 040066 04 4400 040069 04 4920 040076 04 4400 040078 04 4400 040080 04 3700 040088 04 7680 040091 04 8360 040107 04 8360 040119 04 4400 050042 05 6690 050045 05 7320 050069 5945 4480 050071 7400 5775 050073 8720 5775 050076 7360 5775 050101 8720 5775 050150 05 6920 050174 7500 8720 050192 2840 05 050228 7360 5775 050230 5945 4480 050236 8735 4480 050286 8780 05 050296 05 7120 050301 05 7500 050325 05 5170 050335 05 5170 050419 05 6690 050446 0680 05 050457 7360 5775 050464 5170 8120 050469 6780 05 050494 05 6920 050510 7360 5775 050528 4940 05 050541 7360 5775 050549 8735 4480 050569 05 7500 050594 5945 4480 050609 5945 4480 050686 6780 5945 050701 6780 7320 060003 1125 2080 2080 060013 06 0200 060018 06 2995 060023 2995 6520 060027 1125 2080 2080 060044 06 2080 060049 06 2670 060075 06 2995 060076 06 3060 060096 06 2080 060103 1125 2080 2080 070006 5483 5600 070018 5483 5600 070033 5483 5600 070034 5483 5600 070036 3283 5483 080002 08 0720 080004 2190 9160 080006 08 2190 080007 08 2190 100022 5000 2680 100023 10 5960 100024 10 5000 100045 2020 5960 100048 6080 10 100049 10 3980 100098 10 8960 8960 100103 10 3600 3600 100105 10 2710 100109 10 5960 100118 2020 10 100150 10 5000 100157 3980 8280 100176 8960 2710 100211 8280 3980 100217 10 2710 100232 10 5790 2900 100239 8280 7510 100249 10 8280 100268 8960 2680 110001 11 0520 110002 11 0520 110003 11 3600 110016 11 1800 110023 11 0520 110025 11 3600 110029 11 0520 110038 11 10 110040 11 0500 0500 110050 11 0520 110054 11 0520 110075 11 7520 110100 11 0600 110118 11 0120 110122 11 10 110150 11 4680 110168 11 0520 110187 11 0520 110188 11 0520 110189 11 0520 110190 11 4680 110205 11 0520 120015 12 3320 130002 13 29 130003 13 50 130011 13 50 130018 13 6340 130049 13 7840 130060 13 1080 140012 14 1600 140015 14 7040 140031 14 1400 140032 14 7040 140034 14 7040 140040 14 6120 140043 14 6880 140046 14 7040 140058 14 7880 140064 14 6120 140086 14 7040 140093 14 1400 140102 14 7880 7880 140110 14 6120 140141 14 7040 7040 140143 14 6120 140155 3740 1600 140160 14 6880 140161 14 1600 140164 14 7040 140189 14 1400 140199 14 7040 140230 14 1400 140234 14 6120 140245 14 7040 140271 14 7800 7800 150002 2960 1600 150004 2960 1600 150006 15 7800 150008 2960 1600 150011 15 3480 3480 150015 15 1600 150027 15 3480 150030 15 3480 3480 150034 2960 1600 150036 15 3850 150048 15 2000 150051 1020 3480 150062 15 3480 3480 150065 15 3480 150067 15 3480 150069 15 1640 1640 150076 15 7800 150090 2960 1600 150096 15 2330 150105 15 3480 3480 150112 15 3480 3480 150122 15 3480 150125 2960 1600 1600 150126 2960 1600 1600 150132 2960 1600 150133 15 2330 150146 15 2330 160001 16 2120 160016 16 2120 160026 16 2120 160030 16 2120 160037 16 24 160057 16 3500 160064 16 8920 160080 16 1960 160089 16 2120 160094 16 8920 160122 16 14 160147 16 2120 170001 17 9040 170006 17 3710 170010 17 8560 170012 17 9040 170013 17 9040 170014 17 3760 170020 17 9040 170022 17 7000 170023 17 9040 170025 17 9040 170033 17 9040 170058 17 26 170060 17 28 170094 17 8440 170120 17 3710 170131 17 8440 170137 4150 17 170142 17 8440 170145 17 8560 170166 17 0320 170175 17 9040 180005 18 3400 180011 18 4280 180012 18 4520 180013 18 5360 180016 18 4520 180018 18 4280 180027 18 1660 180028 18 3400 180029 18 3660 180044 18 3400 180048 18 4280 180054 18 1660 180065 18 1640 180066 18 5360 180069 18 3400 180078 18 3400 180102 18 1660 180104 18 1660 180116 18 1660 180124 18 5360 180127 18 4520 180132 18 4280 180139 18 4280 190001 19 5560 5560 190003 19 3880 190010 19 5560 5560 190014 19 3880 190015 19 5560 190018 19 3880 190025 19 3880 190048 3350 19 190054 19 3880 190083 19 5200 190086 19 5200 190099 19 3880 190106 19 3880 190110 3880 19 190131 19 5560 190218 19 0220 200020 6403 1123 1123 200024 4243 6403 200034 4243 6403 200039 20 6403 200040 6403 1123 200063 20 6403 220060 1123 0743 220077 8003 3283 230015 23 3720 230022 23 3720 230027 23 3000 3000 230030 23 6960 230036 23 6960 230037 23 0440 230040 23 3720 3720 230054 23 3080 230078 0870 23 230080 23 6960 230093 23 3000 230096 23 3720 230097 23 3000 230105 23 6960 230106 23 3000 230121 23 2640 2640 230188 23 6960 6960 230199 23 0870 0870 230235 23 6960 6960 230253 23 2160 240008 24 6820 240011 24 5120 240014 24 5120 240016 24 2520 240018 24 5120 240023 24 5120 240045 24 2240 240064 24 2240 240075 24 6980 240088 24 6980 240089 24 5120 240100 24 2985 240121 24 2240 240139 24 5120 240142 24 6980 240152 24 5120 250004 25 4920 250009 25 3580 250012 25 4920 250025 25 1 250030 25 3560 250031 25 3560 250034 25 4920 250042 25 4920 250058 25 3285 250069 25 3560 250078 3285 0920 250079 25 3560 250081 25 3560 250082 25 6240 250084 25 19 250088 25 0760 250094 3285 0920 250097 25 0760 250100 25 8600 250101 25 3560 250104 25 3560 250122 25 19 250126 25 4920 260006 7000 26 260009 26 3760 260011 26 1740 260015 26 3700 260017 26 7040 260022 26 1740 260025 26 14 260034 26 3760 260047 26 1740 260050 26 7000 260064 26 1740 260074 26 1740 260078 26 7920 260094 26 7920 260110 26 7040 7040 260113 26 14 260116 26 7040 260119 26 3700 260120 26 3700 260127 26 7040 260131 26 1740 260183 26 7040 260186 26 1740 270002 27 0880 270003 27 3040 270011 27 3040 270016 27 0880 270017 27 5140 270051 27 5140 270057 27 0880 270083 27 5140 280009 28 4360 280023 28 4360 280032 28 4360 280054 28 4360 280061 28 53 280065 28 3060 280077 28 5920 280111 28 5920 280125 28 7720 290006 29 6720 290019 29 6720 300003 30 1123 300005 30 1123 1123 300009 1123 30 300019 30 22 300024 30 1123 310001 0875 5600 310002 5640 5600 310003 3640 5600 310015 5640 0875 310021 8480 5190 310031 6160 5190 310038 5015 5600 310039 5015 5190 310045 0875 5600 310048 5015 5640 310049 3640 5640 310070 5015 5640 310076 5640 5600 310087 8760 6160 310108 5015 5190 310118 3640 0875 310119 5640 5600 320005 32 0200 320006 32 7490 320011 32 7490 320013 32 7490 320063 32 5800 320065 32 5800 330001 5660 5600 330004 33 5660 330023 2281 5660 330027 5380 5600 330084 33 1303 330085 33 8160 330103 33 1280 330106 5380 5600 330126 5660 5600 330135 5660 5600 330136 33 8160 330157 33 8160 330181 5380 5600 330182 5380 5600 330205 5660 5600 330209 5660 5600 330224 33 3283 330235 8160 6840 330239 3610 2360 330250 33 1303 330264 5660 5600 330307 33 8160 330386 33 5660 340003 34 3120 340008 34 2560 340013 34 1520 340017 34 0480 340021 34 1520 340023 34 0480 340027 34 3150 340039 34 1520 1520 340050 34 2560 340051 34 3290 340052 3120 1520 340064 34 3120 340068 34 9200 340071 34 6640 6640 340084 34 1520 340088 34 0480 340097 34 3120 340109 34 5720 5720 340115 34 6640 340124 34 6640 6640 340126 34 6640 6640 340129 34 1520 340131 34 3150 340143 3290 1520 340144 34 1520 340147 6895 6640 350005 35 2985 350006 35 1010 350009 35 2520 350017 35 27 350043 35 1010 360002 36 1680 360008 36 3400 360010 36 0080 360011 36 1840 360013 36 2000 360014 36 1840 360024 36 1680 1680 360025 36 1680 1680 360036 36 0080 360037 1680 0080 360039 36 1840 360046 3200 1640 1640 360056 3200 1640 1640 360063 36 1680 1680 360065 36 1680 1680 360071 36 4320 4320 360076 3200 1640 1640 360078 0080 1680 360084 1320 0080 360088 36 1840 360089 36 8400 360090 8400 2160 360092 36 1840 1840 360095 36 8400 360101 1680 0080 360107 36 8400 360108 36 4800 360109 36 1840 360112 8400 0440 360121 36 0440 360132 3200 1640 1640 360142 36 1640 360144 1680 0080 360159 36 1840 360175 36 1840 1640 360197 36 1840 1840 360211 8080 6280 370004 37 3710 370006 37 8560 370014 37 7640 370015 37 8560 370018 37 8560 370022 37 4200 370023 37 4200 370025 37 8560 370034 37 2720 370047 37 7640 370048 37 8360 370049 37 5880 370054 37 5880 370084 37 2720 370103 37 45 370153 37 4200 370200 37 5880 380001 38 6440 380002 38 4890 380003 38 2400 380006 38 6440 380027 38 2400 380040 38 2400 380047 38 2400 380050 38 4890 380051 7080 6440 380065 38 2400 380070 38 6440 380084 7080 38 380090 38 2400 390006 39 3240 390008 39 6280 6280 390013 39 3240 390016 39 6280 6280 390017 39 6280 6280 390030 39 0240 6680 390031 39 0240 6680 390048 39 3240 390052 39 0280 390065 39 8840 9280 390079 39 0960 390091 39 6280 390093 39 6280 390110 3680 6280 390113 39 9320 390133 0240 6160 390138 39 8840 390150 39 6280 390151 39 8840 390181 39 6680 6680 390183 39 6680 6680 390189 39 3240 390197 0240 6160 390201 39 5660 5640 390263 0240 6160 400018 40 1310 410010 6483 1123 410013 6483 5523 420020 42 1440 420036 42 1520 420059 42 2655 420062 42 1520 420068 42 0600 420070 8140 1760 420071 42 0600 420080 42 7520 420085 5330 9200 430008 43 24 430012 43 7760 430013 43 7760 430014 43 2520 430015 43 6660 430047 43 28 430048 43 53 430089 43 7720 440020 44 3440 440024 44 1560 440050 44 0480 440058 44 1560 440059 44 5360 440067 44 3840 440068 44 1560 440073 44 5360 440083 44 3840 440143 44 5360 440148 44 5360 440175 44 3440 440180 44 3840 440182 44 3580 440185 44 1560 440186 44 5360 440187 44 18 440192 44 5360 440200 44 5360 440203 44 1560 450007 45 7240 450014 45 8750 450053 45 8750 450072 1145 3360 450080 45 4420 450085 45 9080 450098 45 4420 450099 45 0320 450113 45 1920 450140 45 5800 450144 45 5800 450146 45 0320 450155 45 0320 450163 45 1880 450178 45 5800 450187 45 3360 450192 45 1920 450194 45 1920 450196 45 1920 450211 45 3360 450214 45 3360 450224 45 8640 450246 45 8750 450347 45 3360 450351 45 2800 450353 45 1880 450373 45 4420 450395 45 3360 450400 45 8800 450438 45 0640 450447 45 1920 450451 45 2800 450484 45 3360 450508 45 8640 450534 45 0320 450587 45 40 450591 1145 3360 450623 45 1920 450626 45 8750 450653 45 5800 450656 45 8640 450694 45 3360 450747 45 1920 450755 45 4600 450763 45 320 460007 46 2620 460011 46 6520 460021 46 4120 460027 46 6520 460032 46 6520 460036 46 6520 460039 46 7160 470001 47 1303 470003 1303 1123 470011 47 1123 1123 470012 47 6323 470018 47 1123 490001 49 3660 490004 49 1540 490005 49 8840 490013 49 1950 490018 49 4640 490038 49 3660 490047 49 8840 490060 49 3660 490066 5720 6760 490079 49 3120 490126 49 6800 500002 50 6740 500003 50 7600 500007 50 0860 500016 50 7600 500041 50 6440 500059 50 7600 500072 50 7600 500079 8200 7600 510001 51 6280 510002 51 6800 510006 51 6280 510024 51 6280 6280 510028 51 1480 510046 51 1480 510047 51 6280 510048 51 3400 510062 51 1480 510070 51 1480 510071 51 1480 520002 52 8940 520006 52 8940 520011 52 2290 520021 3800 1600 1600 520028 52 4720 520037 52 8940 520059 6600 5080 5080 520066 3620 4720 520071 52 5080 5080 520076 52 5080 520084 52 4720 520088 52 5080 520091 52 23 520094 6600 5080 5080 520096 6600 5080 5080 520102 52 5080 5080 520107 52 3080 520113 52 3080 520116 52 5080 5080 520152 52 3080 520173 52 2240 520189 3800 1600 1600 530008 53 1350 530009 53 1350 530015 53 6340 530025 53 2670 530032 53 7160 Table 10.—Means and Standard Deviations, by Diagnosis Related Groups
(DRGs)1 DRG Cases Mean + 1 standard deviation 1 27,704 $66,748 2 14,078 $34,337 3 7 $55,030 4 6,426 $41,870 5 93,104 $23,280 6 398 $14,095 7 14,187 $46,968 8 4,349 $28,253 9 1,737 $24,223 10 18,015 $22,246 11 3,398 $15,519 12 49,619 $15,429 13 6,637 $13,922 14 235,975 $21,928 15 101,681 $16,969 16 9,257 $21,632 17 2,870 $11,541 18 28,000 $17,036 19 8,672 $12,308 20 5,616 $51,920 21 1,429 $27,335 22 2,722 $18,422 23 11,189 $14,276 24 55,342 $17,340 25 27,205 $10,640 26 34 $13,463 27 3,839 $23,063 28 12,339 $23,674 29 4,928 $12,505 31 3,814 $15,329 32 1,891 $9,174 34 22,336 $17,368 35 7,323 $11,138 36 2,481 $10,985 37 1,418 $18,071 38 93 $9,775 39 666 $10,551 40 1,524 $14,863 42 1,936 $11,289 43 110 $8,855 44 1,295 $11,245 45 2,598 $12,352 46 3,373 $13,685 47 1,350 $9,302 49 2,337 $31,134 50 2,477 $13,972 51 251 $16,197 52 238 $13,055 53 2,517 $20,530 55 1,564 $16,073 56 526 $16,460 57 692 $17,299 59 127 $13,165 60 6 $10,986 61 243 $21,950 62 3 $6,623 63 2,900 $25,070 64 3,131 $23,886 65 39,014 $9,512 66 7,668 $9,851 67 439 $13,316 68 8,752 $11,567 69 3,034 $8,666 70 25 $8,029 71 87 $12,279 72 926 $12,429 73 7,070 $13,912 75 39,852 $53,451 76 41,676 $50,324 77 2,444 $21,281 78 35,270 $22,207 79 166,273 $29,036 80 8,304 $15,356 81 2 $17,479 82 63,407 $25,645 83 6,390 $16,990 84 1,558 $8,753 85 21,262 $21,607 86 2,179 $12,312 87 59,447 $24,541 88 396,490 $15,658 89 502,217 $18,132 90 46,781 $10,653 91 57 $12,409 92 14,806 $21,600 93 1,710 $13,018 94 12,571 $20,639 95 1,679 $10,242 96 53,684 $13,018 97 28,583 $9,626 98 15 $16,431 99 21,274 $12,269 100 8,941 $9,245 101 21,119 $14,939 102 5,557 $9,489 103 428 $349,756 104 19,511 $130,539 105 27,278 $94,418 106 3,307 $121,657 107 85,660 $86,239 108 6,200 $95,309 109 59,511 $64,065 110 53,164 $71,438 111 9,392 $42,529 113 41,401 $49,111 114 8,849 $29,028 115 15,270 $58,727 116 109,194 $38,515 117 4,176 $23,091 118 8,104 $27,103 119 1,316 $22,646 120 37,306 $39,416 121 167,277 $27,051 122 81,670 $17,860 123 41,145 $28,071 124 138,236 $23,982 125 89,996 $18,048 126 5,015 $48,094 127 681,606 $17,412 128 8,240 $12,365 129 4,100 $19,186 130 88,663 $16,401 131 27,776 $9,821 132 152,256 $11,138 133 8,915 $9,314 134 39,612 $10,344 135 7,552 $15,416 136 1,237 $10,011 138 203,304 $14,336 139 89,960 $8,832 140 66,409 $9,140 141 102,377 $12,604 142 51,706 $9,672 143 250,001 $9,216 144 88,480 $21,330 145 7,594 $10,378 146 10,796 $45,993 147 2,797 $25,903 148 129,351 $59,354 149 19,315 $24,710 150 20,330 $49,351 151 4,962 $22,681 152 4,424 $33,239 153 2,013 $19,418 154 28,996 $73,715 155 7,260 $21,846 156 3 $32,596 157 8,151 $22,041 158 4,560 $10,941 159 17,109 $23,315 160 12,156 $13,554 161 11,153 $19,125 162 7,270 $10,677 163 3 $7,876 164 5,116 $39,084 165 2,184 $20,580 166 3,902 $24,579 167 3,799 $14,801 168 1,381 $22,419 169 869 $12,657 170 12,155 $49,736 171 1,359 $19,892 172 30,603 $24,475 173 2,709 $13,824 174 247,084 $17,229 175 35,141 $9,564 176 15,215 $18,581 177 9,422 $15,760 178 3,756 $11,718 179 12,540 $18,881 180 88,253 $16,534 181 27,085 $9,241 182 260,632 $13,956 183 91,215 $9,962 184 93 $8,646 185 5,069 $15,675 186 3 $17,560 187 666 $14,847 188 79,377 $19,332 189 13,104 $10,335 190 74 $12,681 191 9,220 $77,337 192 1,257 $30,601 193 4,862 $59,463 194 733 $27,612 195 4,151 $50,509 196 1,050 $26,194 197 18,557 $42,811 198 5,667 $20,952 199 1,644 $42,977 200 1,042 $53,497 201 2,013 $67,182 202 26,142 $23,012 203 29,301 $24,716 204 61,516 $20,412 205 24,447 $21,124 206 2,048 $12,455 207 32,101 $19,874 208 10,740 $11,426 209 370,349 $31,852 210 121,438 $29,326 211 32,517 $19,885 212 7 $11,988 213 9,875 $32,709 216 6,916 $38,905 217 17,022 $53,503 218 22,732 $25,771 219 20,855 $16,751 223 13,650 $17,145 224 12,431 $12,855 225 6,124 $19,539 226 5,698 $26,964 227 4,915 $13,522 228 2,481 $19,438 229 1,175 $11,756 230 2,406 $21,932 231 12,530 $24,031 232 880 $16,464 233 7,178 $34,665 234 4,607 $21,908 235 5,089 $13,039 236 39,744 $12,220 237 1,743 $9,880 238 8,617 $24,817 239 48,197 $17,565 240 11,800 $23,191 241 3,218 $11,428 242 2,515 $19,784 243 93,611 $12,959 244 13,570 $12,429 245 5,726 $8,349 246 1,346 $9,926 247 19,616 $10,001 248 12,060 $14,559 249 12,649 $11,805 250 3,793 $11,824 251 2,489 $8,063 253 20,842 $12,750 254 10,802 $7,656 256 6,400 $14,186 257 16,692 $14,784 258 16,950 $11,403 259 3,812 $15,230 260 5,072 $11,046 261 1,888 $16,770 262 686 $15,951 263 24,560 $37,753 264 3,982 $19,495 265 4,052 $27,077 266 2,676 $14,584 267 267 $15,879 268 899 $19,361 269 9,060 $29,801 270 2,746 $12,961 271 19,594 $18,154 272 5,470 $17,426 273 1,387 $10,047 274 2,343 $22,054 275 247 $10,261 276 1,326 $11,997 277 93,843 $14,927 278 31,720 $9,470 279 3 $19,964 280 17,038 $12,041 281 7,827 $8,003 283 5,635 $12,585 284 1,950 $7,589 285 6,568 $35,890 286 2,183 $35,565 287 6,457 $32,850 288 3,675 $36,854 289 6,414 $16,097 290 9,482 $14,860 291 78 $10,570 292 5,422 $44,164 293 345 $24,530 294 95,355 $13,252 295 3,358 $13,707 296 250,808 $14,775 297 47,716 $8,713 298 103 $10,114 299 1,218 $16,149 300 17,532 $19,436 301 3,639 $11,261 302 7,896 $54,753 303 20,698 $41,205 304 12,041 $40,662 305 3,006 $20,536 306 7,210 $21,938 307 2,164 $10,268 308 7,244 $28,300 309 4,331 $15,304 310 24,587 $19,325 311 8,309 $10,483 312 1,547 $18,439 313 644 $11,749 315 33,708 $36,795 316 115,275 $23,727 317 1,889 $12,419 318 5,736 $21,305 319 494 $11,322 320 193,134 $14,735 321 30,723 $9,566 322 64 $8,657 323 18,621 $14,311 324 7,451 $8,122 325 8,937 $11,466 326 2,802 $7,872 327 2 $10,679 328 685 $13,051 329 105 $8,650 331 49,123 $18,734 332 5,117 $10,727 333 311 $13,719 334 10,262 $24,961 335 12,370 $18,084 336 36,313 $14,365 337 29,498 $9,686 338 1,055 $21,430 339 1,505 $18,435 341 3,670 $21,442 342 723 $13,001 344 3,838 $22,438 345 1,335 $19,558 346 4,559 $18,995 347 373 $10,844 348 3,280 $12,862 349 597 $7,194 350 6,493 $12,462 352 768 $12,805 353 2,655 $31,864 354 7,485 $25,534 355 5,670 $14,447 356 25,920 $12,488 357 5,710 $39,602 358 20,605 $20,138 359 31,042 $13,346 360 15,575 $14,638 361 369 $18,778 362 2 $9,180 363 2,683 $15,573 364 1,629 $14,738 365 1,834 $34,245 366 4,432 $23,297 367 520 $10,108 368 3,285 $21,162 369 3,279 $10,693 370 1,242 $16,029 371 1,413 $10,589 372 919 $9,639 373 3,876 $6,330 374 116 $12,936 375 8 $21,289 376 262 $8,664 377 29 $24,590 378 169 $15,095 379 408 $6,916 380 76 $6,684 381 181 $10,112 382 25 $2,798 383 1,841 $9,336 384 149 $7,372 389 5 $11,692 392 2,246 $55,515 394 2,326 $31,257 395 100,607 $14,330 396 11 $12,749 397 17,906 $21,719 398 17,113 $22,322 399 1,788 $12,303 400 6,486 $47,400 401 5,836 $50,173 402 1,599 $19,649 403 31,999 $32,078 404 4,588 $15,824 406 2,494 $48,934 407 701 $21,576 408 2,122 $36,343 409 2,515 $21,666 410 30,760 $18,311 411 14 $7,688 412 18 $4,980 413 5,766 $24,842 414 763 $12,866 415 39,905 $66,206 416 181,072 $28,177 417 37 $21,802 418 23,398 $18,311 419 15,719 $15,131 420 2,957 $10,195 421 9,270 $11,869 422 69 $7,590 423 7,269 $31,897 424 1,292 $41,189 425 16,304 $11,890 426 4,481 $9,206 427 1,576 $9,291 428 744 $12,949 429 27,018 $14,174 430 63,051 $12,703 431 320 $10,737 432 411 $11,105 433 5,520 $4,883 439 1,457 $29,345 440 5,435 $32,696 441 612 $15,577 442 16,693 $42,597 443 3,807 $17,673 444 5,675 $13,003 445 2,724 $8,465 447 6,278 $8,499 449 30,470 $14,241 450 7,366 $7,229 451 5 $4,039 452 25,215 $18,340 453 5,643 $9,105 454 4,623 $14,423 455 1,096 $8,019 461 4,563 $21,124 462 11,981 $19,956 463 25,204 $12,097 464 7,101 $8,636 465 224 $10,305 466 1,795 $11,397 467 1,043 $9,854 468 54,705 $66,153 470 49 $302,446 471 12,391 $47,581 473 8,235 $63,556 475 104,025 $67,384 476 3,812 $40,882 477 25,600 $32,847 478 108,611 $42,010 479 24,176 $24,354 480 622 $176,423 481 726 $123,849 482 5,299 $61,539 483 43,282 $288,420 484 317 $100,224 485 3,028 $50,619 486 1,867 $85,814 487 3,533 $35,194 488 776 $88,052 489 13,548 $32,178 490 5,247 $18,195 491 13,575 $26,985 492 2,874 $74,770 493 58,081 $30,868 494 30,883 $16,784 495 211 $155,662 496 1,841 $98,777 497 19,917 $57,641 498 14,635 $41,713 499 32,659 $24,252 500 49,444 $15,562 501 2,352 $44,432 502 636 $25,677 503 5,888 $20,546 504 123 $281,048 505 147 $31,985 506 937 $84,055 507 288 $30,296 508 667 $24,629 509 177 $16,475 510 1,671 $20,337 511 616 $11,613 512 450 $95,226 513 142 $99,439 514 19,241 $104,112 515 4,568 $87,754 516 76,169 $45,006 517 190,940 $36,508 518 51,620 $30,281 519 7,216 $39,899 520 11,045 $25,111 521 28,562 $12,663 522 6,139 $10,035 523 14,802 $6,921 524 136,805 $12,350 525 492 $209,675 1 Cases are taken from the FY 2001 MedPAR file; DRGs are from GROUPER V20.0. Appendix A—Regulatory Impact Analysis I. Introduction We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act
(RFA)(September 19, 1980, Public Law 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandate Reform Act of 1995 (Public Law 104-4), and Executive Order 13132. Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety 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 total impact of these changes for FY 2003 payments compared to FY 2002 payments to be approximately a $0.3 billion increase. The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $5 million to $25 million in any 1 year. 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. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area
(MSA)or New England County Metropolitan Area (NECMA). Section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the hospital inpatient prospective payment systems, we classify these hospitals as urban hospitals. It is clear that the changes being proposed in this document would affect both a substantial number of small rural hospitals as well as other classes of hospitals, and the effects on some may be significant. Therefore, the discussion below, in combination with the rest of this proposed rule, constitutes a combined regulatory impact analysis and regulatory flexibility analysis. Section 202 of the Unfunded Mandate Reform Act of 1995 (Public Law 104-4) also requires that agencies assess anticipated costs and benefits before issuing any proposed rule (or a final rule that has been preceded by a proposed rule) that may result in an expenditure in any one year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. This proposed rule would not mandate any requirements for State, local, or tribal governments. 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. We have reviewed this proposed rule in light of Executive Order 13132 and have determined that it will not have any negative impact on the rights, roles, and responsibilities of State, local, or tribal governments. In accordance with the provisions of Executive Order 12866, this proposed rule was reviewed by the Office of Management and Budget. II. Objectives The primary objective of the acute care hospital inpatient prospective payment system 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 Trust Fund. We believe the proposed changes 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 2003, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but we do not attempt to predict behavioral responses to our policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. As we have done in previous proposed rules, we are soliciting comments and information about the anticipated effects of these changes on hospitals and our methodology for estimating them. IV. Hospitals Included In and Excluded From the Acute Care Hospital Inpatient Prospective Payment System The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general, short-term, acute care hospitals that participate in the Medicare program. There were 44 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment method for these hospitals. Among other short-term, acute care hospitals, only the 67 such hospitals in Maryland remain excluded from the hospital inpatient prospective payment system under the waiver at section 1814(b)(3) of the Act. There are approximately 515 critical access hospitals (CAHs). These small, limited service hospitals are paid on the basis of reasonable costs rather than under the acute care hospital inpatient prospective payment system. The remaining 20 percent are specialty hospitals that are excluded from the acute-care, short-term prospective payment system. These hospitals include psychiatric hospitals and units, rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals. The impacts of our final policy changes on these hospitals are discussed below. Thus, as of February 2002, we have included 4,301 hospitals in our analysis. This represents about 80 percent of all Medicare-participating hospitals. The majority of this impact analysis focuses on this set of hospitals. V. Impact on Excluded Hospitals and Hospital Units As of February 2002, there were 1,065 specialty hospitals excluded from the acute care hospital inpatient prospective payment system and instead paid on a reasonable cost basis subject to the rate-of-increase ceiling under § 413.40. Broken down by specialty, there were 493 psychiatric, 216 rehabilitation, 270 long-term care, 75 children's, and 11 cancer hospitals. In addition, there were 1,436 psychiatric units and 936 rehabilitation units in hospitals otherwise subject to the acute care hospital inpatient prospective payment system. Under § 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 67 specialty hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act. In the past, hospitals and units excluded from the acute care hospital inpatient prospective payment system 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 based on their reasonable costs are subject to TEFRA limits for FY 2003. For these hospitals, the proposed update is the percentage increase in the excluded hospital market basket (currently estimated at 3.4 percent). Inpatient rehabilitation facilities
(IRFs)are paid under the IRF prospective payment system for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2003, the IRF prospective payment is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually (see the August 7, 2001 final rule (66 FR 41316 through 41430)). Therefore, these hospitals are not impacted by this proposed rule. Effective for cost reporting periods beginning during FY 2003, we have proposed that long-term care hospitals would be paid under a long-term care hospital prospective payment system, where long-term care hospitals receive payment based on a 5-year transition period (see the March 22, 2002 proposed rule (67 FR 13416 through 13494)). However, under this proposed payment system, a long-term care hospital may also elect to be paid at 100 percent of the Federal prospective rate at the beginning of any of its cost reporting periods during the 5-year transition period. For purposes of the update factor, the portion of the proposed prospective payment system transition blend payment based on reasonable costs for inpatient operating services would be determined by updating the long-term care hospital's TEFRA limit by the proposed estimate of the excluded hospital market basket (or 3.4 percent). The impact on excluded hospitals and hospital units of the update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the rate-of-increase limits since their base period, the major effect will be 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 will be the amount of excess costs that would 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. At the same time, however, by generally limiting payment increases, we continue to provide an incentive for excluded hospitals and hospital units to restrain the growth in their spending for patient services. VI. Quantitative Impact Analysis of the Proposed Policy Changes Under the Hospital Inpatient Prospective Payment System for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing policy changes and payment rate updates for the hospital inpatient prospective payment systems for operating and capital-related costs. We estimate the total impact of these changes for FY 2003 payments compared to FY 2002 payments to be approximately a $0.3 billion increase. We have prepared separate impact analyses of the proposed changes to each system. This section deals with changes to the operating prospective payment system. The data used in developing the quantitative analyses presented below are taken from the FY 2001 MedPAR file and the most current provider-specific file that is used for payment purposes. Although the analyses of the changes to the operating prospective payment system do not incorporate cost data, the most recently available hospital cost report data were used to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to these proposed policy changes. Second, due to the interdependent nature of the hospital inpatient prospective payment system, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we draw upon 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. For individual hospitals, however, some miscategorizations are possible. Using cases in the FY 2001 MedPAR file, we simulated payments under the operating prospective payment system given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the short-term acute-care hospital inpatient prospective payment systems (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations. The impact of payments under the capital prospective payment system, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of proposed FY 2003 changes to the capital prospective payment system are discussed in section IX. of this Appendix. The proposed changes discussed separately below are the following: • The effects of the proposed change to the labor portion of the standardized amounts from 71.1 percent to 72.5 percent. • The effects of the proposed changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 1999, compared to the FY 1998 wage data, and the effects of removing from the wage data the costs and hours associated with graduate medical education
(GME)and certified registered nurse anesthetists (CRNAs). • The effects of the proposed annual reclassification of diagnoses and procedures and the recalibration of the diagnosis-related group
(DRG)relative weights required by section 1886(d)(4)(C) of the Act. • The effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB) that will be effective in FY 2003. • The total change in payments based on FY 2003 policies relative to payments based on FY 2002 policies. To illustrate the impacts of the FY 2003 proposed changes, our analysis begins with a FY 2003 baseline simulation model using: the FY 2002 DRG GROUPER (version 19.0); the FY 2002 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total DRG plus outlier payments. Each proposed and statutory policy change is then added incrementally to this baseline model, finally arriving at an FY 2003 model incorporating all of the changes. This allows us to isolate the effects of each change. Our final comparison illustrates the percent change in payments per case from FY 2002 to FY 2003. Six factors have significant impacts here. The first is the update to the standardized amounts. In accordance with section 1886(d)(3)(A)(iv) of the Act, as amended by section 301 of Public Law 106-554, we are proposing to update the large urban and the other areas average standardized amounts for FY 2003 using the most recently forecasted hospital market basket increase for FY 2003 of 3.3 percent minus 0.55 percentage points (for an update of 2.75 percent). Under section 1886(b)(3) of the Act, the updates to the hospital-specific amounts for sole community hospitals
(SCHs)and for Medicare-dependent small rural hospitals
(MDHs)is also equal to the market basket increase of 3.3 percent minus 0.55 percentage points (for an update of 2.75 percent). A second significant factor that impacts changes in hospitals' payments per case from FY 2002 to FY 2003 is the change in MGCRB status from one year to the next. That is, hospitals reclassified in FY 2002 that are no longer reclassified in FY 2003 may have a negative payment impact going from FY 2002 to FY 2003; conversely, hospitals not reclassified in FY 2002 that are reclassified in FY 2003 may have a positive impact. In some cases, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. This effect is alleviated, however, by section 304(a) of Public Law 106-554, which provided that reclassifications for purposes of the wage index are for a 3-year period. A third significant factor is that we currently estimate that actual outlier payments during FY 2002 will be 6.7 percent of total DRG payments. When the FY 2002 final rule was published, we projected FY 2002 outlier payments would be 5.1 percent of total DRG plus outlier payments; the standardized amounts were offset correspondingly. The effects of the higher than expected outlier payments during FY 2002 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2002 payments per case to estimated FY 2003 payments per case. Fourth, section 213 of Public Law 106-554 provided that all SCHs may receive payment on the basis of their costs per case during their cost reporting period that began during 1996. This option was to be phased in over 4 years. For FY 2003, the proportion of payments based on affected SCHs' FY 1996 hospital-specific amount increases from 50 percent to 75 percent. Fifth, under section 1886(d)(5)(B)(ii) of the Act, the formula for indirect medical education
(IME)is reduced beginning in FY 2003. The reduction is from approximately a 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio during FY 2002 to approximately a 5.5 percent increase. Sixth, the disproportionate share hospital
(DSH)adjustment increases in FY 2003 compared with FY 2002. In accordance with section 1886(d)(5)(F)(ix) of the Act, during FY 2002, DSH payments that the hospital would otherwise receive were reduced by 3 percent. This reduction is no longer applicable beginning with FY 2003. Table I demonstrates the results of our analysis. 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 4,301 hospitals included in the analysis. This number is 494 fewer hospitals than were included in the impact analysis in the FY 2002 final rule (66 FR 40087). Of this number, 437 are now CAHs and are excluded from our 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 2,613 hospitals located in urban areas (MSAs or NECMAs) included in our analysis. Among these, there are 1,511 hospitals located in large urban areas (populations over 1 million), and 1,102 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 1,688 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 2003 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 are 2,645, 1,570, 1,075, and 1,656, 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 3,195 nonteaching hospitals in our analysis, 872 teaching hospitals with fewer than 100 residents, and 234 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 after MGCRB reclassifications. Hospitals in the rural DSH categories, therefore, represent hospitals that were not reclassified for purposes of the standardized amount or for purposes of the DSH adjustment. (They may, however, have been reclassified for purposes of the wage index.) The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next five rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, rural referral centers (RRCs), and MDHs), as well as rural hospitals not receiving a special payment designation. The RRCs (159), SCHs (540), MDHs (216), and hospitals that are both SCH and RRC
(75)shown here were not reclassified for purposes of the standardized amount. There are 4 RRCs and 1 SCH and RRC that will be reclassified as urban for the standardized amount in FY 2003 and, therefore, are not included in these rows. The next two groupings are based on type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data are taken primarily from the FY 1999 Medicare cost report files, if available (otherwise FY 1998 data are used). Data needed to determine ownership status were unavailable for 213 hospitals. Similarly, the data needed to determine Medicare utilization were unavailable for 109 hospitals. The next series of groupings concern the geographic reclassification status of hospitals. The first grouping displays all hospitals that were reclassified by the MGCRB for FY 2003. The next two groupings separate the hospitals in the first group by urban and rural status. The final row in Table I contains hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act. Table I.—Impact Analysis of Changes for FY 2003 Operating Prospective Payment System [Percent changes in payments per case] Number of hosps. 1
(0)New labor share 2
(1)DRG changes. 3
(2)New wage data 4
(3)Remove GME & CRNA 80/20 5
(4)Remove GME & CRNA 100 percent 6
(5)DRG & WI changes 7
(6)MCGRB reclassification 8
(7)All FY 2003 changes 9
(8)By Geographic Location: All hospitals 4,301 0.0 −0.2 0.0 0.0 0.0 0.0 0.0 0.4 Urban hospitals 2,613 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.5 0.1 Large urban areas (populations over 1 million) 1,511 0.1 −0.2 −0.2 0.0 0.0 −0.2 −0.5 −0.3 Other urban areas (populations of 1 million of fewer) 1,102 −0.1 −0.1 0.1 0.0 0.0 0.3 −0.4 0.8 Rural hospitals 1,688 −0.2 −0.4 0.5 0.1 0.1 0.3 2.5 2.1 Bed Size (Urban): 0-99 beds 647 0.0 −0.2 0.0 0.1 0.1 0.3 −0.6 1.5 100-199 beds 904 0.0 −0.3 −0.1 0.0 0.1 0.0 −0.5 1.0 200-299 beds 528 0.0 −0.3 0.0 0.0 0.1 0.1 −0.4 0.5 300-499 beds 387 0.0 −0.1 −0.2 0.0 0.0 0.0 −0.4 0.1 500 or more beds 147 0.1 −0.2 −0.1 0.0 0.0 −0.1 −0.5 −1.1 Bed Size (Rural): 0-49 beds 819 −0.2 −0.6 0.6 0.1 0.1 0.2 0.5 2.6 50-99 beds 507 −0.2 −0.5 0.4 0.1 0.1 0.2 1.0 2.4 100-149 beds 216 −0.2 −0.4 0.6 0.1 0.1 0.5 2.9 2.0 150-199 beds 78 −0.2 −0.4 0.5 0.1 0.1 0.5 4.8 1.9 200 or more beds 68 −0.2 −0.3 0.4 0.1 0.1 0.4 4.1 1.4 Urban by Region: New England 134 0.2 −0.3 0.1 0.0 0.1 0.9 −0.2 0.0 Middle Atlantic 402 0.2 −0.1 −0.8 0.0 0.0 −0.8 −0.1 −1.8 South Atlantic 380 −0.1 −0.2 0.1 0.1 0.1 0.2 −0.5 0.9 East North Central 431 0.0 −0.2 0.1 0.0 0.0 0.2 −0.5 0.4 East South Central 158 −0.2 −0.2 0.2 0.0 0.0 0.1 −0.7 0.9 West North Central 180 −0.1 −0.3 0.5 0.1 0.1 0.6 −0.7 0.9 West South Central 334 −0.2 −0.2 −0.2 0.1 0.1 −0.1 −0.7 0.4 Mountain 132 0.0 0.0 −0.3 0.1 0.1 0.0 −0.6 0.6 Pacific 416 0.2 −0.4 0.0 0.1 0.1 0.1 −0.5 0.7 Puerto Rico 46 −0.7 −0.4 −0.8 0.0 0.0 −0.7 −0.8 0.0 Rural by Region: New England 40 0.0 −0.4 0.2 0.0 0.0 0.0 2.8 1.0 Middle Atlantic 68 −0.1 −0.4 −0.1 0.0 0.0 −0.3 2.5 1.6 South Atlantic 239 −0.2 −0.5 0.4 0.1 0.1 0.2 3.0 1.9 East North Central 225 −0.1 −0.3 0.4 0.1 0.1 0.4 2.1 2.5 East South Central 243 −0.3 −0.6 1.0 0.1 0.1 0.8 2.4 2.0 West North Central 311 −0.2 −0.4 0.8 0.0 0.0 0.7 1.5 2.4 West South Central 294 −0.3 −0.6 0.3 0.1 0.1 0.0 3.4 1.8 Mountain 151 −0.1 −0.4 0.2 0.0 0.0 0.1 1.6 2.0 Pacific 112 0.0 −0.4 0.8 0.1 0.1 0.6 2.3 2.7 Puerto Rico 5 −0.7 −0.5 −4.9 0.1 0.1 −5.0 −0.5 −2.8 By Payment Classification: Urban hospitals 2,645 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.4 0.2 Large urban areas (populations over 1 million) 1,570 0.1 −0.2 −0.2 0.0 0.0 −0.2 −0.4 −0.2 Other urban areas (populations of 1 million of fewer) 1,075 −0.1 −0.1 0.1 0.0 0.0 0.3 −0.4 0.8 Rural areas 1,656 −0.2 −0.5 0.5 0.1 0.1 0.3 2.4 2.1 Teaching Status: Non-teaching 3,195 −0.1 −0.4 0.2 0.1 0.1 0.2 0.3 1.5 Fewer than 100 Residents 872 0.0 −0.1 −0.1 0.0 0.0 0.0 −0.3 0.5 100 or more Residents 234 0.1 −0.2 −0.3 0.0 0.0 −0.3 −0.3 −1.7 Urban DSH: Non-DSH 1,565 0.0 −0.1 0.0 0.0 0.0 0.2 0.1 0.7 100 or more beds 1,354 0.0 −0.2 −0.2 0.0 0.0 −0.1 −0.5 0.0 Less than 100 beds 295 0.0 −0.4 0.1 0.1 0.1 0.1 −0.3 1.5 Rural DSH: Sole Community
(SCH)470 −0.1 −0.7 0.4 0.0 0.0 −0.1 0.1 2.3 Referral Center
(RRC)156 −0.2 −0.4 0.5 0.1 0.1 0.5 5.1 1.6 Other Rural: 100 or more beds 78 −0.3 −0.5 0.6 0.1 0.1 0.6 1.2 2.0 Less than 100 beds 383 −0.3 −0.6 0.7 0.1 0.1 0.5 0.8 2.5 Urban teaching and DSH: Both teaching and DSH 758 0.0 −0.2 −0.3 0.0 0.0 −0.2 −0.5 −0.6 Teaching and no DSH 278 0.0 0.0 0.0 0.0 0.0 0.2 −0.1 −0.1 No teaching and DSH 891 0.0 −0.4 0.1 0.1 0.1 0.2 −0.4 1.4 No teaching and no DSH 718 0.0 −0.2 0.0 0.0 0.1 0.2 −0.4 1.0 Rural Hospital Types: Non special status hospitals 666 −0.3 −0.5 0.7 0.1 0.1 0.6 1.2 2.3 RRC 159 −0.3 −0.3 0.6 0.1 0.1 0.6 6.0 1.2 SCH 540 −0.1 −0.6 0.2 0.0 0.0 −0.2 0.3 2.3 Medicare-dependent hospitals
(MDH)216 −0.2 −0.6 0.7 0.1 0.1 0.3 0.5 2.7 SCH and RRC 75 −0.1 −0.3 0.3 0.0 0.0 0.1 1.8 2.5 Type of Ownership: Voluntary 2,473 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.1 0.4 Proprietary 705 0.0 −0.2 −0.2 0.1 0.1 −0.1 −0.1 0.3 Government 910 −0.1 −0.5 0.3 0.1 0.1 0.2 0.2 0.8 Unknown 213 −0.1 −0.3 0.2 0.1 0.1 0.2 −0.4 0.6 Medicare Utilization as a Percent of Inpatient Days: 0-25 319 0.1 −0.4 −0.3 0.1 0.1 −0.4 −0.3 −0.7 25-50 1,650 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.3 0.0 50-65 1,706 −0.1 −0.2 0.1 0.0 0.0 0.2 0.3 1.1 Over 65 517 −0.1 −0.4 −0.1 0.0 0.0 −0.1 0.5 0.6 Unknown 109 0.2 0.1 −1.1 0.0 0.0 −0.8 −0.7 −0.4 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2003 Reclassifications: All Reclassified Hospitals 620 −0.1 −0.3 0.3 0.0 0.1 0.4 4.4 1.0 Standardized Amount Only 29 0.0 −0.4 0.6 0.1 0.1 0.6 0.3 1.6 Wage Index Only 527 −0.1 −0.3 0.3 0.0 0.1 0.3 4.5 0.8 Both 41 −0.2 −0.2 0.4 0.1 0.1 0.6 5.1 1.1 Nonreclassified Hospitals 3,666 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.7 0.3 All Reclassified Urban Hospitals 108 0.1 −0.1 0.1 0.0 0.0 0.4 4.0 −0.4 Standardized Amount Only 1 0.0 −0.1 0.4 −0.1 −0.1 0.4 −0.9 1.6 Wage Index Only 95 0.1 −0.1 0.1 0.0 0.0 0.4 4.1 0.6 Both 12 −0.1 −0.2 0.6 0.1 0.1 0.9 2.9 4.1 Urban Nonreclassified Hospitals 2,471 0.0 −0.2 −0.1 0.0 0.0 0.0 −0.7 0.2 All Reclassified Rural Hospitals 512 −0.2 −0.4 0.4 0.1 0.1 0.4 4.6 1.8 Standardized Amount Only 1 −0.4 0.1 0.1 0.1 0.1 0.6 0.9 3.7 Wage Index Only 502 −0.2 −0.4 0.5 0.1 0.1 0.4 4.6 1.8 Both 9 −0.2 −0.2 0.2 0.1 0.1 0.2 4.7 0.7 Rural Nonreclassified Hospitals 1,175 −0.2 −0.6 0.5 0.1 0.1 0.3 −0.4 2.4 Other Reclassified Hospitals (Section 1886(D)(8)(B)) 35 −0.1 −0.6 −0.1 0.0 0.0 −0.5 −1.4 2.8 1 Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 2001, and hospital cost report data are from reporting periods beginning in FY 1999 and FY 1998. 2 This column displays impact of the proposed change to the labor share from 71.1 percent to 72.5 percent. 3 This column displays the payment impact of the recalibration of the DRG weights based on FY 2001 MedPAR data and the DRG reclassification changes, in accordance with section 1886(d)(4)(C) of the Act. 4 This column displays the impact of updating the wage index with wage data from hospitals' FY 1999 cost reports. 5 This column displays the impact of an 80/20 percent blend of removing the labor costs and hours associated with graduate medical education and for the Part A costs of certified registered nurse anesthetists. 6 This column displays the impact of completely removing the labor costs and hours associated with graduate medical education
(GME)and for the Part A costs of certified registered nurse anesthetists (CRNAs). 7 This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate the wage index, the phase-out of GME and CRNA costs and hours, and the budget neutrality adjustment factor for DRG and wage index changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in columns 2, 3, 4 and 5, and the FY 2003 budget neutrality factor of 1.001026. 8 Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2003 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2003. Reclassification for prior years has no bearing on the payment impacts shown here. 9 This column shows changes in payments from FY 2002 to FY 2003. It incorporates all of the changes displayed in columns 1, 6 and 7 (the changes displayed in columns 2, 3, 4, and 5 are included in column 6). It also displays the impact of the FY 2003 update, changes in hospitals' reclassification status in FY 2003 compared to FY 2002, and the difference in outlier payments from FY 2002 to FY 2003. It also reflects the gradual phase-in for some SCHs of the full 1996 hospital-specific rate. Finally, the impacts of the reduction in IME adjustment payments, and the increase in the DSH adjustment are shown in this column. The sum of these impacts may be different from the percentage changes shown here due to rounding and interactive effect. B. Impact of the Proposed Changes to the Labor Share (Column 1) In Column 1 of Table 1, we present the effects of our proposal to update the labor share from 71.10 percent to 72.49 percent. We estimate the impact of this change by calculating payments using payment rates updated to FY 2003, but using the FY 2002 DRG GROUPER and wage index. The change in this column represents the impact upon various hospital categories of the proposed change to the labor share. This proposed change negatively impacts hospitals with wage indexes less than 1.0, and positively affects those with wage indexes greater than 1.0. This proposed change has no impact on overall hospital payments. However, there are redistributive impacts generally in the range of plus or minus 0.1 percent or 0.2 percent. The net redistributive impact from those positively and negatively affected is approximately $65 million. Hospitals in large urban areas would experience an increase of 0.1 percent. Hospitals in both “other” urban and rural areas would experience −0.1 and −0.2 percent decreases, respectively. Under the urban by region category, New England, Middle Atlantic and Pacific regions would experience a 0.2 percent increase. The urban East South Central and West South Central regions would experience −0.2 percent decreases. Puerto Rico has a projected decrease of −0.7 percent, due to the low wage indexes in the Puerto Rico MSAs. All rural regions would experience a negative percent decrease except New England and Pacific regions (at 0.0 percent change). The South Atlantic and West North Central regions would experience a decrease of −0.2 percent. The East South Central and West South Central regions each would experience a −0.3 percent decrease, while Puerto Rico would experience a −0.7 percent decrease. Rural nonspecial status hospitals and RRCs would decline by −0.3. SCH and MDHs also would experience decreases of −0.1 and −0.2 percent, respectively. The relatively smaller negative impact for these hospitals is due to the fact that the hospital-specific rate is not adjusted by the wage index. Therefore, this proposed change would have no effect on hospitals paid on that basis (other than SCHs receiving a blended of their FY 1996 hospital-specific rate and the Federal rate). C. Impact of the Proposed Changes to the DRG Reclassifications and Recalibration of Relative Weights (Column 3) In column 3 of Table I, we present the combined effects of the DRG reclassifications and recalibration, as discussed in section II. of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act requires us to annually make appropriate classification changes and to recalibrate the DRG weights in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. We compared aggregate payments using the FY 2002 DRG relative weights (GROUPER version 19.0) to aggregate payments using the proposed FY 2003 DRG relative weights (GROUPER version 20.0). Overall payments decrease −0.2 percent due to the DRG reclassification and recalibration. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we have applied a budget neutrality factor to ensure that the overall payment impact of the DRG changes (combined with the wage index changes) is budget neutral. This budget neutrality factor of 1.001026 is applied to payments in Column 6. Because this is a combined DRG reclassification and recalibration and wage index budget neutrality factor, it is not applied to payments in this column. The DRG changes we are proposing would result in 0.2 percent lower payments to hospitals overall. This is the reason the budget neutrality factor is greater than 1.0. This change is largely related to the proposed changes we are making to DRGs 14 (proposed to be retitled, Intracranial Hemorrhage and Stroke with Infarction) and 15 (proposed to be retitled, Nonspecific Cerebrovascular and Precerebral Occlusion without Infarction), and new DRG 524 (Transient Ischemia). With the new configuration of these DRGs, over 80,000 cases that previously would have been assigned to DRG 14 (with a FY 2003 proposed relative weight of 1.2742) would now be assigned to DRG 15 (with a FY 2003 proposed relative weight of 0.9844). This change is evident most dramatically in small and rural hospitals. Rural hospitals with fewer than 50 beds would experience a 0.6 percent decrease, and rural hospitals with between 50 and 99 beds would experience a 0.5 percent decrease. Among rural hospitals categorized by region, the East South Central and West South Central would experience a 0.6 percent decrease in payments. Among special rural hospital categories, SCHs and MDHs both would experience 0.6 percent decreases. D. Impact of Wage Index Changes (Columns 3, 4, and 5) Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the proposed wage index for FY 2003 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 1998 and before October 1, 1999. As with column 2, the impact of the new data on hospital payments is isolated in columns 3, 4 and 5 by holding the other payment parameters constant in the three simulations. That is, columns 3, 4, and 5 show the percentage changes in payments when going from a model using the FY 2002 wage index (based on FY 1997 wage data before geographic reclassifications to a model using the FY 2003 pre- reclassification wage index based on FY 1998 wage data). The wage data collected on the FY 1999 cost reports are similar to the data used in the calculation of the FY 2002 wage index. Also, as described in section III.B of this preamble, the proposed FY 2003 wage index is calculated by removing 100 percent of hospitals' GME and CRNA costs (and hours). The FY 2002 wage index was calculated by blending 60 percent of hospitals' average hourly wages, excluding GME and CRNA data, with 40 percent of average hourly wages including these data. Column 3 shows the impacts of updating the wage data using FY 1999 cost reports. This column maintains the same 60/40 phase-out of GME and CRNA costs as the FY 2002 wage index, which is the baseline for comparison. Among regions, the largest impact of updating the wage data is seen in rural Puerto Rico (a 4.9 percent decrease). Rural hospitals in the East South Central region experience the next largest impact, a 1.0 percent increase. This is primarily due to a 6 percent increase in the rural Alabama wage index, and a little under a 3 percent increase in the rural Mississippi wage index. Among urban hospitals, the Middle Atlantic region would experience a 0.8 percent decrease, largely due to a 2.4 percent decrease in the New York City wage index and a 2.3 percent decrease in the Philadelphia wage index. The next two columns show the impacts of removing the GME and CRNA data from the wage index calculation. Under the 5-year phaseout of these data, FY 2003 would be the fourth year of the phaseout. This means that, under the phaseout, the FY 2003 wage index would be calculated with 20 percent of the GME and CRNA data included and 80 percent with these data removed, and FY 2004 would begin the calculation with 100 percent of these data removed. However, we are proposing to remove 100 percent of GME and CRNA costs from the FY 2003 wage index. To demonstrate the impacts of this proposal, we first show the impacts of moving to a wage index with 80 percent of these data removed (Column 4), then show a wage index with 100 percent of these data removed (Column 5). As expected, the impacts in the two columns are similar, with some differences due to rounding. Generally, no group of hospitals is impacted by more than 0.1 percent by this change. Even among the hospital group most likely to be negatively impacted by this change, teaching hospitals with 100 or more residents, the net effect of removing 100 percent of GME and CRNA data is 0.0 percent change in payments. We note that the wage data used for the proposed wage index are based upon the data available as of February 22, 2001 and, therefore, do not reflect revision requests received and processed by the fiscal intermediaries after that date. To the extent these requests are granted by hospitals' fiscal intermediaries, these revisions will be reflected in the final rule. In addition, we continue to verify the accuracy of the data for hospitals with extraordinary changes in their data from the prior year. The following chart compares the shifts in wage index values for labor market areas for FY 2002 relative to FY 2003. This chart demonstrates the impact of the proposed changes for the FY 2003 wage index, including updating to FY 1999 wage data and removing 100 percent of GME and CRNA data. The majority of labor market areas
(324)experience less than a 5 percent change. A total of 19 labor market areas experience an increase of more than 5 percent and less than 10 percent. One area experiences an increase greater than 10 percent. A total of 26 areas experience decreases of more than 5 percent and less than 10 percent. Finally, 2 areas experience declines of 10 percent or more. Percentage change in area wage index values Number of labor market areas FY 2002 FY 2003 Increase more than 10 percent 2 1 Increase more than 5 percent and less than 10 percent 26 19 Increase or decrease less than 5 percent 335 320 Decrease more than 5 percent and less than 10 percent 10 26 Decrease more than 10 percent 1 2 Among urban hospitals, 24 would experience an increase of between 5 and 10 percent and 2 more than 10 percent. A total of 53 rural hospitals have increases greater than 5 percent, but none greater than 10 percent. On the negative side, 75 urban hospitals have decreases in their wage index values of at least 5 percent but less than 10 percent. Six urban hospitals have decreases in their wage index values greater than 10 percent. There are 19 rural hospitals with decreases in their wage index values greater than 5 percent or with increases of more than 10 percent. 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 2 0 Increase more than 5 percent and less than 10 percent 24 53 Increase or decrease less than 5 percent 2506 1616 Decrease more than 5 percent and less than 10 percent 75 19 Decrease more than 10 percent 6 0 E. Combined Impact of DRG and Wage Index Changes—Including Budget Neutrality Adjustment (Column 6) The impact of DRG reclassifications and recalibration on aggregate payments is required by section 1886(d)(4)(C)(iii) of the Act to be budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this proposed rule, we compared simulated aggregate payments using the FY 2002 DRG relative weights and wage index to simulated aggregate payments using the proposed FY 2003 DRG relative weights and blended wage index. Based on this comparison, we computed a wage and recalibration budget neutrality factor of 1.001026. In Table I, the combined overall impacts of the effects of both the DRG reclassifications and recalibration and the updated wage index are shown in column 6. The 0.0 percent impact for all hospitals demonstrates that these changes, in combination with the budget neutrality factor, are budget neutral. For the most part, the changes in this column are the sum of the changes in columns 2, 3, 4, and 5, plus approximately 0.1 percent attributable to the budget neutrality factor. In addition, section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State. This provision is required to be budget neutral. The impact of this provision, which is to increase overall payments by 0.1 percent, is not shown in columns 2, 3, 4, and 5. It is included in the impacts shown in column 6. There also may be some variation of plus or minus 0.1 percent due to rounding. F. Impact of MGCRB Reclassifications (Column 7) 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 bases other than where they are geographically located, such as hospitals in rural counties that are deemed urban under section 1886(d)(8)(B) of the Act). The changes in column 6 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2003. These decisions affect hospitals' standardized amount and 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 standardized amount, wage index value, or both. The proposed FY 2003 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2003. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process for MGCRB decisions as of February 28, 2002. Additional changes that result from the Administrator's review of MGCRB decisions or a request by a hospital to withdraw its application will be reflected in the final rule for FY 2003. The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we applied an adjustment of 0.990536 to ensure that the effects of reclassification are budget neutral. (See section II.A.4.b. of the Addendum to this proposed rule.) As a group, rural hospitals benefit from geographic reclassification. Their payments rise 2.5 percent in column 6. Payments to urban hospitals decline 0.5 percent. Hospitals in other urban areas see a decrease in payments of 0.5 percent, while large urban hospitals lose 0.5 percent. Among urban hospital groups (that is, bed size, census division, and special payment status), payments generally decline. A positive impact is evident among most of the rural hospital groups. The smallest increases among the rural census divisions are 1.5 and 1.6 percent for West North Central and Mountain regions, respectively. The largest increases are in rural South Atlantic and West South Central regions. These regions receive increases of 3.0 and 3.4 percent, respectively. Among all the hospitals that were reclassified for FY 2003 (including hospitals that received wage index reclassification in a FY 2001 or FY 2002 that extend for 3-years), the MGCRB changes are estimated to provide a 4.4 percent increase in payments. Urban hospitals reclassified for FY 2003 are expected to receive an increase of 4.0 percent, while rural reclassified hospitals are expected to benefit from the MGCRB changes with a 4.6 percent increase in payments. Overall, among hospitals that were reclassified for purposes of the standardized amount only, a payment increase of 0.3 percent is expected, while those reclassified for purposes of the wage index only show a 4.5 percent increase in payments. Payments to urban and rural hospitals that did not reclassify are expected to decrease slightly due to the MGCRB changes, decreasing by 0.7 for urban hospitals and 0.4 for rural hospitals. Those hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act are expected to receive a decrease in payments of 1.4 percent. The foregoing analysis was based on MGCRB and CMS Administrator decisions made by February 28, 2002. As previously noted, there may be changes to some MGCRB decisions through the appeals, review, and applicant withdrawal process. The outcome of these cases will be reflected in the analysis presented in the final rule. G. All Changes (Column 8) Column 8 compares our estimate of payments per case, incorporating all changes reflected in this proposed rule for FY 2003 (including statutory changes), to our estimate of payments per case in FY 2002. This column includes all of the policy changes to date, including the proposed new labor share shown in column 1, and the combined DRG and wage index changes from column 6. Because the reclassifications shown in column 7 do not reflect FY 2002 reclassifications, the impacts of FY 2003 reclassifications only affect the impacts from FY 2002 to FY 2003 if the reclassification impacts for any group of hospitals are different in FY 2003 compared to FY 2002. It includes the effects of the 2.75 percent update to the standardized amounts and the hospital-specific rates for MDHs and SCHs. It also reflects the 1.7 percentage point difference between the projected outlier payments in FY 2002 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2002 (6.8 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. Section 213 of Public Law 106-554 provided that all SCHs may receive payment on the basis of their costs per case during their cost reporting period that began during 1996. For FY 2003, eligible SCHs that rebase receive a hospital-specific rate comprised of 25 percent of the higher of their FY 1982 or FY 1987 hospital-specific rate or their Federal rate, and 75 percent of their 1996 hospital-specific rate. The impact of this provision is modeled in column 8 as well. Under section 1886(d)(5)(B)(ii) of the Act, the formula for IME is reduced beginning in FY 2003. The reduction is from approximately a 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio during FY 2002 to approximately a 5.5 percent increase. We estimate the impact of this change to be a 0.9 percent reduction in hospitals' overall FY 2003 payments. The impact upon teaching hospitals would be larger. Finally, the DSH adjustment increases in FY 2003 compared with FY 2002. In accordance with section 1886(d)(5)(F)(ix) of the Act, during FY 2002, DSH payments that the hospital would otherwise receive were reduced by 3 percent. This reduction is no longer applicable beginning with FY 2003. The estimated impact of this change is to increase overall hospital payments by 0.2 percent. There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in column 8 may not equal the sum of the changes in columns 6 and 7, plus the other impacts that we are able to identify. The overall change in payments per case for hospitals in FY 2003 increases by 0.4 percent. This reflects the update of 2.75 percent, the 1.7 percent higher outlier payments in FY 2002 than projected for FY 2003, a 0.9 percent reduction in payments for IME, and a 0.2 percent increase in payments due to higher DSH payments in FY 2003. Hospitals in urban areas experience a 0.1 percent increase in payments per case compared to FY 2002, although hospitals in large urban areas experience a 0.3 percent decline in payments, largely due to reduction in IME payments. The impact of the reduction in IME payments is most evident among teaching hospitals with 100 or more residents, who would experience a decrease in payments per case of 1.7 percent. Hospitals in rural areas, meanwhile, experience a 2.1 percent payment increase. Among urban census divisions, the largest payment increase was 0.9 percent in South Atlantic, East South Central, and West North Central. Hospitals in urban Middle Atlantic would experience an overall decrease of 1.8 percent. This is primarily due to the combination of the negative impact on these hospitals of reducing IME and the lower outlier payments during FY 2003. The rural census division experiencing the smallest increase in payments were New England and the Middle Atlantic regions (1.0 and 1.6 percent, respectively). The only decreases by rural hospitals are in Puerto Rico, where payments appear to decrease by 2.8 percent, largely due to the updated wage data. In the Pacific, payments appear to increase by 2.7 percent. Rural East and West North Central regions also benefited, with 2.5 and 2.4 percent increases, respectively. Among special categories of rural hospitals, those hospitals receiving payment under the hospital-specific methodology (SCHs, MDHs, and SCH/RRCs) experience payment increases of 2.3 percent, 2.7 percent, and 2.5 percent, respectively. This outcome is primarily related to the fact that, for hospitals receiving payments under the hospital-specific methodology, there are no outlier payments. Therefore, these hospitals do not experience negative payment impacts from the decline in outlier payments from FY 2002 to FY 2003 (from 6.8 percent of total DRG plus outlier payments to 5.1 percent) as do hospitals paid based on the national standardized amounts. Among hospitals that were reclassified for FY 2003, hospitals overall are estimated to receive a 1.0 percent increase in payments. Urban hospitals reclassified for FY 2003 are anticipated to receive a decrease of −0.4 percent, while rural reclassified hospitals are expected to benefit from reclassification with a 1.8 percent increase in payments. Overall, among hospitals reclassified for purposes of the standardized amount, a payment increase of 1.6 percent is expected, while those hospitals reclassified for purposes of the wage index only show an expected 0.8 percent increase in payments. Those hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act are expected to receive an increase in payments of 2.8 percent. Table II.—Impact Analysis of Changes for FY 2003 Operating Prospective Payment System [Payments per Case] Number of hosps.
(1)Average FY 2002 payment per case 1
(2)Average FY 2003 payment per case 1
(3)All FY 2003 changes
(4)By Geographic Location: All hospitals 4,301 7,194 7,224 0.4 Urban hospitals 2,613 7,707 7,718 0.1 Large urban areas (populations over 1 million) 1,511 8,269 8,245 -0.3 Other urban areas (populations of 1 million of fewer) 1,102 6,977 7,034 0.8 Rural hospitals 1,688 5,108 5,213 2.1 Bed Size (Urban): 0-99 beds 647 5,299 5,380 1.5 100-199 beds 904 6,436 6,498 1.0 200-299 beds 528 7,391 7,425 0.5 300-499 beds 387 8,276 8,280 0.1 500 or more beds 147 10,046 9,932 -1.1 Bed Size (Rural): 0-49 beds 819 4,204 4,313 2.6 50-99 beds 507 4,754 4,866 2.4 100-149 beds 216 5,052 5,154 2.0 150-199 beds 78 5,494 5,600 1.9 200 or more beds 68 6,651 6,742 1.4 Urban by Region: New England 134 8,228 8,225 0.0 Middle Atlantic 402 8,832 8,675 -1.8 South Atlantic 380 7,287 7,353 0.9 East North Central 431 7,269 7,296 0.4 East South Central 158 6,919 6,984 0.9 West North Central 180 7,330 7,399 0.9 West South Central 334 7,089 7,121 0.4 Mountain 132 7,505 7,553 0.6 Pacific 416 9,319 9,383 0.7 Puerto Rico 46 3,310 3,311 0.0 Rural by Region: New England 40 6,227 6,290 1.0 Middle Atlantic 68 5,345 5,430 1.6 South Atlantic 239 5,221 5,319 1.9 East North Central 225 5,059 5,185 2.5 East South Central 243 4,723 4,819 2.0 West North Central 311 5,093 5,214 2.4 West South Central 294 4,547 4,627 1.8 Mountain 151 5,424 5,531 2.0 Pacific 112 6,592 6,772 2.7 Puerto Rico 5 2,754 2,677 -2.8 By Payment Classification: Urban hospitals 2,645 7,691 7,703 0.2 Large urban areas (populations over 1 million) 1,570 8,194 8,175 -0.2 Other urban areas (populations of 1 million of fewer) 1,075 7,003 7,057 0.8 Rural areas 1,656 5,094 5,199 2.1 Teaching Status: Non-teaching 3,195 5,866 5,952 1.5 Fewer than 100 Residents 872 7,479 7,515 0.5 100 or more Residents 234 11,431 11,239 -1.7 Urban DSH: Non-DSH 1,565 6,538 6,581 0.7 100 or more beds 1,354 8,299 8,299 0.0 Less than 100 beds 295 5,235 5,312 1.5 Rural DSH: 470 4,938 5,053 2.3 Sole Community
(SCH)Referral Center
(RRC)156 5,906 6,001 1.6 Other Rural: 100 or more beds 78 4,509 4,598 2.0 Less than 100 beds 383 4,076 4,179 2.5 Urban teaching and DSH: Both teaching and DSH 758 9,185 9,134 -0.6 Teaching and no DSH 278 7,724 7,717 -0.1 No teaching and DSH 891 6,510 6,600 1.4 No teaching and no DSH 718 6,066 6,124 1.0 Rural Hospital Types: Non special status hospitals 666 4,247 4,345 2.3 RRC 159 5,667 5,737 1.2 SCH 540 5,223 5,344 2.3 Medicare-dependent hospitals
(MDH)216 4,032 4,142 2.7 SCH and RRC 75 6,429 6,589 2.5 Type of Ownership: Voluntary 2,473 7,322 7,349 0.4 Proprietary 705 6,907 6,929 0.3 Government 910 6,764 6,815 0.8 Unknown 213 7,281 7,326 0.6 Medicare Utilization as a Percent of Inpatient Days: 0-25 319 9,820 9,755 -0.7 25-50 1,650 8,252 8,252 0.0 50-65 1,706 6,225 6,293 1.1 Over 65 517 5,645 5,679 0.6 Unknown 109 8,871 8,832 -0.4 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2002 Reclassifications: All Reclassified Hospitals 620 6,513 6,579 1.0 Standardized Amount Only 29 5,918 6,016 1.6 Wage Index Only 527 6,678 6,728 0.8 Both 41 5,874 5,936 1.1 All Nonreclassified Hospitals 3,666 7,310 7,335 0.3 All Urban Reclassified Hospitals 108 8,752 8,720 -0.4 Urban Nonreclassified Hospitals 1 5,484 5,569 1.6 Standardized Amount Only 95 9,003 8,951 -0.6 Wage Index Only 12 5,680 5,911 4.1 Both 2,471 7,672 7,685 0.2 All Reclassified Rural Hospitals 512 5,666 5,768 1.8 Standardized Amount Only 1 5,408 5,605 3.7 Wage Index Only 502 5,650 5,754 1.8 Both 9 6,370 6,415 0.7 Rural Nonreclassified Hospitals 1,175 4,478 4,585 2.4 Other Reclassified Hospitals (Section 1886(D)(8)(B)) 35 4,892 5,031 2.8 1 These payment amounts per case do not reflect any estimates of annual case-mix increase. Table II presents the projected impact of the proposed changes for FY 2003 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 2002 with the average estimated per case payments for FY 2003, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the changes presented in Table I. The percentage changes shown in the last column of Table II equal the percentage changes in average payments from column 8 of Table I. VII. Impact of Specific Proposed Policy Changes A. Impact of Proposed Policy Changes Relating to Hospital Bed Counts As discussed in section V.E.3. of the preamble of this proposed rule, we are proposing that if a hospital's reported bed count results in an occupancy rate below 35 percent, the applicable bed count for that hospital would be the number of beds that would result in an occupancy rate of 35 percent. We have calculated an estimated impact on the Medicare program for FY 2003 as a result of this policy. We first identified urban hospitals receiving DSH with bed counts above 100, but with occupancy rates below 35 percent. Then, we determined the amount of DSH payments made to these hospitals in FY 1999. Next, we simulated what these hospitals' DSH payments would have been had their bed counts been less than 100. We compared the difference between actual DSH payments using 100 or more beds to simulated DSH payments using fewer than 100 beds, and determined that the reductions in DSH payments to these hospitals, inflated to FY 2003 using the update to the average standardized amount, would be approximately $38.9 million. B. Impact of Proposed Changes Relating to EMTALA Provisions In section V.J. of the preamble to this proposed rule, we discuss our proposed changes to our policies relating to the responsibilities of Medicare-participating hospitals under the patient antidumping statute (EMTALA) to medically screen all patients seeking emergency services and provide stabilizing medical treatment as necessary to patients whose conditions warrant it. In summary, to help promote consistent application of our regulations concerning EMTALA, we are proposing to clarify certain policies in areas where issues have arisen and at the same time address concerns about EMTALA raised by the Secretary's Regulatory Reform Task Force, including the following: • We are proposing to change the requirements relating to emergency patients presenting at those off-campus outpatient clinics that do not routinely provide emergency services. We believe these changes would enhance the quality and promptness of emergency care by permitting individuals to be referred to appropriately equipped emergency facilities close to such clinics. • We are proposing to clarify when EMTALA applies to both inpatients and outpatients. We believe these clarifications would enhance overall patient access to emergency services by helping to relieve administrative burdens on frequently overcrowded emergency departments. • We are proposing to clarify the circumstances in which physicians, particularly specialty physicians, must serve on hospital medical staff “on-call” lists. We expect these clarifications would help improve access to physician services for all hospital patients by permitting hospitals local flexibility to determine how best to maximize their available physician resources. We are currently aware of reports of physicians, particularly specialty physicians, severing their relationships with hospitals, especially when those physicians belong to more than one hospital medical staff. Physician attrition from these medical staffs could result in hospitals having no specialty physician service coverage for their patients. Our proposed clarification of the on-call list requirement would permit hospitals to continue to attract physicians to serve on their medical staffs and thereby continue to provide services to emergency room patients. • We are proposing to clarify the responsibilities of hospital-owned ambulances so that these ambulances can be more fully integrated with citywide and local community EMS procedures for responding to medical emergencies and thus use these resources more efficiently for the benefit of these communities. We believe it would be difficult to quantify the impact of these changes and are soliciting comments on these issues. C. Impact of Proposed Policy Changes Relating to Provider-Based Entity In section V.K. of the preamble of this proposed rule, we discuss our proposed Medicare payment policy changes relating to determinations of provider-based status for entities of main providers. These changes are intended to focus mainly on issues raised by the hospital industry surrounding the provider-based regulations and to allow for a orderly and uniform implementation strategy once the grandfathering provision for these entities expires on September 30, 2002. We believe it would be difficult to quantify the impact of these changes and are soliciting comments on these issues. VIII. Impact of Proposed Policies Affecting Rural Hospitals A. Raising the Threshold To Qualify for the CRNA Pass-Through Payments In section V. of the preamble of this proposed rule, we are proposing to raise the maximum number of surgical procedures (including inpatient and outpatient procedures) requiring anesthesia services that a rural hospital may perform to qualify for pass-through payments for the costs of CRNAs to 800 from 500. Currently, we have identified 622 hospitals that qualify under this provision. To measure the impact of this provision, we determined that approximately half of the hospitals that would appear to be eligible based on the current number of procedures appear to receive this adjustment. In order to be eligible, hospitals must employ the CRNA and the CRNA must agree not to bill for services under Part B. We estimate approximately 90 rural hospitals would qualify under the increased maximum volume threshold. If one-half of these hospitals then met the other criteria, 45 additional hospitals would be eligible for these pass-through payments under this proposed change. B. Removal of Requirement for CAHs To Use State Resident Assessment Instrument In section VII. of the preamble of this proposed rule, we are proposing to eliminate the requirement that CAHs use the State resident assessment instrument
(RAI)to conduct patient assessments. There are approximately 600 CAHs. The overwhelming majority of CAHs, 95 percent, provide SNF level care. The elimination of the requirement to use the State RAI would greatly reduce the burden on CAHs because facilities would no longer be required to complete an RAI document for each SNF patient (which would involve approximately 12,000 admissions based on the most recent claims data). Facilities would have the flexibility to document the assessment data in the medical record in a manner appropriate for their facility. The elimination of the requirement for use of the State RAI would reduce the amount of time required to perform patient assessments and allow more time for direct patient care. IX. Impact of Proposed Changes in the Capital Prospective Payment System A. General Considerations Fiscal year 2001 was the last year of the 10-year transition period established to phase in the prospective payment system 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 Federal rate and their hospital-specific rate (see § 412.340). Under the hold-harmless methodology, unless a hospital elected payment based on 100 percent of the 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 Federal rate (see § 412.344). As we state in section VI.A. of the preamble of this proposed rule, the end of the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), capital prospective payment system payments for most hospitals are based solely on the Federal rate in FY 2003. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis. In accordance with section § 412.312, the basic methodology for determining a capital prospective payment system payment is: (Standard Federal Rate) × (DRG weight) × (Geographic Adjustment Factor(GAF)) × (Large Urban Add-on, if applicable) × (COLA adjustment for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share
(DSH)Adjustment Factor + Indirect Medical Education
(IME)Adjustment Factor, if applicable). In addition, hospitals may also receive outlier payments for those cases that qualify under the proposed threshold established for each fiscal year. The data used in developing the impact analysis presented below are taken from the December 2001 update of the FY 2001 MedPAR file and the December 2001 update of the Provider Specific File that is used for payment purposes. Although the analyses of the changes to the capital prospective payment system do not incorporate cost data, we used the December 2001 update of the most recently available hospital cost report data (FY 1999) to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to policy changes. Second, due to the interdependent nature of the prospective payment system, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases (for instance, the number of beds), there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available sources overall. However, for individual hospitals, some miscategorizations are possible. Using cases from the December 2001 update of the FY 2001 MedPAR file, we simulated payments under the capital prospective payment system for FY 2002 and FY 2003 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general hospital inpatient prospective payment systems (Indian Health Service Hospitals and hospitals in Maryland) are excluded from the simulations. As we explain in section III.A.4. of the Addendum of this proposed rule, payments will no longer be made under the regular exceptions provision under §§ 412.348(b) through (e). Therefore, we are no longer using the actuarial capital cost model (described in Appendix B of August 1, 2001 final rule (66 FR 40099)). We modeled payments for each hospital by multiplying the Federal rate by the GAF and the hospital's case-mix. We then added estimated payments for indirect medical education, disproportionate share, large urban add-on, and outliers, if applicable. For purposes of this impact analysis, the model includes the following assumptions: • We estimate that the Medicare case-mix index will increase by 0.99800 percent in FY 2002 and will increase by 1.01505 percent in FY 2003. • We estimate that the Medicare discharges will be 13,398,000 in FY 2002 and 13,658,000 in FY 2003 for a 1.9 percent increase from FY 2002 to FY 2003. • The Federal capital rate was updated beginning in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. The proposed FY 2003 update is 1.1 percent (see section III.A.1.a. of the Addendum to this proposed rule). • In addition to the proposed FY 2003 update factor, the proposed FY 2003 Federal rate was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0224, a proposed outlier adjustment factor of 0.9460, a proposed exceptions adjustment factor of 0.9960, and a proposed special adjustment for FY 2003 of 1.0255 (see section III.A. of the Addendum of this proposed rule). 2. Results In the past, in this impact section we presented the redistributive effects that were expected to occur between “hold-harmless” hospitals and “fully prospective” hospitals and a cross-sectional summary of hospital groupings by the capital prospective payment system transition period payment methodology. We are no longer including this information since all hospitals (except new hospitals under § 412.324(b) and under proposed § 412.32(c)(2)) are paid 100 percent of the Federal rate in FY 2003. We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2003 on total capital payments per case, using a universe of 4,300 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2001 update of the MedPAR file, the December 2001 update to the Provider-Specific File, and the most recent cost report data. In Table III, we present a comparison of total payments per case for FY 2002 compared to FY 2003 based on proposed FY 2003 payment policies. Column 3 shows estimates of payments per case under our model for FY 2002. Column 4 shows estimates of payments per case under our model for FY 2003. Column 5 shows the total percentage change in payments from FY 2002 to FY 2003. The change represented in Column 5 includes the 1.1 percent increase in the Federal rate, a 1.01505 percent increase in case-mix, changes in the adjustments to the Federal rate (for example, the effect of the new hospital wage index on the geographic adjustment factor), and reclassifications by the MGCRB, as well as changes in special exception payments. The comparisons are provided by:
(1)Geographic location;
(2)region; and
(3)payment classification. The simulation results show that, on average, capital payments per case can be expected to increase 3.7 percent in FY 2003. Our comparison by geographic location shows an overall increase in payments to hospitals in all areas. This comparison also shows that urban and rural hospitals will experience slightly different rates of increase in capital payments per case (3.5 percent and 5.1 percent, respectively). This difference is due to a projection that urban hospitals will experience a larger decrease in outlier payments from FY 2002 to FY 2003 compared to rural hospitals. All regions are estimated to receive an increase in total capital payments per case, partly due to the elimination of the 2.1 percent reduction to the Federal rate for FY 2003 (see section VI.D. of the preamble of this proposed rule). Changes by region vary from a minimum increase of 2.1 percent (Middle Atlantic urban region) to a maximum increase of 5.7 percent (West North Central rural region). Hospitals located in Puerto Rico are expected to experience an increase in total capital payments per case of 4.3 percent. By type of ownership, government hospitals are projected to have the largest rate of increase of total payment changes (4.4 percent). Similarly, payments to voluntary hospitals will increase 3.9 percent, while payments to proprietary hospitals will increase 2.0 percent. Section 1886(d)(10) of the Act established the MGCRB. Hospitals may apply for reclassification for purposes of the standardized amount, wage index, or both. Although the Federal capital rate is not affected, a hospital's geographic classification for purposes of the operating standardized amount does affect a hospital's capital payments as a result of the large urban adjustment factor and the disproportionate share adjustment for urban hospitals with 100 or more beds. Reclassification for wage index purposes also affects the geographic adjustment factor, since that factor is constructed from the hospital wage index. To present the effects of the hospitals being reclassified for FY 2003 compared to the effects of reclassification for FY 2002, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. For FY 2003 reclassifications, we indicate those hospitals reclassified for standardized amount purposes only, for wage index purposes only, and for both purposes. The reclassified groups are compared to all other nonreclassified hospitals. These categories are further identified by urban and rural designation. Hospitals reclassified for FY 2003 as a whole are projected to experience a 4.2 percent increase in payments. Payments to nonreclassified hospitals will increase slightly less (3.6 percent) than reclassified hospitals, overall. Hospitals reclassified during both FY 2002 and FY 2003 are projected to receive an increase in payments of 3.9 percent. Hospitals reclassified during FY 2003 only are projected to receive an increase in payments of 9.0 percent. This increase is primarily due to changes in the GAF (wage index). Table III.—Comparison of Total Payments Per Case [FY 2002 Payments Compared To FY 2003 Payments] Number of hospitals Average FY 2002 payments/case Average FY 2003 payments/case Change By Geographic Location: All hospitals 4,300 667 692 3.7 Large urban areas (populations over 1 million) 1,511 773 798 3.1 Other urban areas (populations of 1 million of fewer) 1,102 652 678 4.0 Rural areas 1,687 448 471 5.1 Urban hospitals 2,613 721 746 3.5 0-99 beds 647 511 533 4.3 100-199 beds 904 611 634 3.7 200-299 beds 528 692 717 3.6 300-499 beds 387 762 790 3.7 500 or more beds 147 935 961 2.8 Rural hospitals 1,687 448 471 5.1 0-49 beds 818 370 393 6.0 50-99 beds 507 412 435 5.6 100-149 beds 216 454 477 5.1 150-199 beds 78 493 517 4.9 200 or more beds 68 566 589 4.1 By Region: Urban by Region 2,613 721 746 3.5 New England 134 771 804 4.3 Middle Atlantic 402 817 834 2.1 South Atlantic 380 690 716 3.7 East North Central 431 687 718 4.5 East South Central 158 649 675 4.0 West North Central 180 703 735 4.6 West South Central 334 666 685 2.9 Mountain 132 695 724 4.2 Pacific 416 841 866 2.9 Puerto Rico 46 305 319 4.3 Rural by Region 1,687 448 471 5.1 New England 40 549 575 4.6 Middle Atlantic 68 472 497 5.4 South Atlantic 239 467 489 4.8 East North Central 225 456 481 5.5 East South Central 243 414 435 5.0 West North Central 311 440 465 5.7 West South Central 294 403 423 5.0 Mountain 150 460 483 5.0 Pacific 112 528 557 5.5 By Payment Classification: All hospitals 4,300 667 692 3.7 Large urban areas (populations over 1 million) 1,570 767 791 3.2 Other urban areas (populations of 1 million of fewer) 1,075 654 680 4.0 Rural areas 1,655 447 469 5.1 Teaching Status: Non-teaching 3,194 545 568 4.2 Fewer than 100 Residents 872 699 726 3.8 100 or more Residents 234 1,041 1,069 2.7 Urban DSH: 100 or more beds 1,354 759 784 3.3 Less than 100 beds 295 492 512 4.2 Rural DSH: Sole Community (SCH/EACH) 469 392 414 5.6 Referral Center (RRC/EACH) 156 518 540 4.3 Other Rural: 100 or more beds 78 418 439 5.0 Less than 100 beds 383 378 400 5.8 Urban teaching and DSH: Both teaching and DSH 758 838 864 3.1 Teaching and no DSH 278 746 776 4.0 No teaching and DSH 891 600 623 3.8 No teaching and no DSH 718 600 623 3.8 Rural Hospital Types: Non special status hospitals 666 398 420 5.5 RRC/EACH 159 526 548 4.2 SCH/EACH 539 415 438 5.5 Medicare-dependent hospitals
(MDH)216 368 391 6.3 SCH, RRC and EACH 75 503 530 5.3 Hospitals Reclassified by the Medicare Geographic Classification Review Board: Reclassification Status During FY2002 and FY2003: Reclassified During Both FY2002 and FY2003 567 588 611 3.9 Reclassified During FY2003 Only 53 516 563 9.0 Reclassified During FY2002 Only 77 623 651 4.4 FY2003 Reclassifications: All Reclassified Hospitals 620 583 607 4.2 All Nonreclassified Hospitals 3,645 683 708 3.6 All Urban Reclassified Hospitals 108 799 826 3.4 Urban Nonreclassified Hospitals 2,471 718 743 3.5 All Reclassified Rural Hospitals 512 500 524 4.7 Rural Nonreclassified Hospitals 1,174 389 411 5.7 Other Reclassified Hospitals (Section 1886(D)(8)(B)) 35 454 484 6.4 Type of Ownership: Voluntary 2,473 680 707 3.9 Proprietary 705 658 671 2.0 Government 909 600 627 4.4 Medicare Utilization as a Percent of Inpatient Days: 0-25 318 859 885 3.0 25-50 1,650 767 792 3.3 50-65 1,706 582 606 4.2 Over 65 517 525 547 4.3 BILLING CODE 4120-01-P Appendix B—Report to Congress EP09MY02.000 EP09MY02.001 EP09MY02.002 EP09MY02.003 EP09MY02.004 BILLING CODE 4120-01-C Appendix C: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background Section 1886(e)(4) of the Act requires that the Secretary, taking into consideration the recommendations of the Medicare Payment Advisory Commission (MedPAC), recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5) of the Act, we are required to publish the update factors recommended under section 1886(e)(4) of the Act. Accordingly, this Appendix provides the recommendations of appropriate update factors and the analysis underlying our recommendations. We also respond to MedPAC's recommendations concerning the update factors. Section 1886(b)(3)(B)(i)(XVIII) of the Act, as amended by Section 301 Public Law 106-554, sets the FY 2003 percentage increase in the operating cost standardized amounts equal to the rate of increase in the hospital market basket minus 0.55 percent for prospective payment hospitals in all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2003 percentage increase in the hospital-specific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act, that is, the same update factor as all other hospitals subject to the acute care hospital inpatient prospective payment system, or the rate of increase in the market basket minus 0.55 percentage points. Under section 1886(b)(3)(B)(ii) of the Act, the FY 2003 percentage increase in the rate-of-increase limits for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment system is the market basket percentage increase. In accordance with section 1886(d)(3)(A) of the Act, we are proposing to update the standardized amounts, the hospital-specific rates, and the rate-of-increase limits for hospitals and hospital units excluded from the prospective payment system as provided in section 1886(b)(3)(B) of the Act. Based on the proposed revised and rebased first quarter 2002 forecast of the FY 2003 market basket increase of 3.3 percent for hospitals subject to the acute care hospital inpatient prospective payment system, the proposed update to the standardized amounts is 2.75 percent (that is, the market basket rate of increase minus 0.55 percent percentage points) for hospitals in both large urban and other areas. The proposed update to the hospital-specific rate applicable to SCHs and MDHs is also 2.75 percent. Consistent with section 1886(e)(3) of the Act, we are proposing a recommendation for updating payments for hospitals and distinct-part hospital units that are excluded from the hospital inpatient prospective payment system. Facilities excluded from the hospital inpatient prospective payment system include psychiatric hospitals and units, rehabilitation hospitals and units, long-term care hospitals, cancer hospitals, and children's hospitals. In the past, hospitals and hospital units excluded from the hospital inpatient prospective payment system 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 based on their reasonable costs are subject to TEFRA limits for FY 2003. For these hospitals, the proposed update is the percentage increase in the excluded hospital market basket (currently estimated at 3.4 percent). Inpatient rehabilitation facilities
(IRFs)are paid under the IRF prospective payment system for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2003, the Federal prospective payment for IRFs is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually (see the August 7, 2001 final rule (66 FR 41316)). Effective for cost reporting periods beginning during FY 2003, we are proposing that long-term care hospitals would be paid under a prospective payment system under which long-term care hospitals receive payment based on a 5-year transition period (see the March 22, 2002 proposed rule (67 FR 13416)). We are also proposing that long-term care hospitals may elect to be paid on 100 percent of the Federal prospective rate at the beginning of any of its cost reporting periods during the 5-year transition period. For purposes of the update factor, the portion of the proposed prospective payment system transition blend payment based on reasonable costs for inpatient operating services would be determined by updating the long-term care hospital's TEFRA limit by the current estimate of the excluded hospital market basket (or 3.4 percent). In its March 1, 2002 Report to the Congress, MedPAC recommended that the base payment rates for Medicare covered services under the hospital inpatient prospective payment system be increased by the market basket percentage increase minus 0.55 percent for hospitals located in large urban areas, and by the full market basket percentage increase for hospitals located in all other areas (page 66). MedPAC did not make a separate recommendation for the hospital-specific rate applicable to SCHs and MDHs. MedPAC also presented a new approach for updating the hospital inpatient prospective system payment rates, which assesses the adequacy of current payments and accounts for the increase in efficient providers' costs in the upcoming year. While this approach is not fundamentally different from what MedPAC has done in the past, it no longer produces a detailed update framework for direct comparison with the Secretary's framework. We discuss MedPAC's recommendations concerning the update factors and our responses to these recommendations in section III. of this Appendix C. Below we describe the basis of our FY 2003 update recommendation (as shown in Table 1). II. Secretary's Recommendations Under section 1886(e)(4) of the Act, we are recommending that an appropriate update factor for the standardized amounts is the market basket percentage increase minus 0.55 percentage points for hospitals located in large urban and other areas. We are also recommending an update factor of the market basket percentage increase minus 0.55 percentage points for the hospital-specific rate for SCHs and MDHs. We believe these recommended update factors for FY 2003 would ensure that Medicare acts as a prudent purchaser and provide incentives to hospitals for increased efficiency, thereby contributing to the solvency of the Medicare Part A Trust Fund. Rehabilitation hospitals and units are now paid under the IRF prospective payment system. For cost reporting periods beginning on or after October 1, 2002, the IRF prospective payment is based on 100 percent of the adjusted Federal IRF prospective payment system amount updated annually. Effective for cost reporting periods beginning during FY 2003, we have proposed that long-term care hospitals be paid under a prospective payment system (67 FR 13416). For purposes of the update factor, the portion of the proposed prospective payment system transition blend payment based on reasonable costs for inpatient operating services for FY 2003 would be determined by updating the TEFRA target amount for long-term care hospitals by the most recent available estimate of the increase in the excluded hospital operating market basket (or 3.4 percent). We recommend that the remaining excluded hospitals and units (which are excluded from the acute care hospital inpatient prospective payment system and will continue to be paid on a reasonable cost basis in FY 2003) receive an update of 3.4 percent. The update for excluded hospitals and hospital units is equal to the most recent available estimate of the increase in the excluded hospital operating market basket. Based on the proposed revised and rebased first quarter 2002 forecast for FY 2003, the proposed market basket rate of increase for excluded hospitals and hospital units is 3.4 percent. As required by section 1886(e)(4) of the Act, we have taken into consideration the recommendations of MedPAC in setting these recommended update factors. Our responses to the MedPAC recommendations concerning the update factors are discussed below. Consistent with current law, we are proposing an update recommendation of the market basket percentage increase minus 0.55 percentage points for the hospital inpatient prospective payment system operating cost standardized amounts for FY 2003. This proposed update recommendation is supported by the following analyses that measure changes in hospital productivity, scientific and technological advances, practice pattern changes, changes in case-mix, the effect of reclassification on recalibration, and forecast error correction. A. Productivity Service level labor productivity is defined as the ratio of total service output to full-time equivalent employees (FTEs). While we recognize that productivity is a function of many variables (for example, labor, nonlabor material, and capital inputs), we use the portion of productivity attributed to direct labor since this update framework applies to operating payment. To recognize that we are apportioning the short-run output changes to the labor input and not considering the nonlabor inputs, we weight our productivity measure by the share of direct labor services in the market basket to determine the expected effect on cost per case. Our recommendation for the service productivity component is based on historical trends in productivity and total output for both the hospital industry and the general economy, and projected levels of future hospital service output. MedPAC's predecessor, the Prospective Payment Assessment Commission (ProPAC), estimated cumulative service productivity growth to be 4.9 percent from 1985 through 1989 or 1.2 percent annually. At the same time, ProPAC estimated total output growth at 3.4 percent annually, implying a ratio of service productivity growth to output growth of 0.35. Absent a productivity measure specific to Medicare patients, we examined productivity (output per hour) and output (gross domestic product) for the economy. Depending on the exact time period, annual changes in productivity range from 0.3 to 0.35 percent of the change in output (that is, a 1.0 percent increase in output would be correlated with a 0.3 to 0.35 percent change in output per hour). Under our framework, the recommended update is based in part on expected productivity—that is, projected service output during the year, multiplied by the historical ratio of service productivity to total service output, multiplied by the share of direct labor in total operating inputs, as calculated in the hospital market basket. This method estimates an expected productivity improvement in the same proportion to expected total service growth that has occurred in the past and assumes that, at a minimum, growth in FTEs changes proportionally to the growth in total service output. Thus, the recommendation allows for unit productivity to be smaller than the historical averages in years that output growth is relatively low and larger in years that output growth is higher than the historical averages. Based on the above estimates from both the hospital industry and the economy, we have chosen to employ the range of ratios of productivity change to output change of 0.30 to 0.35. The expected change in total hospital service output is the product of projected growth in total admissions (adjusted for outpatient usage), projected real case-mix growth, expected quality-enhancing intensity growth, and net of expected decline in intensity due to reduction of cost-ineffective practice. Case-mix growth and intensity numbers for Medicare are used as proxies for those of the total hospital, since case-mix increases (used in the intensity measure as well) are unavailable for non-Medicare patients. Thus, expected FY 2003 hospital output growth is simply the sum of the expected change in intensity (1.0 percent), projected admissions change (1.9 percent), and projected real case-mix growth (1.0 percent), or 3.9 percent. The share of direct labor services in the market basket (consisting of wages, salaries, and employee benefits) is 61.7 percent (based on the proposed revised and rebased hospital market basket discussed in section IV. of the preamble of this proposed rule). Multiplying the expected change in total hospital service output (3.9 percent) by the ratio of historical service productivity change to total service growth of 0.30 to 0.35 and by the direct labor share percentage 61.6, provides our productivity standard of 0.9 to 0.7 percent. Because productivity gains hold down the rate of increase in hospitals' costs, this factor is applied as a negative offset to the market basket increase. B. Intensity We base our intensity standard on the combined effect of three separate factors: changes in the use of quality enhancing services, changes in the use of services due to shifts in within-DRG severity, and changes in the use of services due to reductions of cost-ineffective practices. For FY 2003, we recommend an adjustment of 1.0 percent. The basis of this recommendation is discussed below. Following methods developed by CMS’ Office of the Actuary for deriving hospital output estimates from total hospital charges, we have developed Medicare-specific intensity measures based on a 5-year average using FYs 1997 through 2001 MedPAR billing data. Case-mix constant intensity is calculated as the change in total Medicare charges per discharge adjusted for changes in the average charge per unit of service as measured by the Consumer Price Index
(CPI)for hospital and related services and changes in real case-mix. 1 The 5-year average percentage change in charge per discharge was 6.3 percent, the 5-year average annual change in the CPI for hospital and related services was 4.5 percent, and the 5-year average annual change in case-mix was −0.3 percent. Dividing the change in charge per discharge by the product of the real case-mix index change and the CPI for hospital and related services yields a 5-year average annual change in intensity of 2.0 percent. To account for the proportions of the overall annual intensity increases due to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume that one-half of the annual increase is due to each of these factors. Our recommended adjustment excludes the estimated amount of the overall intensity increase due to ineffective practice patterns. Thus, we are recommending an intensity adjustment for FY 2003 of 1.0 percent. 1 In the past, we have considered the upper bound of real case mix to be from 1.0 to 1.4 percent annually, with any increase beyond this bound assumed to be due to changes in coding practices. Because none of the annual changes in observed case mix change during the 5-year period from FY 1997 through FY 2001 exceeded 1.0 percent, it is all assumed to be real case mix change. C. Change in Case-Mix Our analysis takes into account projected changes in case-mix, adjusted for changes attributable to improved coding practices. For our FY 2003 update recommendation, we are projecting a 1.0 percent increase in the case-mix index. We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs, but do not reflect greater resource requirements. We do not believe changes in coding behavior will impact the overall case-mix in FY 2003. As such, for FY 2003, we estimate that real case-mix is equal to projected change in case-mix. Thus, we are recommending a 0.0 percent adjustment for case-mix. D. Effect of FY 2001 DRG Reclassification and Recalibration We estimate that DRG reclassification and recalibration for FY 2001 resulted in a 0.3 percent change in the case-mix index when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the GROUPER. Therefore, we are recommending a −0.3 percent adjustment for the effect of FY 2001 DRG reclassification and recalibration. E. Forecast Error Correction We make a forecast error correction if the actual market basket changes differ from the forecasted market basket by 0.25 percentage points or more. There is a 2-year lag between the forecast and the measurement of forecast error. The estimated market basket percentage increase used to update the FY 2001 payment rates was 3.4 percent. Our most recent data indicates the actual FY 2001 increase was 4.1 percent. The resulting forecast error in the FY 2001 market basket rate of increase is 0.7 percentage points. This forecast error is a result of prices for wages, benefits, and utilities increasing more rapidly than expected. The effects of a labor shortage within the health services industry caused hospitals to increase wages greater than initially projected. Increases in actual benefits were faster than projected due to a greater than expected increase in health insurance premiums. Finally, market conditions for natural gas and electricity caused prices for those products to increase more rapidly than expected. The following is a summary of the update range supported by our analyses: HHS's FY 2003 Update Recommendation Market basket MB Policy Adjustment Factors: Productivity −0.9 to −0.7 Intensity 1.0 Subtotal 0.1 to 0.3 Case-Mix Adjustment Factors: Projected Case-Mix Change 1.0 Real Across DRG Change −1.0 Subtotal 0.0 Effect of FY 2001 DRG Reclassification and Recalibration −0.3 Forecast Error Correction 0.7 Total Recommendation Update MB + 0.5 to MB + 0.7 While the above analysis would suggest an update between market basket plus 0.5 percentage points and the market basket plus 0.7 percentage points, the Secretary is recommending, consistent with current law, an update of the market basket percentage increase minus 0.55 percentage points (or 2.75 percent) for hospitals in all areas. We believe that a 2.75 percent update factor for FY 2003 will appropriately reflect current trends in health care delivery, including the recent decreases in the use of hospital inpatient services and the corresponding increase in the use of hospital outpatient and postacute care services. Also, consistent with current law, we are recommending that the hospital-specific rates applicable to SCHs and MDHs be increased by the same update, 2.75 percentage points. Since the inception of the acute care hospital inpatient prospective payment system, hospitals have received a full market basket update only once, in FY 2001. The stabilization of overall hospital margins in recent years suggests that the restrictions on market basket increases have not resulted in inadequate hospital payments. Modest limits below full market basket updates could be linked to continued careful review of Medicare hospital margin data to ensure that margins do not worsen among certain hospital types with negative and declining Medicare margins. III. MedPAC Recommendations for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In its FY 2002 Report to Congress, MedPAC developed a new approach for updating fee-for-service payments that breaks the process into two basic parts: assessing the adequacy of current payments; and accounting for the increase in efficient providers' costs in the coming year. MedPAC points out this new approach “is not fundamentally different from what the Commission has done in the past, but we expect formalizing the two parts of our process will lead to greater emphasis on the broad question of whether the amount of money in the system currently is right and less emphasis on the role of specific cost-influencing factors” (page 39). In assessing payment adequacy, MedPAC reviews the relationship between costs and payments (conventionally expressed as a margin). On the payment side, MedPAC applied the annual payment updates specified in law through FY 2002 and then modeled the effects of other policy changes that have affected the level of payments. On the cost side, MedPAC estimated the increases in costs per unit of output over the same period using the change in cost per adjusted admission in the American Hospital Association's annual survey of hospitals for FY 2000, and the CMS projected increase in the FYs 2001 and 2002 market baskets (page 58). MedPAC estimated that the inpatient Medicare margin would be 10.8 percent in FY 2002 (with FY 2003 payment rules). This amount is down slightly from MedPAC's estimate of 11.9 percent in FY 1999. In addition to the inpatient Medicare margin, MedPAC measured the overall Medicare margin, incorporating almost all Medicare-related payments and costs to hospitals. This overall Medicare margin was estimated to be 3.8 percent. The report notes that “the Commission does not plan to specify a 'standard margin,' although we will take the need for a small positive margin into account as we assess the adequacy of various fee-for-service payments” (page 43). In addition to considering the relationship between estimated payments and costs, MedPAC also considered the following three factors to assess whether current payments are adequate (page 43): • Changes in access to or quality of care; • Changes in the volume of services or number of providers; and • Changes in providers access to capital. MedPAC found no evidence that the hospital cost base is inappropriate and concluded that Medicare payment is adequate and no payment adequacy adjustment is needed for FY 2003. MedPAC recommends gradually eliminating the differential in the standardized amounts for hospitals in large urban and other areas. MedPAC's data on margins and its analysis of costs suggest that a different standardized amount (the large urban standardized amount is 1.6 percent higher than the amount for other areas) is unwarranted. MedPAC estimates the FY 2002 Medicare inpatient margins will range from 5 percent for rural hospitals to 14 percent for hospitals in large urban areas. Because much of this difference is due to the greater proportion of IME and DSH payments going to hospitals in large urban areas, MedPAC removed DSH payments and the portion of the IME payment above the measured cost relationship between IME and hospitals' costs, and found that hospitals in large urban areas still have Medicare margins that are about 4 percentage points higher than other urban and rural hospitals (page 64). MedPAC believes that “(e)liminating the differential would improve payment equity across geographic areas and also help to simplify the payment system” (page 63). For example, eliminating the standardized amount differential would also eliminate the need for hospitals to reclassify for a higher standardized amount through the MGCRB. Therefore, MedPAC recommends holding the update for hospitals in large urban areas to the legislated level of the market basket percentage increase minus 0.55 percent for FY 2003, while updating the other areas standardized amount by the full market basket percentage increase. MedPAC accounts for providers' cost changes in the coming payment year primarily through a forecast of input price inflation, which estimates how much providers' costs would rise in the coming year if the quality and mix of inputs they use to furnish care and the types of patients they treat remain constant. MedPAC relies on CMS' market basket estimate to forecast input price inflation, but considers other factors that may affect providers' costs. These other factors are scientific and technological advances, changes in DRG case-mix complexity, site-of-service substitution, and other one-time factors. In the past, MedPAC recommended specific adjustments to its update recommendation for each of these factors. In its March 2002 Report to Congress, MedPAC did not provide specific estimates for these factors, but stated “(a)fter considering all factors that might potentially affect the rate of growth in efficient providers' costs, we conclude that the appropriate adjustment for cost growth in fiscal year 2003 is the forecasted increase in the market basket, or 2.9 percent” (page 66). This market basket forecast was based on the December 2001 market basket estimated by CMS' Office of the Actuary, and does not reflect the proposed revisions and rebasing discussed in section IV. of the preamble of this proposed rule. MedPAC's second recommendation related to updating payments under the hospital inpatient prospective payment system is that the Congress should increase the base rate for inpatient services covered by Medicare's prospective payment system in FY 2003 by the market basket percentage increase minus 0.55 percent for hospitals in large urban areas and by the market basket percentage increase for hospitals in all other areas. MedPAC focused on the operating update only because it applies to 92 percent of hospitals' Medicare costs. The report noted that, in its March 2000 report to Congress, MedPAC recommended combining the operating and capital payment systems into a single prospective payment system. *Response:* As described above, we continue to use our detailed update framework to develop our recommended update for FY 2003. However, we believe MedPAC's new approach will be useful to focusing the policy discussion more directly on the overall adequacy of hospital payments. We look forward to continuing to work with MedPAC to refine and utilize both methodologies in an effort to produce analyses that provide the most helpful information for setting the annual updates. We agree with MedPAC's recommendation that the current law update for FY 2003 of the market basket percentage increase minus 0.55 percentage points is appropriate for the operating system update. However, we are not recommending differential updates to gradually eliminate the higher standardized amount for hospitals in large urban areas, as recommended by MedPAC. We believe the stabilization of overall hospital margins in recent years suggests that modest limits below full market basket updates provide adequate payments. We agree, however, that certain hospital types that show clear evidence of negative and declining Medicare margins should be monitored closely. Because the operating and capital prospective payment systems remain separate, CMS continues to use separate updates for operating and capital payments. The proposed update to the capital payment rate is discussed in section III. of the Addendum of this proposed rule. [FR Doc. 02-11290 Filed 5-8-02; 8:45 am]
Connectionstraces to 7
34 references not yet in our index
  • 14 CFR 13
  • 42 CFR 412
  • Pub. L. 105-33
  • Pub. L. 106-113
  • Pub. L. 106-554
  • 42 CFR 413
  • Pub. L. 101-239
  • Pub. L. 103-66
  • 42 CFR 405
  • Pub. L. 98-369
  • Pub. L. 99-509
  • Pub. L. 100-485
  • Pub. L. 100-458
  • Pub. L. 99-272
  • 42 CFR 489.24
  • 42 CFR 482
  • 42 CFR 410.2
  • 42 CFR 482.55
  • 42 CFR 414
  • 42 CFR 421.1(c)
  • 525 U.S. 449
  • 257 F.3d 807
  • 171 F. Supp. 2d 1215
  • 42 CFR 412.22(e)
  • 42 CFR 485
  • 42 CFR 413.70(b)
  • 42 CFR 483
  • 5 CFR 1320.3(b)(2)
  • 5 CFR 1320.3(b)
  • 42 CFR 489
  • Pub. L. 100-203
  • Pub. L. 96-354
  • Pub. L. 104-4
  • Pub. L. 98-21
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U.S.C.§ 1302
U.S.C.§ 1320
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Fed. Reg.Proposed Rules
U.S.C.§ 804
SCOTUS525 U.S. 449
F. App'x257 F.3d 807
F. Supp.171 F. Supp. 2d 1215
Cite14 CFR 13
Cite42 CFR 412
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