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Code · REGISTER · 2003-05-19 · Centers for Medicare and Medicaid Services (CMS), HHS · Presidential Documents

Presidential Documents. Proposed rule

189,241 words·~860 min read·/register/2003/05/19/03-11966

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Billing code 3195-01-P 68 96 Monday, May 19, 2003 CORRECTIONS Amelia SECURITIES AND EXCHANGE COMMISSION [Release No. 34-47704; File No. SR-NASD-2003-70] Self-Regulatory Organizations; Notice of Filing and Order Granting Accelerated Approval of Proposed Rule Change by the National Association of Securities Dealers, Inc. Relating to the Listing and Trading of Market Recovery Notes Linked to the PHLX Semiconductor Sector April 18, 2003. Correction In notice document 03-10217 beginning on page 20413 in the issue of Friday, April 25, 2003, make the following corrections: 1.
On page 20413, in the second column, at the bottom of the page, in the footnotes, footnote “ 4 ” should read footnote “ 1 ”. 2. On the same page, in the same column, at the bottom of the page, in the footnotes, footnote “ 5 ” should read footnote “ 2 ”. [FR Doc. C3-10217 Filed 5-16-03; 8:45 am] BILLING CODE 1505-01-D 68 96 Monday, May 19, 2003 Proposed Rules Part II Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 412 and 413 Medicare Program;
Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2004 Rates; Proposed Rule DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 412 and 413 [CMS-1470-P] RIN 0938-AL89 Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2004 Rates AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems
(IPPS)for operating and capital costs to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this proposed rule, we are describing 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, 2003. We also are setting forth proposed rate-of-increase limits as well as proposed policy changes for hospitals and hospital units excluded from the IPPS. Among other changes that we are proposing are changes to the policies governing postacute care transfers, payments to hospitals for the direct and indirect costs of graduate medical education, determination of hospital beds and patient days for payment adjustment purposes, and payments to critical access hospitals (CAHs). DATES: Comments will be considered if received at the appropriate address, as provided below, no later than 5 p.m. on July 18, 2003. 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-1470-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-1470-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 Strategic Operations and Regulatory Affairs, Security and Standards Group, Office of Regulations Development and Issuances, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Attn: Julie Brown, CMS-1470-P; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 3001, New Executive Office Building, Washington, DC 20503, Attn: Brenda Aguilar, CMS Desk Officer. FOR FURTHER INFORMATION CONTACT: Stephen Phillips,
(410)786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology, Patient Transfers, Counting Beds and Patient Days, and Hospital Geographic Reclassifications Issues; Tzvi Hefter,
(410)786-4487, Capital Prospective Payment, Excluded Hospitals, Nursing and Allied Health Education, Graduate Medical Education, and Critical Access Hospital Issues. 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 $10.00. 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). Table of Contents I. Background A. Summary B. Major Contents of This Proposed Rule II. Proposed Changes to DRG Classifications and Relative Weights A. Background B. DRG Reclassification 1. General 2. Review of DRGs for CC Split 3. MDC 1 (Diseases and Disorders of the Nervous System) a. Revisions of DRGs 1 and 2 b. DRG 23 (Nontraumatic Stupor and Coma) 4. MDC 5 (Diseases and Disorders of the Circulatory System) a. DRG 478 (Other Vascular Procedures With CC) and DRG 479 (Other Vascular Procedures Without CC) b. DRGs 514 (Cardiac Defibrillator Implant With Cardiac Catheterization) and 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization) 5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) 6. MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period) a. Nonneonate Diagnoses b. Heart Failure Codes for Newborns and Neonates 7. MDC 17 (Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms) 8. MDC 23 (Factors Influencing Health Status and Other Contracts with Health Services) a. Implantable Devices b. Malignancy Codes 9. Medicare Code Editor
(MCE)Change 10. Surgical Hierarchies 11. Refinement of Complications and Comorbidities
(CC)12. Review of Procedure Codes in DRGs 468, 476, and 477 a. Moving Procedure Codes from DRG 468 or DRG 477 to MDCs b. Reassignment of Procedures among DRGs 468, 476, and 477 c. Adding Diagnosis Codes to MDCs 13. Changes to the ICD-9-CM Coding System 14. Other Issues a. Cochlear Implants b. Burn Patients on Mechanical Ventilation c. Multiple Level Spinal Fusion d. Heart Assist System Implant e. Drug-Eluting Stents f. Artificial Anal Spincter C. Recalibration of DRG Weights D. Proposed LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2004 1. Background 2. Proposed Changes in the LTC-DRG Classifications a. Background b. Patient Classifications into DRGs 3. Development of the Proposed FY 2004 LTC-DRG Relative Weights a. General Overview of Development of the LTC-DRG Relative Weights b. Data c. Hospital-Specific Relative Value Methodology d. Low Volume LTC-DRGs 4. Steps for Determining the Proposed FY 2004 LTC-DRG Relative Weights E. Add-On Payments for New Services and Technologies 1. Background 2. FY 2004 Status of Technology Approved for FY 2003 Add-On Payments: Drotrecogin Alfa (Activated)—Xigris® 3. FY 2004 Applicants for New Technology Add-On Payments a. Bone Morphogenetic Proteins
(BMPs)for Spinal Fusions b. GLIADEL® Wafer 4. Review of the High-Cost Threshold 5. Technical Changes III. Proposed Changes to the Hospital Wage Index A. Background B. Proposed FY 2004 Wage Index Update C. FY 2004 Wage Index Proposals 1. Elimination of Wage Costs Associated with Rural Health Clinics and Federally Qualified Health Centers 2. Paid Hours D. Verification of Wage Data from the Medicare Cost Reports E. Computation of the Proposed FY 2004 Wage Index F. Proposed Revisions to the Wage Index Based on Hospital Redesignation 1. General 2. Effects of Reclassification G. Requests for Wage Data Corrections H. Modification of the Process and Timetable for Updating the Wage Index IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Transfer Payment Policy 1. Transfers to Another Acute Care Hospital 2. Technical Correction 3. Expanding the Postacute Care Transfer Policy to Additional DRGs B. Rural Referral Centers 1. Case-Mix Index 2. Discharges C. Indirect Medical Education
(IME)Adjustment and Disproportionate Share Hospital
(DSH)Adjustment 1. Available Beds and Patient Days: Background 2. Unoccupied Beds 3. Nonacute Care Beds and Days 4. Observation Beds and Swing-Beds 5. Labor, Delivery, Recovery, and Postpartum Beds and Days 6. Days Associated with Demonstration Projects under Section 1115 of the Act 7. Dual-Eligible Patient Days 8. Medicare+Choice (M+C) Days D. Medicare Geographic Classification Review Board (MGCRB) Reclassification Process E. Costs of Approved Nursing and Allied Health Education Activities 1. Background 2. Continuing Education Issue for Nursing and Allied Health Education Activities 3. Programs Operated by Wholly Owned Subsidiary Educational Institutions of Hospitals F. Payment for Direct Costs of Graduate Medical Education 1. Background 2. Prohibition Against Counting Residents Where Other Entities First Incur the Training Costs 3. Rural Track FTE Limitation for Purposes of Direct GME and IME for Urban Hospitals that Establish Separately Accredited Approved Medical Programs in a Rural Area a. Change in the Amount of Rural Training Time Required for an Urban Hospital to Qualify for an Increase in the Rural Track FTE Limitation b. Inclusion of Rural Track FTE Residents in the Rolling Average Calculation 4. Technical Changes Related to Affiliated Groups and Affiliated Agreements G. Notification of Updates to the Reasonable Compensation Equivalent
(RCE)Limits 1. Background 2. Publication of the Updated RCE Limits V. PPS for Capital-Related Costs VI. Proposed Changes for Hospitals and Hospital Units Excluded from the IPPS A. Payments to Excluded Hospitals and Hospital Units 1. Payments to Existing Excluded Hospitals and Hospital Units 2. Updated Caps for New Excluded Hospitals and Units 3. Implementation of a PPS for IRFs 4. Implementation of a PPS for LTCHs B. Payment for Services Furnished at Hospitals-Within-Hospitals and Satellite Facilities C. Clarification of Classification Requirements for LTCHs D. Criteria for Payment on a Reasonable Cost Basis for Clinical Diagnostic Laboratory Services Performed by CAHs E. Technical Changes VII. MedPAC Recommendations VIII. Other Required Information A. Requests for Data from the Public B. Collection of Information Requirements Regulation Text Addendum—Proposed Schedule of Standardized Amounts Effective with Discharges Occurring On or After October 1, 2003 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2003 Tables 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 2002 (1998 Wage Data), 2003 (1999 Wage Data), and 2004 (2000 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, and Geometric and Arithmetic Mean Length of Stay
(LOS)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 from the CC Exclusions List Table 7A—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V20.0 Table 7B—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V21.0 Table 8A—Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) March 2003 Table 8B—Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) March 2003 Table 9—Hospital Reclassifications and Redesignations by Individual Hospital—FY 2004 Table 10—Mean and Standard Deviations by Diagnosis-Related Groups (DRGs)—FY 2004 Table 11—Proposed LTC-DRGs Relative Weights and Geometric and Five-Sixths of the Average Length of Stay—FY 2004 Appendix A—Regulatory Impact Analysis Appendix B—Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services Acronyms AHIMA American Health Information Management Association AHA American Hospital Association CAH Critical access hospital CBSAs Core Based Statistical Areas CC Complication or comorbidity CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Areas COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-272 CPI Consumer Price Index CRNA Certified registered nurse anesthetist DRG Diagnosis-related group DSH Disproportionate share hospital FDA Food and Drug Administration FQHC Federally qualified health center FTE Full-time eguivalent FY Federal fiscal year GME Graduate medical education HIPC Health Information Policy Council HIPAA Health Insurance Portability and Accountability Act, Pub. L. 104-191 HHA Home health agency ICD-9-CM International Classification of Diseases, Ninth Revision, and Clinical Modification ICD-10-PCS International Classification of Diseases Tenth Edition, and Procedure Coding System IME Indirect medical education IPPS Acute care hospital inpatient prospective payment system IRF Inpatient Rehabilitation Facility LDRP Labor, delivery room, and postpartum LTC-DRG Long-term care diagnosis-related group LTCH Long-term care hospital MCE Medicare Code Editor MDC Major diagnostic category MDH Medicare-dependent small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MPFS Medicare Physician Fee Schedule MSA Metropolitan Statistical Area NECMA New England County Metropolitan Areas NCHS National Center for Health Statistics NCHVS National Committee on Health and Vital Statistics O.R. Operating room PPS Prospective payment system PRA Per resident amount ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board RCE Reasonable compensation equivalent RHC Rural health center RRC Rural referral center SCH Sole community hospital SNF Skilled nursing facility TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248 UHDDS Uniform Hospital Discharge Data Set I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System
(IPPS)Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system (PPS). Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital
(DSH)adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the statutory calculations. If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS (known as the indirect medical education
(IME)adjustment). This percentage varies, depending on the ratio of residents to beds. Additional payments may be made for cases that involve new technologies that have been approved for special add-on payments. To qualify, a new technology must demonstrate that it is a substantial clinical improvement over technologies otherwise available, and that, absent an add-on payment, it would be inadequately paid under the regular DRG payment. The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology add-on adjustments. Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 1996) or the IPPS rate based on the standardized amount. For example, sole community hospitals
(SCHs)are the sole source of care in their areas, and Medicare-dependent, small rural hospitals
(MDHs)are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries (although MDHs receive only 50 percent of the difference between the IPPS rate and their hospital-specific rates if the hospital-specific rate is higher than the IPPS rate). Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services “in accordance with a prospective payment system established by the Secretary.” The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital PPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Similar adjustments are also made for IME and DSH as under the operating IPPS. In addition, hospitals may receive an outlier payment for those cases that have unusually high costs. The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR part 412, subparts A through M. 2. Hospitals and Hospital Units Excluded From the IPPS Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Psychiatric hospitals and units, rehabilitation hospitals and units; long-term care hospitals (LTCHs); children's hospitals; and cancer hospitals. Various sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106-554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), psychiatric hospitals and units, and LTCHs, as discussed below. Children's hospitals and cancer hospitals continue to be paid under reasonable cost-based reimbursement. The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR parts 412 and 413. a. Inpatient Rehabilitation Facilities. Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units
(IRFs)have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and prospective payments for cost reporting periods beginning January 1, 2002 through September 30, 2002, to payment on a full prospective payment system basis effective for cost reporting periods beginning on or after October 1, 2002 (66 FR 41316, August 7, 2001 and 67 FR 49982, August 1, 2002). The existing regulations governing payments under the IRF PPS are located in 42 CFR part 412, subpart P. b. LTCHs. Under the authority of sections 123(a) and
(c)of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, LTCHs are being transitioned from being paid for inpatient hospital services based on a blend of reasonable cost-based reimbursement under section 1886(b) of the Act to fully Federal prospective rates during a 5-year period, beginning with cost reporting periods that start on or after October 1, 2002. For cost reporting periods beginning on or after October 1, 2006, LTCHs will be paid under the fully Federal prospective payment rate (the August 30, 2002 LTCH PPS final rule (67 FR 55954)). LTCHs may elect to be paid based on full PPS payments instead of a blended payment in any year during the 5-year transition period. The existing regulations governing payment under the LTCH PPS are located in 42 CFR part 412, subpart O. c. Psychiatric Hospitals and Units. Sections 124(a) and
(c)of Pub. L. 106-113 provide for the development of a per diem PPS for payment for inpatient hospital services furnished in 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 maintain budget neutrality. We are in the process of developing a proposed rule, to be followed by a final rule, to implement the PPS 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 payments to the various types of hospitals 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 IPPS for operating costs and for capital-related costs in FY 2004. We also are proposing changes relating to payments for GME costs, payments to CAHs, and payments to providers classified as psychiatric hospitals and units that continue to be excluded from the IPPS and paid on a reasonable cost basis. The proposed changes would be effective for discharges occurring on or after October 1, 2003. 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 make changes to the designation of diagnosis and procedure codes under other existing DRGs. Our proposed changes for FY 2004 are set forth in section II. of this preamble. Among the proposed changes discussed are: • Expanding the number of DRGs that are split on the basis of the presence or absence of complications or comorbidities (CCs). The DRGs we are proposing to split are: DRG 4 (Spinal Procedures), DRG 5 (Extracranial Vascular Procedures), DRG 231 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur) and DRG 400 (Lymphoma and Leukemia With Major O.R. Procedure). • Creating two new DRGs to differentiate current DRG 514 (Cardiac Defibrillator Implant With Cardiac Catheterization) on the basis of whether the patient does or does not experience any of the following symptoms: acute myocardial infarction, heart failure, or shock. • Changing the DRG assignments of certain congenital anomalies that currently result in patients being assigned to newborn DRGs even when the patient is actually an adult. We also are adding to the list of major problems in newborns that affect DRG assignment. • Modifying DRG 492 (Chemotherapy With Acute Leukemia as Secondary Diagnosis) to include in this DRG cases receiving high-dose Interleukin-2 (IL-2) chemotherapy for patients with advanced renal cell cancer and advanced melanoma. 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 proposed FY 2004 wage index update, using wage data from cost reporting periods that began during FY 2000. • Proposed exclusion of the wage data for rural health centers
(RHCs)and Federally qualified health centers (FQHCs) from the calculation of the FY 2004 wage index. • Proposed exclusion of paid hours associated with military and jury duty leave from the wage index calculation, and request for comments on possible exclusion of paid lunch or meal break hours. • Proposed revisions to the wage index based on hospital redesignations and reclassifications. • Proposed amendments to the timetable for reviewing and verifying the wage data that will be in effect for the FY 2005 wage index. 3. Other Decisions and Proposed Changes to the PPS for Inpatient Operating and GME Costs In section IV. 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: • Proposed expansion of the current postacute transfer policy to 19 additional DRGs. • Proposed clarification of our policies that would be applied to counting hospital beds and patient days, in particular with regard to the treatment of swing-beds and observation beds, for purposes of the IME and DSH adjustments. • Proposed changes in our policy relating to nursing and allied health education payments to wholly owned subsidiary educational institutions of hospitals. • Proposed clarification of policy relating to application of redistribution of costs and community support funds in determining a hospital's resident training costs. • Proposed change in the amount of rural training time required for an urban hospital to qualify for an increase in the rural track FTE limitation. • Proposed inclusion of FTE residents training in rural tracks in a hospital's rolling average calculation. 4. PPS for Capital-Related Costs In section V., of this preamble, we discuss the payment requirements for capital-related costs. We are not proposing any changes to the policies on payments to hospitals for capital-related costs. 5. Proposed Changes for Hospitals and Hospital Units Excluded from the IPPS In section VI., of this preamble, we discuss the following proposals concerning excluded hospitals and hospital units and CAHs: • Revisions relating to the operation of excluded “grandfathered” hospitals-within-hospitals in effect on September 30, 1999. • Clarification of the classification criteria for LTCHs. • Clarification of the policy on payments for laboratory services provided by a CAH to patients outside a CAH. 6. 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 2004 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 2004 for hospitals and hospital units excluded from the PPS. 7. 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 hospitals. 8. Proposed Recommendation of Update Factor for Hospital Inpatient Operating Costs As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix B provides our recommendation of the appropriate percentage change for FY 2004 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 IPPS 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 IPPS. 9. 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, no 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 VII., 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 Web site at: *http://www.medpac.gov.* II. Proposed Changes to DRG Classifications and Relative Weights A. Background Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG relative to the average resources used to treat cases in all DRGS. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. The proposed changes to the DRG classification system and the proposed recalibration of the DRG weights for discharges occurring on or after October 1, 2003 are discussed below. B. DRG Reclassification 1. General Cases are classified into DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). For FY 2003, cases are assigned to one of 510 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. This approach is used because the clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). The table below lists the 25 MDCs. Major Diagnostic Categories 1 Diseases and Disorders of the Nervous System. 2 Diseases and Disorders of the Eye. 3 Diseases and Disorders of the Ear, Nose, Mouth, and Throat. 4 Diseases and Disorders of the Respiratory System. 5 Diseases and Disorders of the Circulatory System. 6 Diseases and Disorders of the Digestive System. 7 Diseases and Disorders of the Hepatobiliary System and Pancreas. 8 Diseases and Disorders of the Musculoskeletal System and Connective Tissue. 9 Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast. 10 Endocrine, Nutritional and Metabolic Diseases and Disorders. 11 Diseases and Disorders of the Kidney and Urinary Tract. 12 Diseases and Disorders of the Male Reproductive System. 13 Diseases and Disorders of the Female Reproductive System. 14 Pregnancy, Childbirth, and the Puerperium. 15 Newborns and Other Neonates with Conditions Originating in the Perinatal Period. 16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders. 17 Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms. 18 Infectious and Parasitic Diseases (Systemic or Unspecified Sites). 19 Mental Diseases and Disorders. 20 Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders. 21 Injuries, Poisonings, and Toxic Effects of Drugs. 22 Burns. 23 Factors Influencing Health Status and Other Contacts with Health Services. 24 Multiple Significant Trauma. 25 Human Immunodeficiency Virus Infections. In general, cases are assigned to an MDC based on the patient's principal diagnosis before assignment to a DRG. However, for FY 2003, 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 (less than or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or a comorbidity (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). After cases are screened through the MCE and assigned to a DRG by the GROUPER, a payment is calculated by the PRICER software. The PRICER calculates the payments for each case covered by the IPPS based on the DRG relative weight and factors associated with each hospital, such as IME and DSH adjustments. 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 IPPS 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 for consideration in conjunction with the next year's proposed rule, 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 by early December for consideration in conjunction with the next year's proposed rule. Many of the changes to the DRG classifications are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about the DRG classifications to bring those concerns to our attention in a timely manner so they can be carefully considered for possible inclusion in the next proposed rule and so any proposed changes may be subjected to public review and comment. Therefore, similar to the timetable for interested parties to submit non-MedPAR data for consideration in the DRG recalibration process, concerns about DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS. The changes we are proposing to the DRG classification system for FY 2004 GROUPER version 21.0 and to the methodology to recalibrate the DRG weights are set forth below. Unless otherwise noted, our DRG analysis is based on data from the December 2002 update of the FY 2002 MedPAR file, which contains hospital bills received through December 31, 2002, for discharges in FY 2002. 2. Review of DRGs for CC Split In an effort to improve the clinical and cost cohesiveness of the DRG classification system, we have evaluated whether additional DRGs should be split based on the presence or absence of a CC. There are currently 116 paired CC split DRGs. We last performed a systematic evaluation and considered changes to the DRGs to recognize the within-DRG cost differences based on the presence or absence of CCs in 1994 (May 27, 1994 IPPS proposed rule, 59 FR 27715). In 1994, we described a refined DRG system based on a list of secondary diagnoses that have a major effect on the resources used by hospitals in treating patients across DRGs. We analyzed how the presence of the secondary diagnosis affected resource use compared to other secondary diagnoses, and classified these secondary diagnoses as non-CC, CC, or major CC. After finalizing the classification of secondary diagnoses, we evaluated which collapsed DRGs should be split on the basis of the presence 8 of a major CC, other CC, or both. 1 However, this refined system was not implemented because we did not believe it would be prudent policy to make changes for which we could not predict the effect on the case-mix (the average DRG relative weight for all cases) and, thus, payments (60 FR 29209). We were concerned that we would be unable to fulfill the requirement of section 1886(d)(4)(C)(iii) of the Act that aggregate payments may not be affected by DRG reclassification and recalibration of weighting factors. That is, our experience has been that hospitals respond to major changes to the DRGs by changing their coding practices in ways that increase total payments (for example, by beginning to include ICM-9-CM codes that previously did not affect payment for a case). Because changes in coding behavior do not represent a real increase in the severity of the overall mix of cases, total payments should not increase. The only way to ensure this behavioral response does not lead to higher total payments is to make an offsetting adjustment to the system in advance of the fiscal year when the changes are effective. 1 The complete description of the analysis was published in the *Health Care Financing Review* (Edwards, N., Honemann, D., Burley, D., Navarro, M., “Refinement of the Medicare Diagnosis-Related Groups to Incorporate a Measure of Severity,” *Health Care Financing Review,* Winter 1994, Vol. 16, No. 2, p. 45). Section 301(e) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 Public Law 106-554 authorized the Secretary to make such a prospective adjustment to the average standardized amounts for discharges occurring on or after October 1, 2001, to ensure the total payment impacts of changes to the DRGs do not result in any more or less total spending than would otherwise occur without the changes (budget neutrality). Pending a decision whether to replace ICD-9-CM with another classification system, we are not proposing to proceed with implementing a refined DRG system at this time. The refined DRG system discussed in the 1994 **Federal Register** involved a complete and thorough assessment of all of the ICD-9-CM diagnosis codes in order to establish an illness severity level associated with each code. Rather than undertaking the time-consuming process of establishing illness severity levels for all ICD-9-CM codes at this time, we believe the more prudent course would be to delay this evaluation pending the potential replacement of ICD-9-CM. For example, the National Committee on Health and Vital Statistics (NCHVS) is considering making a recommendation to the Secretary on whether to recommend the adoption of ICD-10-CM and the ICD-10-Procedure Coding System
(PCS)as the national uniform standard coding system for inpatient reporting. In the meantime, we have undertaken an effort to identify groups of DRGs where a CC-split appears most justified. Our analysis identified existing DRGs that meet the following criteria: a reduction in variance in charges within the DRG of at least 4 percent; fewer than 75 percent of all patients in the current DRG would be assigned to the with-CC DRG; and the overall payment impact (higher payments for cases in the with-CC DRG offset by lower payments for cases in the without-CC DRG) is at least $40 million. The following four DRGs meet these criteria: DRG 4 (Spinal Procedures) and DRG 5 (Extracranial Vascular Procedures) in MDC 1 (Diseases and Disorders of the Nervous System); DRG 231 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur) in MDC 8 (Diseases and Disorders of the Musculoskeletal and Connective Tissue); and DRG 400 (Lymphoma and Leukemia with Major O.R. Procedure) in MDC 17 (Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms). The following data indicate that the presence or absence of a CC was found to have a significant impact on patient charges and average length of stays in these four DRGs. DRG Number of cases Average charges Average length of stay DRG 4 (Current) 4,488 $35,074 7.3 With CC 2,514 46,071 10.0 Without CC 1,974 21,070 3.9 DRG 5 (Current) 64,942 18,613 2.9 With CC 29,296 23,213 4.1 Without CC 35,646 14,833 2.0 DRG 231 (Current) 8,971 20,147 4.9 With CC 4,565 25,948 6.9 Without CC 4,406 14,136 2.9 DRg 400 (Current) 4,275 39,953 9.0 With CC 2,990 49,044 11.2 Without CC 1,285 18,799 4.0 Therefore, we are proposing to establish the following new DRGs: proposed DRG 531 (Spinal Procedures With CC) and proposed DRG 532 (Spinal Procedures Without CC) in MDC 1; proposed DRG 533 (Extracranial Vascular Procedures With CC) and proposed DRG 534 (Extracranial Vascular Procedures Without CC) in MDC 1; proposed DRG 537 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With CC) and proposed DRG 538 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur Without CC) in MDC 8; and proposed DRG 539 (Lymphoma and Leukemia With Major O.R. Procedure With CC) and DRG 540 (Lymphoma and Leukemia With Major O.R. Procedure Without CC) in MDC 17. We are proposing that DRGs 4, 5, 231, and 400 would become invalid. 3. MDC 1 (Diseases and Disorders of the Nervous System) a. Revisions of DRGs 1 and 2. In the FY 2003 IPPS final rule, we split DRGs 1 and 2 (Craniotomy Age >17 With and Without CC, respectively) based on the presence or absence of a CC (67 FR 49986). We have received several proposals related to devices or procedures that are used in a small subset of cases from these DRGs. These proposals argue that the current payment for these devices or procedures under DRGs 1 and 2 is inadequate. 2 2 We also examined the issue of treating brain tumors through the implantation of chemotherapy wafers. This analysis is discussed later in this preamble under section II.E.2.b. relative to the application for new technology add-on payments for the GLIADEL® Wafer. Therefore, we undertook an analysis of the charges of various procedures and diagnoses within DRGs 1 and 2 to assess whether further changes to these DRGs may be warranted. Currently, the average charges for cases assigned to DRGs 1 and 2 are approximately $55,000 and $30,000, respectively. We are proposing to create two separate new DRGs for: Cases with an intracranial vascular procedure and a principal diagnosis of an intracranial hemorrhage; and craniotomy cases with a ventricular shunt procedure (absent another procedure). The former set of cases are much more expensive than those presently in DRGs 1 and 2; the latter set of cases are much less expensive.
(1)Intracranial Vascular Procedures Our analysis indicated that patients with an intracranial vascular procedure and a principal diagnosis of an intracranial hemorrhage were significantly more costly than other cases in DRGs 1 and 2. These patients have an acute condition with a high severity of illness and risk of mortality. There were 917 cases in DRGs 1 and 2 with an intracranial vascular procedure and a principal diagnosis of hemorrhage with average charges of approximately $113,884, which are much higher than the average charges of DRGs 1 and 2 noted above. We also found 890 cases that had an intracranial vascular procedure without a principal diagnosis of hemorrhage (for example, nonruptured aneurysms). These cases are generally less acutely ill than those involving ruptured aneurysms, and have a lower risk of mortality. Among these 890 cases, the average charges were approximately $52,756, which are much more similar to the average charges for all cases in DRGs 1 and 2. Based on this analysis, we are proposing to create new DRG 528 (Intracranial Vascular Procedure With a Principal Diagnosis of Hemorrhage) for patients with an intracranial vascular procedure and an intracranial hemorrhage. We are proposing that cases involving intracranial vascular procedures without a principal diagnosis of hemorrhage would remain in DRGs 1 and 2. Proposed new DRG 528 would have the following principal diagnoses: • 094.87, Syphilitic ruptured cerebral aneurysm • 430, Subarachnoid hemorrhage • 431, Intracerebral hemorrhage • 432.0, Nontraumatic extradural hemorrhage • 432.1, Subdural hemorrhage • 432.9, Unspecified intracranial hemorrhage And operating room procedures: • 02.13, Ligation of meningeal vessel • 38.01, Incision of vessel, intracranial vessels • 38.11, Endarterectomy, intracranial vessels • 38.31, Resection of vessel with anastomosis, intracranial vessels • 38.41, Resection of vessel with replacement, intracranial vessels • 38.51, Ligation and stripping of varicose veins, intracranial vessels • 38.61, Other excision of vessels, intracranial vessels • 38.81, Other surgical occlusion of vessels, intracranial vessels • 39.28, Extracranial-intracranial (EC-IC) vascular bypass • 39.51, Clipping of aneurysm • 39.52, Other repair of aneursym • 39.53, Repair of arteriovenous fistula • 39.72, Endovascular repair or occlusion of head and neck vessels • 39.79, Other endovascular repair of aneurysm of other vessels
(2)Ventricular Shunt Procedures We also found that craniotomy patients who had a ventricular shunt procedure (absent another procedure) were significantly less costly than other craniotomy patients in DRGs 1 and 2. Ventricular shunts are normally performed for draining intracranial fluid. A ventricular shunt is a less extensive procedure than the other intracranial procedures in DRGs 1 and 2. As a result, if a ventricular shunt is the only intracranial procedure performed, these cases will typically be less costly. There were 4,373 cases in which only ventricular shunt procedures were performed. These cases had average charges of approximately $27,188. However, the presence or absence of a CC had a significant impact on patient charges and lengths of stay. There were 2,533 cases with CC, with average charges of approximately $33,907 and an average length of stay of 8.2 days. In contrast, there were 1,840 cases without CC, with average charges of approximately $17,939 and an average length of stay of 3.7 days. Therefore, we are proposing to create two new DRGs, splitting on CC, for patients with only a vascular shunt procedure: proposed new DRG 529 (Ventricular Shunt Procedures With CC) and proposed new DRG 530 (Ventricular Shunt Procedures Without CC). Proposed new DRG 529 would consist of any principal diagnosis in MDC 5, with the presence of a CC and one of the following operating room procedures: • 02.31, Ventricular shunt to structure in head and neck • 02.32, Ventricular shunt to circulatory system • 02.33, Ventricular shunt to thoracic cavity • 02.34, Ventricular shunt to abdominal cavity and organs • 02.35, Ventricular shunt to urinary system • 02.39, Other operations to establish drainage of ventricle • 02.42, Replacement of ventricular shunt • 02.43, Removal of ventricular shunt Proposed new DRG 530 would consist of any principal diagnosis in MDC 5 with one of the operating room procedures listed above for the proposed new DRG 529, but without the presence of a CC. b. DRG 23 (Nontraumatic Stupor and Coma). In DRG 23 (Nontraumatic Stupor and Coma), there are currently six principal diagnoses identified by the following ICD-9-CM diagnosis codes: 348.4, Compression of the brain; 348.5, Cerebral edema; 780.01, Coma; 780.02, Transient alteration of awareness; 780.03, Persistent vegetative state; and 780.09, Other alteration of consciousness. Code 780.02 is often used to describe the diagnosis of psychiatric patients rather than the diagnosis of patients with severe neurological disorders. The treatment plan for a patient with “transient alteration of awareness” is clinically very different from the treatment plan for a coma patient. Furthermore, many patients with this diagnosis are treated in psychiatric facilities rather than in acute care hospitals. Although there are neurological patients who present with the complaint of “transient alteration of awareness,” the cause of this alteration of consciousness is commonly identified, and the principal diagnosis for the hospital admission is the etiology of the alteration of consciousness rather than the symptom itself. For the few remaining neurological patients for whom the cause is not identified and for whom code 780.02 is assigned as the principal diagnosis, we still believe that the care of these patients is different than the care of patients with coma or cerebral edema. Because we believe the patients with a principal diagnosis of “transient alteration of consciousness” are more clinically related to the patients in DRG 429 (Organic Disturbances and Mental Retardation) in MDC 19 (Mental Diseases and Disorders), we are proposing that patients who are assigned a principal diagnosis of code 780.02 will be assigned to DRG 429 instead of DRG 23. DRG 429 also contains similar diagnoses, such as code 293.81, Organic delusional syndrome and code 293.82, Organic hallucinosis syndrome. We note that the charges for the patient cases in DRGs 23 and 429 are very similar ($11,559 and $11,713, respectively), so the proposed movement of code 780.02 from DRG 23 to DRG 429 would have minimal payment impact. Moving this diagnosis code would also consolidate diagnoses treated frequently in psychiatric hospitals in those DRGs that are likely to be a part of the upcoming proposed Medicare psychiatric facility PPS. 4. MDC 5 (Diseases and Disorders of the Circulatory System) a. DRG 478 (Other Vascular Procedures With CC) and DRG 479 (Other Vascular Procedures Without CC) Code 37.64 (Removal of heart assist system) in DRGs 478 and 479 describes the operative, as opposed to bedside, removal of a heart assist system. Based on comments we received suggesting that code 37.64 was inappropriately assigned to DRGs 478 and 479, we reviewed the MedPAR data for both DRGs 478 and 479 and DRG 110 (Major Cardiovascular Procedures With CC) and DRG 111 (Major Cardiovascular Procedures Without CC) to assess the appropriate assignment of code 37.64. We found that there were only 17 cases of code 37.64 in DRGs 478 and 479, with an average length of stay of 14.1 days and average charges of $105,153. There were a total of 90,591 cases in DRGs 478 and 479 that did not contain code 37.64. These cases had an average length of stay of 6.6 days and average charges of $31,879. In DRGs 110 and 111, we found an average length of stay of 8.1 days, with average charges of $54,653. We are proposing to remove code 37.64 from DRGs 478 and 479 and reassign it to DRGs 110 and 111. The surgical removal of a heart assist system is a major cardiovascular procedure and, therefore, more appropriately assigned to DRGs 110 and 111. Accordingly, we believe this DRG assignment for this procedure is more clinically and financially appropriate. b. DRGs 514 (Cardiac Defibrillator Implant With Cardiac Catheterization) and 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization)
(1)Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction We received a recommendation that we modify DRG 514 (Cardiac Defibrillator Implant With Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization) so that these DRGs are split based on the presence or absence of acute myocardial infarction, heart failure, or shock. We note that the increased cost of treating cardiac patients with acute myocardial infarction, heart failure, or shock is recognized in the payment logic for pacemaker implants (DRG 115 (Permanent Cardiac Pacemaker Implant With Acute Myocardial Infarction, Heart Failure or Shock, or AICD Lead or Generator) and DRG 116 (Other Permanent Cardiac Pacemaker Implant)). We examined FY 2002 MedPAR data regarding the number of cases and the average charges for DRGs 514 and 515. The results of our examination are summarized in the following table. DRG Number of cases Average charges With AMI, heart failure, or shock count Average charges 514 16,743 $97,133 3,623 $120,852 515 4,674 76,537 935 84,140 A cardiac catheterization is generally performed to establish the nature of the patient's cardiac problem and determine if implantation of a cardiac defibrillator is appropriate. Generally, the cardiac catheterization can be done on an outpatient basis. Patients who are admitted with acute myocardial infarction, heart failure, or shock and have a cardiac catheterization are generally acute patients who require emergency implantation of the defibrillator. Thus, there are very high costs associated with these patients. We found that the average charges for patients with cardiac catheterizations who also had acute myocardial infarction, heart failure, or shock were $120,852, compared to the average charges for all DRG 514 cases of $97,133. Therefore, we are proposing to split DRG 514 and create a new DRG for patients receiving a cardiac defibrillator implant with cardiac catheterization and with acute myocardial infarction, heart failure, or shock. Patients without cardiac catheterization generally have had the need for the defibrillator established on an outpatient basis prior to admission. We found 935 cases with acute myocardial infarction, heart failure, or shock, with average charges of $84,140. The average charges for all cases in DRG 515 were $76,537. Because of the relatively small number of patients and the less-than-10-percent charge difference for patients in DRG 515 who have acute myocardial infarction, heart failure, or shock, we are not proposing to create a separate DRG for patients with a cardiac defibrillator implant without cardiac catheterization with acute myocardial infarction, heart failure, or shock. Specifically, we are proposing to create two new DRGs that would replace the current DRG 514. The two new DRGs would have the same procedures currently listed for DRG 514, but would be split based on the presence or absence of acute myocardial infarction, heart failure, or shock. The proposed new DRGs would be DRG 535 (Cardiac Defibrillator Implant With Cardiac Catheterization and With Acute Myocardial Infarction, Heart Failure, or Shock) and DRG 536 (Cardiac Defibrillator Implant With Cardiac Catheterization and Without Acute Myocardial Infarction, Heart Failure, or Shock). Proposed new DRG 536 would exclude the following principal diagnosis codes from MDC 5 associated with acute myocardial infarction, heart failure, or shock. • 398.91, Rheumatic heart failure • 402.01, Malignant hypertensive heart disease with heart failure • 402.11, Benign hypertensive heart disease with heart failure • 402.91, Hypertensive heart disease not otherwise specified with heart failure • 404.01, Malignant hypertensive heart and renal disease with heart failure • 404.03, Malignant hypertensive heart and renal disease with heart failure and renal failure • 404.11, Benign hypertensive heart and renal disease with heart failure • 404.13, Benign hypertensive heart and renal disease with heart failure and renal failure • 404.91, Hypertensive heart and renal disease not otherwise specified with heart failure • 404.93, Hypertensive heart and renal disease not otherwise specified with heart failure and renal failure • 410.01, AMI anterolateral, initial • 410.11, AMI anterior wall, initial • 410.21, AMI inferolateral, initial • 410.31, AMI inferopost, initial • 410.41, AMI inferior wall, initial • 410.51, AMI lateral not elsewhere classified, initial • 410.61, True posterior infarction, initial • 410.71, Subendocardial infarction, initial • 410.81, AMI not elsewhere classified, initial • 410.91, AMI not otherwise specified, initial • 428.0, Congestive heart failure, not otherwise specified • 428.1, Left heart failure • 428.20, Systolic heart failure, not otherwise specified • 428.21, Acute systolic heart failure • 428.22, Chronic systolic heart failure • 428.23, Acute on chronic systolic heart failure • 428.30, Diastolic heart failure, not otherwise specified • 428.31, Acute diastolic heart failure • 428.32, Chronic diastolic heart failure • 428.33, Acute on chronic diastolic heart failure • 428.40, Combined systolic and diastolic heart failure not otherwise specified • 428.41, Acquired combined systolic and diastolic heart failure • 428.42, Chronic combined systolic and diastolic heart failure • 428.43, Acute on chronic combined systolic and diastolic heart failure • 428.9, Heart failure, not otherwise specified • 785.50, Shock, not otherwise specified • 785.51, Cardiogenic shock
(2)Cardiac Resynchronization Therapy
(CRT)We received a comment from a provider who pointed out that we did not include the following combination of codes under the list of procedure combinations that would lead to an assignment of DRG 514 or DRG 515: • 39.75, Implantation of automatic cardioverter/defibrillator lead(s) only • 00.54, Implantation or replacement of cardiac resynchronization defibrillator, pulse generator device only [CRT-D] The commenter pointed out that cases are assigned to DRGS 514 and 515 when a total cardiodefibrillator or CRT-D system is implanted. In addition, cases are assigned to DRGs 514 and 515 when implantation of a variety of combinations of defibrillator leads and device combinations are reported. The commenter indicated that total defibrillator and CRT-D system may be replaced with completely new systems or all new devices and leads, and added that it is also possible to replace a generator, a lead, or a combination of generators and up to three leads. When the CRT-D generator (code 00.54) and one of the cardioverter/defibrillator leads are replaced, the case currently is assigned to DRG 115 (Permanent Cardiac Pacemaker Implant with AMI, Heart Failure, or Shock or AICD Lead or Generator Procedure). The commenter recommended that we include the combination of codes 39.75 and 00.54 as a combination that would result in assignment to DRG 514 or DRG 515, as do other combinations of generators and leads. Our medical advisors agree with this recommendation. As discussed previously, we are proposing to delete DRG 514 and replace it with proposed new DRGs 535 and 536. Therefore, we are proposing to add codes 39.75 and 00.54 to the list of procedure combinations that would result in assignment to DRG 515 or new proposed DRGs 535 and 536. 5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) We received a comment that two codes for cervical fusion of the spine are not included within DRG 519 (Cervical Spinal Fusion With CC) and DRG 520 (Cervical Spinal Fusion Without CC). The two cervical fusion codes are: • 81.01, Atlas-axis spinal fusion • 81.31, Refusion of atlas-axis The atlas-axis includes the first two vertebrae of the cervical spine (C1 and C2). These two cervical fusion codes are currently assigned to DRG 497 (Spinal Fusion Except Cervical With CC) and DRG 498 (Spinal Fusion Except Cervical Without CC). Because codes 81.01 and 81.31 involve the cervical spine, we are proposing to remove these codes from DRGs 497 and 498 and reassign them to DRGs 519 and 520. 6. MDC 15 (Newborns and Other Neonates With Conditions Originating in the Perinatal Period) a. Nonneonate Diagnoses. As indicated earlier, ICD-9-CM diagnosis codes are assigned to MDCs based on 25 groupings corresponding to a single organ system or etiology and, in general, are associated with a particular medical specialty. MDC 15 is comprised of diagnoses that relate to newborns and other neonates with conditions originating in the perinatal period. Some of the codes included in MDC 15 consist of conditions that originate in the neonatal period but can persist throughout life. These conditions are referred to as congenital anomalies. When an older (not neonate) population is treated for a congenital anomaly, DRG assignment problems can arise. For instance, if a patient is over 65 years old and is admitted with a congenital anomaly, it is not appropriate to assign the patient to a newborn DRG. This situation occurs when a congenital anomaly code is classified within MDC 15. We have received a recommendation to move the following congenital anomaly codes from MDC 15 and reassign them to other appropriate MDCs based on the body system being treated: • 758.9, Chromosome anomaly, not otherwise specified • 759.4, Conjoined twins • 759.7, Multiple congenital anomalies, not elsewhere classified • 759.81, Prader-Willi syndrome • 759.83, Fragile X syndrome • 759.89, Specified congenital anomalies, not elsewhere classified • 759.9, Congenital anomaly, not otherwise specified • 779.7, Periventricular leukomalacia • 795.2, Abnormal chromosomal analysis Each of the congenital anomaly diagnosis codes recommended for reassignment represents a condition that is frequently addressed beyond the neonatal period. In addition, the assignment of these congenital anomaly codes as principal diagnosis currently results in assignment to MDC 15. We have evaluated the recommendation and agree that each of the identified codes represents a condition that is frequently addressed beyond the neonate period and should therefore be removed from the list of principal diagnoses that result in assignment to MDC 15. Therefore, we are proposing to change the MDC and DRG assignments of the congenital anomaly codes as specified in the following table. The table shows the principal diagnosis code for the congenital anomaly and the proposed MDC and DRG to which the code would be assigned. Principal diagnosis code in MDC 15 Code title Proposed MDC assignment Proposed DRG assignment 758.9 Chromosome anomaly, not otherwise specified 23 467 (Other Factors Influencing Health Status). 759.4 Conjoined twins 6 188, 189, and 190 (Other Digestive System Diagnoses, Age >17 with CC, Age >17 without CC, and Age 0-17, respectively). 759.7 Multiple congenital anomalies, not elsewhere classified 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 Specified congenital anomalies, not elsewhere classified 8 256 (Other Musculoskeletal System and Connective Tissue Diagnoses). 759.9 Congenital anomaly, not otherwise specified 23 467 (Other Factors Influencing Health Status). 779.7 Periventricular leukomalacia 1 34 and 35 (Other Disorders of Nervous System with CC, and without CC, respectively). 795.2 Abnormal chromosomal analysis 23 467 (Other Factors Influencing Health Status). b. Heart Failure Codes for Newborns and Neonates. Under MDC 15, cases of newborns and neonates with major problems may be assigned to DRG 387 (Prematurity With Major Problems) or DRG 389 (Full-Term Neonate With Major Problems). Existing DRG 387 has three components:
(1)Principal or secondary diagnosis of prematurity;
(2)principal or secondary diagnosis of major problem (these are the diagnoses that define MDC 15); or
(3)secondary diagnosis of major problem (these are diagnoses that do not define MDC 15, so they will only be secondary diagnosis codes for patients assigned to MDC 15). To be assigned to DRG 389, the neonate must have one of the principal or secondary diagnoses listed under the DRG. We have received correspondence suggesting that the following diagnosis codes for heart failure, which are currently in MDC 5, be added to the list of major problems for neonates under MDC 15. Diagnosis code Title 428.20 Systolic heart failure, not otherwise specified. 428.21 Acute systolic heart failure. 428.22 Chronic systolic heart failure. 428.23 Acute on chronic systolic heart failure. 428.30 Diastolic heart failure, not otherwise specified. 428.31 Acute diastolic heart failure. 428.32 Chronic diastolic heart failure. 428.33 Acute on chronic diastolic heart failure. 428.40 Systolic/diastolic heart failure, not otherwise specified. 428.41 Acute systolic/diastolic heart failure. 428.42 Chronic systolic/diastolic heart failure. 428.43 Acute on chronic systolic/diastolic heart failure. These heart failure-related diagnosis codes were new codes as of October 1, 2002. They were an expansion of the previous 4-digit codes for heart failure and provided additional detail about the specific type of heart failure. The other codes for heart failure that existed prior to October 1, 2002, are classified as major problems within MDC 15 and are currently assigned to DRGs 387 and DRG 389. We agree that diagnosis codes 428.20 through 428.43 listed in the chart above should be included as principal diagnosis of major problem codes within MDC 15 and, therefore, are proposing to add them to DRG 387 and 389. 7. MDC 17 (Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms) High-dose Interleukin-2 (IL-2) Chemotherapy is a hospital inpatient-based regimen requiring administration by experienced oncology professionals. It is used for the treatment of patients with advanced renal cell cancer and advanced melanoma. Unlike traditional cytotoxic chemotherapies that attack cancer cells themselves, Interleukin-2 is designed to enhance the body's defenses by mimicking the way natural IL-2 activates the immune system and stimulates the growth and activity of cancer-killing cells. The IL-2 product on the market was approved for use by the Food and Drug Administration
(FDA)in 1992. High-dose IL-2 therapy is performed only in very specialized treatment settings, such as an intensive care unit or a bone marrow transplant unit. This therapy requires oversight by oncology health care professionals experienced in the administration and management of patients undergoing this intensive treatment because of the severity of the side effects. Unlike most cancer therapies, high-dose IL-2 therapy is associated with predictable toxicities that require extensive monitoring. Often patients require one-on-one nursing or physician care for extended portions of their stay. High-dose IL-2 therapy is significantly different from conventional chemotherapy in terms of the resources required to administer it. Conventional chemotherapy may be given to patients either on an outpatient basis or through a series of short (that is, 1 to 3 day) inpatient stays. High-dose IL-2 therapy is given during two separate hospital admissions. For the first cycle, the IL-2 is administered every 8 hours over 5 days. Patients are then discharged to rest at home for several days and then are admitted for the second cycle of therapy, in which the same regimen and dosing is repeated. The two cycles complete the first course of high-dose IL-2 therapy. This regimen may be repeated at 8 to 12 weeks if the patient is responding. The maximum number of courses for any one patient is predicted to be five courses. Not all patients with end-stage renal cell carcinoma or end-stage melanoma are appropriate candidates for high-dose IL-2 chemotherapy. It is estimated that there are between 15,000 and 20,000 patients in the United States who have one of these two types of cancer. However, only 20 percent of those patients will be appropriate candidates for the rigors of the treatment regimen. It is further estimated that, annually, approximately 1,300 of these patients will be Medicare beneficiaries. However, allegedly due to the level of payment for the DRGs to which these cases are currently assigned, we have been informed by industry sources that only between 100 and 200 Medicare patients receive the treatment each year. According to these industry sources, several treatment centers have had to discontinue their high-dose IL-2 therapy programs for end-stage renal cell carcinoma or end-stage melanoma because of the low Medicare payment. According to industry sources, the wholesale cost of IL-2 is approximately $700 per vial. Dosages range between 15 and 20 vials per treatment, or between $10,500 and $14,000 per patient, per cycle, for the cost of the IL-2 drug alone. There is no ICD-9-CM procedure code that currently identifies patients receiving this therapy. Therefore, it is not possible to identify directly these cases in the MedPAR data. Currently, this therapy is coded using the more general ICD-9-CM code 99.28 (Injection or infusion of biologic response modifier). When we addressed this issue previously in the August 1, 2000 IPPS final rule (65 FR 47067) by examining cases for which procedure code 99.28 was present, our analysis was inconclusive due to the wide range of cases identified (1,179 cases across in 136 DRGs). However, recent data collected by the industry on 30 Medicare beneficiaries who received high-dose IL-2 therapy during FY 2002 show average charges for these cases of approximately $54,000. Depending on the principal diagnosis reported, patients receiving high-dose IL-2 therapy may be assigned to one of the following five DRGs: DRG 272 (Major Skin Disorder With CC) and DRG 273 (Major Skin Disorder Without CC) in MDC 9; DRG 318 (Kidney and Urinary Tract Neoplasms With CC) and DRG 319 (Kidney and Urinary Tract Neoplasms Without CC) in MDC 11; and DRG 410 (Chemotherapy Without Leukemia as Secondary Diagnosis) in MDC 17. The following table illustrates the average charges for patients in these DRGs. DRG Average charges 272 $14,997 273 9,128 318 16,892 319 9,583 410 16,103 Because of the need to identify the subset of patients receiving this type of treatment, the ICD-9-CM Coordination and Maintenance Committee determined, based on its consideration at the December 6, 2002 public meeting, that a new code for high-dose IL-2 therapy was warranted. Therefore, a new code has been created in the 00 Chapter of ICD-9-CM (Procedures and Interventions, Not Elsewhere Classified), in category 00.1 (Pharmaceuticals) at 00.15 (High-dose infusion Interleukin-2 (IL-2)), effective October 1, 2003. We believe patients receiving high-dose IL-2 therapy are clinically similar to other cases currently assigned to DRG 492 (Chemotherapy With Acute Leukemia as Secondary Diagnosis) in MDC 17. The average charge for patients currently assigned to DRG 492 is $55,581. Currently, DRG 492 requires one of the following two principal diagnoses: • V58.1, Encounter for chemotherapy • V67.2, Followup examination following chemotherapy • And one of the following secondary diagnoses: • 204.00, Acute lymphoid leukemia without mention of remission • 204.01, Acute lymphoid leukemia with remission • 205.00, Acute myeloid leukemia without mention of remission • 205.01, Acute myeloid leukemia with remission • 206.00, Acute monocytic leukemia without mention of remission • 206.01, Acute monocytic leukemia with remission • 207.00, Acute erythremia and erythroleukemia without mention of remission • 207.01, Acute erythremia and erythroleukemia with remission • 208.00, Acute leukemia of unspecified cell type without mention of remission • 208.01, Acute leukemia of unspecified cell type without mention of remission We are proposing to modify DRG 492 by adding new procedure code 00.15 to the logic. Assignment to this DRG would require the same two V-code principal diagnosis codes as listed above (V58.1 and V67.2), but would require either one of the leukemia codes listed as a secondary diagnosis, or would require the procedure code 00.15. In addition, we are proposing to change the title of DRG 492 to “Chemotherapy With Acute Leukemia or With Use of High Dose Chemotherapy Agent”. We will monitor cases with procedure code 00.15 as these data become available, and consider potential further refinements to DRG 492 as necessary. 8. MDC 23 (Factors Influencing Health Status and Other Contacts With Health Services) a. Implantable Devices. We received a comment regarding three ICD-9-CM diagnosis codes that are currently assigned to MDC 23: V53.01 (Fitting and adjustment of cerebral ventricular (communicating) shunt); V53.02 (Neuropacemaker (brain) (peripheral nerve) (spinal cord)); and V53.09 (Fitting and adjustment of other devices related to nervous system and special senses). The commenter suggested that we move these three codes from MDC 23 to MDC 1 (Diseases and Disorders of the Nervous System) because these codes are used as the principal diagnosis for admissions involving removal, replacement, and reprogramming of devices such as cerebral ventricular shunts, neurostimulators, intrathecal infusion pumps and thalamic stimulators. Currently, if these diagnosis codes are reported alone without an O.R. procedure, the case would be assigned to DRG 467 (Other Factors Influencing Health Status). However, if an O.R. procedure is reported with the principal diagnosis of V53.01, V53.02, or V53.09, the case would be assigned to DRG 461 (O.R. Procedure with Diagnoses of Other Contact with Health Services). In our analysis of the MedPAR data, we found 30 cases assigned to DRG 467 and 179 cases assigned to DRG 461 with one of these codes as principal diagnosis. We found that the procedures reported with one of these diagnosis codes were procedures in MDC 1. The most frequent procedure was 86.06 (Insertion of totally implantable infusion pump). Because the procedures that are routinely used with these codes are in MDC 1, it would be appropriate to assign these diagnosis codes to MDC 1. As the commenter also stated, this assignment would be consistent with how fitting and adjustments of devices are handled within other MDCs, such as in MDC 5 (Disease and Disorders of the Circulatory System) and MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract). Diagnosis codes V53.31 (Cardiac pacemaker), V53.32 (Automatic implantable cardiac defibrillator), and V53.39 (Other cardiac device) are used for fitting and adjustment of cardiac devices and are assigned to MDC 5. Diagnosis code V53.6 (Urinary devices) is used for fitting and adjustment of urinary devices and is assigned to MDC 11. Therefore, we are proposing to move V53.01, V53.02, and V53.09 from MDC 23 to MDC 1 when an O.R. procedure is performed. If no O.R. procedure is performed, these diagnosis codes would be assigned to DRG 34 (Other Disorders of Nervous System With CC) or DRG 35 (Other Disorders of Nervous System Without CC). If an O.R. procedure is performed on a patient assigned with one of these codes as the principal diagnosis, the case would be assigned to the DRG in MDC 1 to which the O.R. procedure is assigned. b. Malignancy Codes. We received correspondence that indicated that when we recognized code V10.48 (History of malignancy, epididymis) as a new code for FY 2002, we did not include the code as a history of malignancy code in DRG 465 (Aftercare with History of Malignancy as Secondary Diagnosis). All other history of malignancy codes were included in DRG 465. We agree that code V10.48 should have been included in the list of history of malignancy codes within DRG 465 and, therefore, are proposing to add it to the list of secondary diagnoses in DRG 465. 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. We received a request to examine the MCE edit “Adult Diagnosis—Age Greater than 14” because currently the edit rejects claims for patients under age 15 who are being treated for gall bladder disease. We reviewed this issue with our pediatric consultants and determined that, although incidence is rare, gallbladder disease does occur in patients under age 15. Therefore, we are proposing to modify the MCE by removing the following codes from the edit “Adult Diagnosis—Age Greater Than 14”: • 574.00, Calculus of gallbladder with acute cholecystitis without mention of obstruction • 574.01, Calculus of gallbladder with acute cholecystitis with obstruction • 574.10, Calculus of gallbladder with other cholecystitis without mention of obstruction • 574.11, Calculus of gallbladder with other cholecystitis with obstruction • 574.20, Calculus of gallbladder without mention of cholecystitis without mention of obstruction • 574.21, Calculus of gallbladder without mention of cholecystitis with obstruction • 574.30, Calculus of bile duct with acute cholecystitis without mention of obstruction • 574.31, Calculus of bile duct with acute cholecystitis with obstruction • 574.40, Calculus of bile duct with other cholecystitis without mention of obstruction • 574.41, Calculus of bile duct with other cholecystitis with obstruction • 574.50, Calculus of bile duct without mention of cholecystitis without mention of obstruction • 574.51, Calculus of bile duct without mention of cholecystitis with obstruction • 574.60, Calculus of gallbladder and bile duct with acute cholecystitis without mention of obstruction • 574.61, Calculus of gallbladder and bile duct with acute cholecystitis with obstruction) • 574.70, Calculus of gallbladder and bile duct with other cholecystitis without mention of obstruction • 574.71, Calculus of gallbladder and bile duct with other cholecystitis with obstruction • 574.80, Calculus of gallbladder and bile duct with acute and chronic cholecystitis without mention of obstruction • 574.81, Calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction • 574.90, Calculus of gallbladder and bile duct without cholecystitis without mention of obstruction • 574.90, Calculus of gallbladder and bile duct without cholecystitis with obstruction • 575.0, Acute cholecystitis • 575.10, Cholecystitis, not otherwise specified • 575.11, Chronic cholecystitis • 575.12, Acute and chronic cholecystitis • 575.2, Obstruction of gallbladder • 575.3, Hydrops of gallbladder • 576.0, Postcholecystectomy syndrome • 577.1, Chronic pancreatitis 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. Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class. Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization. A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class “kidney transplant” consists of a single DRG (DRG 302) and the class “kidney, ureter and major bladder procedures” consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class involves weighting the average resources for each DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG in the class by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of “other O.R. procedures” as discussed below. This methodology may occasionally result in assignment of a case involving multiple procedures to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER search for the procedure in the most resource-intensive surgical class, 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, assignment to these surgical classes should only occur if no other surgical class more closely related to the diagnoses in the MDC is appropriate. A second example occurs when the difference between the average charges for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy because, as a result of reassigning cases on the basis of the hierarchy change, the average charges are likely to shift such that the higher-ordered surgical class has a lower average charge than the class ordered below it. 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, MDC 1 (Diseases and Disorders of the Nervous System), MDC 5 (Diseases and Disorders of the Circulatory System), MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue), and MDC 17 (Myeloproliferative Disease and Disorders, Poorly Differentiated Neoplasms for Lymphoma and Leukemia) as follows: • In the pre-MDC DRGs, we are proposing to reorder DRG 513 (Pancreas Transplant) above DRG 512 (Simultaneous Pancreas/Kidney Transplant). • In MDC 1, we are proposing to reorder DRG 3 (Craniotomy Age 0-17) above DRG 528 (Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage); DRG 528 above DRGs 1 and 2 (Craniotomy Age >17 With and Without CC, respectively); DRGs 1 and 2 above DRGs 529 and 530 (Ventricular Shunt Procedures With and Without CC, respectively); DRGs 529 and 530 above DRGs 531 and 532 (Spinal Procedures With and Without CC, respectively); DRGs 531 and 532 above DRGs 533 and 534 (Extracranial Procedures With and Without CC, respectively); and DRGs 533 and 534 above DRG 6 (Carpal Tunnel Release). • In MDC 5, we are proposing to reorder DRG 535 (Cardiac Defibrillator Implant With Cardiac Catheterization With AMI, Heart Failure, or Shock) above DRG 536 (Cardiac Defibrillator Implant With Cardiac Catheterization Without AMI, Heart Failure, or Shock), and DRG 536 above DRG 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization). • In MDC 8, we are proposing to reorder DRGs 537 and 538 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With and Without CC, respectively) above DRG 230 (Local Excision and Removal of Internal Fixation Devices of Hip and Femur). • In MDC 17, we are proposing to reorder DRGs 539 and 540 (Lymphoma and Leukemia With Major O.R. Procedure With and Without CC, respectively) above DRGs 401 and 402 (Lymphoma and Non-Acute Leukemia With Other O.R. Procedures With and Without CC, 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; the August 1, 2001 final rule (66 FR 39851) for the FY 2002 revisions; and the August 1, 2002 final rule (67 FR 49998) for the FY 2003 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, 2003. (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, 2003. 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, 2003, 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, 2003, 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, 2002, and 2003) and those in Tables 6G and 6H of the final rule for FY 2004 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, 2003. (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 20.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 21.0 of this manual, which includes the final FY 2003 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, not elsewhere classified • 60.81, Incision of periprostatic tissue • 60.82, Excision of periprostatic tissue • 60.93, Repair of prostate • 60.94, Control of (postoperative) hemorrhage of prostate • 60.95, Transurethral balloon dilation of the prostatic urethra • 60.99, 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). In the August 1, 2002 final rule (67 FR 49999), we did not move any procedures from DRG 477. However, we did move procedures codes from DRG 468 and placed them in more clinically coherent DRGs. a. Moving Procedure Codes from DRG 468 or DRG 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 identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this 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 necessary proposed change under DRG 468 relating to code 50.29 (Other destruction of lesion of liver). We were contacted by a hospital about the fact that code 50.29 is not currently included in MDC 6 (Diseases and Disorders of the Digestive System). The hospital pointed out that it is not uncommon for patients to have procedures performed on the liver when they are admitted for a condition that is classified in MDC 6. For example, DRGs 170 and 171 (Other Digestive System O.R. Procedures With and Without CC, respectively) in MDC 6 currently include liver procedures such as biopsy of the liver. The hospital disagreed with the assignment of code 50.29 to DRG 468 when performed on a patient with a principal diagnosis in MDC 6. We believe that the commenter is correct and are proposing to assign code 50.29 to DRGs 170 and 171 in MDC 6. 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 or Procedure Codes to MDCs. Based on our review this year, we are not proposing to add any diagnosis codes to MDCs. However, we have identified several procedures that we propose to move from DRG 468 and add to DRGs 476 and 477 because the procedures are nonextensive: • 38.21, Biopsy of blood vessel • 77.42, Biopsy of scapula, clavicle and thorax [ribs and sternum] • 77.43, Biopsy of radius and ulna • 77.44, Biopsy of carpals and metacarpals • 77.45, Biopsy of femur • 77.46, Biopsy of patella • 77.47, Biopsy of tibia and fibula • 77.48, Biopsy of tarsals and metatarsals • 77.49, Biopsy of other bones • 92.27, Implantation or insertion of radioactive elements 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 ICD-9-CM Manual contains the list of valid diagnosis and procedure codes. (The ICD-9-CM Manual is available from the Government Printing Office on CD-ROM for $23.00 by calling
(202)512-1800.) The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in the *Tabular List* and *Alphabetic Index for Diseases,* while CMS has lead responsibility for the ICD-9-CM procedure codes included in the *Tabular List* and *Alphabetic Index for Procedures.* The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and various physician specialty groups as well as 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 2004 at a public meeting held on December 6, 2002, and finalized the coding changes after consideration of comments received at the meetings and in writing by January 10, 2003. Those coding changes are announced later in this section of the preamble. Copies of the Committee procedure minutes of the 2002 meetings can be obtained from the CMS home page at: *http://www.cms.gov/paymentsystems/icd9/.* The diagnosis minutes are found at: *http://www.cdc.gov/nchs/icd9.htm.* Paper copies of these minutes are no longer available and the mailing list has been discontinued. The first of the 2003 public meetings was held on April 3, 2003. In the September 7, 2001 final rule implementing the IPPS new technology add-on payments (66 FR 46906), we indicated we would attempt to include all proposals discussed and approved at the April meeting as part of the code revisions effective the following October. Because this proposed rule is being published after the April meeting, we are able to include all new codes that were approved subsequent to that meeting in Table 6F of the Addendum to this proposed rule, including the DRG assignments. For a report of procedure topics discussed at the April 2003 meeting, see the Summary Report at: *http://www.cms.hhs.gov/paymentsystems/icd9/.* For a report of the diagnosis topics discussed at the April 2003 meeting, see the Summary Report at: *http:/www.cdc.gov/nchs/icd9.htm.* 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 2404, 3311 Toledo Road, Hyattsville, MD 20782. Comments may be sent by E-mail to: *dfp4@cdc.gov.* Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; CMS, Center for Medicare Mangement, Hospital and Ambulatory Policy Group, Division of Acute Care; C4-08-06; 7500 Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by E-mail to: *pbrooks@cms.hhs.gov.* The ICD-9-CM code changes that have been approved will become effective October 1, 2003. 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. For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A. New procedure codes are shown in Table 6B. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2003. Table 6D contains invalid procedure codes. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the DRG assignments for these revised codes. Table 6F includes a revised procedure code title for FY 2003. The Department of Health and Human Services has been actively working on the development of new coding systems to replace the ICD-9-CM. For example, the ICD-10-CM (for diagnoses) and the ICD-10-PCS (for procedures) were developed to replace ICD-9-CM. These efforts have become increasingly important because of the many problems with the ICD-9-CM, which was implemented 24 years ago. Implementing ICD-10-PCS as a national standard was discussed at the December 6, 2002, ICD-9-CM Coordination and Maintenance Committee meeting. A complete report of the meeting, including examples of letters supporting and opposing ICD-10-PCS, can be found at the CMS web site: *www.cms.hhs.gov/paymentsystems/icd9/.* Also, the Secretary has asked the NCVHS to recommend whether or not the country should replace ICD-9-CM as a national coding standard with ICD-10-CM and ICD-10-PCS. A complete report on the activities of this committee can be found at: *http://www.ncvhs.hhs.gov.* 14. Other Issues In addition to the specific topics discussed in section II.B.1. through 13. of this proposed rule, we considered a number of other DRG-related issues. Below is a summary of the issues that were addressed. a. Cochlear Implants. Cochlear implants were first covered by Medicare in 1986 and were assigned to DRG 49 (Major Head and Neck Procedures) in MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat). This is the highest weighted surgical DRG in MDC 3. However, commenters have contended that this DRG is clinically and economically inappropriate and have requested a specific DRG for cochlear implants. The commenters contend that, like heart assist systems (we created a new DRG last year, DRG 525 (Heart Assist System Implant) in MDC 5), cochlear implants are low incidence procedures with disproportionately high costs compared to other procedures within DRG 49. As we stated in the FY 2003 final rule in our discussion regarding the creation of DRG 525 (67 FR 49989), we found 185 heart assist system cases in DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization) and 90 cases in DRG 105 (Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization). The average charges for these cases were approximately $36,000 and $85,000, higher than the average charges for cases in DRGS 104 and 105, respectively, but they represented only a small fraction of all cases in these DRGs (1.3 percent and 0.5 percent, respectively). Therefore, despite the drastically higher average charges for heart assist systems, the relative volume was insufficient to affect the DRG weight to any great degree. In our analysis of the FY 2002 MedPAR file, we found 134 cochlear implant cases out of 1,637 cases assigned to DRG 49, which represent more than 8 percent of the total cases in DRG 49. Compared to the situation with the heart assist system implant cases in DRGs 104 and 105, cochlear implants do have a greater effect on the relative weight for DRG 49. Also, while average charges for cochlear implant cases are significantly more than other cases in DRG 49 (average charges for cochlear implant cases were $51,549 compared to $25,052 for noncochlear implant cases), this difference is much less than the $36,000 and $85,000 differences for heart assist systems cited above. Although we are concerned about the disparity between the average costs and payments for cochlear implant patients, we also have concerns about establishing a separate DRG for these cases. Doing so could create an incentive for some of these procedures to be shifted from outpatient settings, where most are currently performed. Even among current cochlear implant cases, our analysis found the average length of stay for Medicare patients receiving this procedure in the inpatient setting was just over 1 day, indicating minimal inpatient care is necessary for these cases. It is unclear whether a shift toward more inpatient stays would be appropriate. We also are concerned whether the volume of cochlear implant cases across all hospitals performing this procedure warrants establishing a new DRG. The DRG relative weights reflect an average cost per case, with the costs of some procedures above the DRG mean costs and some below the mean. It is expected that hospitals will offset losses for certain procedures with payment gains for other procedures, while responding to incentives to maintain efficient operations. An excessive proliferation of new DRGs for specific technologies would fundamentally alter this averaging concept. Accordingly, for the reasons cited above, we are not proposing to change the DRG assignment of cochlear implants at this time. However, we encourage public comments as to whether a new DRG for cochlear implants (or some other solution) is warranted. b. Burn Patients on Mechanical Ventilation. Concerns have been raised by hospitals treating burn patients that the current DRG payment for burn patients on mechanical ventilation is not adequate. The DRG assignment for these cases depends on whether the hospital performed the tracheostomy, or the tracheostomy was performed prior to transfer to the hospital. If the hospital does not actually perform the tracheostomy, the case is assigned to one of the burn DRGs in MDC 22 (Burns). If the hospital performs a tracheostomy, the case is assigned to DRG 482 (Tracheostomy for Face, Mouth, and Neck Diagnoses) or DRG 483 (Tracheostomy with Mechanical Ventilation 96 + Hours, Except Face, Mouth and Neck Diagnoses). In the August 1, 2002 final rule, we modified DRGs 482 and 483 to recognize code 96.72 (Continuous mechanical ventilation for 96 consecutive hours or more) for the first time in the DRG assignment (67 FR 49996). We noted that many patients assigned to DRG 483 did not have code 96.72 recorded. We believed this was due, in part, to the limited number of procedure codes
(six)that can be submitted on the current billing form, and the fact that code 96.72 did not affect the DRG assignment (prior to FY 2003). We stated that we would give future consideration to further modifying DRGs 482 and 483 based on the presence of code 96.72. We anticipate that cases of patients receiving 96 or more hours of continuous mechanical ventilation are more expensive than other tracheostomy patients. Once code 96.72 is reported more frequently, we will be better able to assess the need for future revisions to DRGs 482 and 483. To assess the payment for burn patients on mechanical ventilation when the hospital did not perform the tracheostomy, we analyzed data on cases reporting both code 96.72 and diagnosis code V44.0 (Tracheostomy status). We had hoped that these cases would show patients on long-term ventilation who were admitted to the hospital with a tracheostomy in place. Our data did not include any cases reported in any of the burn DRGs with codes 96.72 and V44.0. We then analyzed data on the frequency of cases reporting code 96.72 along with diagnosis code V46.1 (Respirator dependence). We found only 5 of these cases in the burn DRGs. With so few cases reporting code 96.72, it is difficult for us to determine the effect of long-term ventilation on reimbursement for burn cases. All hospitals, including those that treat burn patients, are encouraged to increase the reporting of code 96.72 for patients who are on continuous mechanical ventilation for 96 or more hours. With better data, we would be able to determine how best to make any future DRG modification for all patients on long-term mechanical ventilation. c. Multiple Level Spinal Fusion. We received a comment recommending the establishment of new DRGs that would differentiate between the number of levels of vertebrae involved in a spinal fusion procedure. The commenter noted that the ICD-9-CM Coordination and Maintenance Committee discussed adding a new series of codes to identify multiple levels of spinal fusions at its December 6, 2002 meeting. The following codes were approved by the Committee, effective for October 1, 2003, and are listed in Table 6B in the Addendum to this proposed rule: • 81.62, Fusion or refusion of 2-3 vertebrae • 81.63, Fusion or refusion of 4-8 vertebrae • 81.64, Fusion or refusion of 9 or more vertebrae The commenter conducted an analysis to support redefining the spinal fusion DRGs using these new ICD-9-CM codes. Using the CMS FY 2001 Standard Analytical File data for physicians and hospitals as the basis for its analysis, the commenter linked a 5-percent sample of hospital spinal fusion cases with the corresponding physician claims. Because there were no ICD-9-CM codes to identify multiple level fusions in 2001, multiple level fusions were identified using Current Procedural Terminology
(CPT)codes on the physician claims. The analysis found that increasing the levels fused from 1 to 2 levels to 3 or more levels increased the mean standardized charges by 38 percent for lumbar/thoracic fusions, and by 47 percent for cervical fusions. The commenter then recommended redefining the spinal fusion DRGs to differentiate between 1 to 2 level spinal fusions and multilevel spinal fusions. The following current spinal fusion DRGs separate cases based on whether or not a CC is present: DRG 497 (Spinal Fusion Except Cervical With CC) and DRG 498 (Spinal Fusion Except Cervical Without CC); and DRG 519 (Cervical Spinal Fusion With CC) and DRG 520 (Cervical Spinal Fusion Without CC). The difference in charges associated with the current CC-split is only slightly greater than the difference attributable to the number of levels fused as found by the commenter's analysis. Therefore, at this time, we are not proposing to redefine these DRGs to differentiate on the basis of the number of levels fused. We note that adopting the commenter's recommendation would necessitate adjusting the DRG relative weights using non-MedPAR data, because Medicare claims data with the new ICD-9-CM codes will not be available until the FY 2003 MedPAR file. Although we considered this possibility, we believe the more prudent course, given that the current DRG structure actually appears to differentiate appropriately among these cases, is to wait until sufficient data with the new multilevel spinal fusion codes are available before making a final determination on whether multilevel spinal fusions should be incorporated into the DRG structure. d. Heart Assist System Implant. During the comment period for the FY 2003 IPPS proposed rule on which the FY 2003 IPPS final rule was based, we received a suggestion that we develop a new heart transplant DRG entitled “Heart Transplant with Left Ventricular Assist Device (LVAD).” The commenter stated that, because a great number of LVAD cases remain inpatients until heart transplant occurs, there is a disparity in costs between heart transplant patients who receive LVADs during the stay and those who do not. Cases in which heart transplantation occurs during the hospitalization are assigned to DRG 103 (Heart Transplant). Therefore, the costs of LVAD cases are included in the DRG relative weight for DRG 103. However, we noted that we would continue to monitor these types of cases. When we reviewed the FY 2002 MedPAR data, we identified only 21 cases in DRG 103 that listed a procedure code that would indicate the use of an LVAD. We do not believe this is a sufficient number of cases to support creation of an additional DRG. Therefore, we are not proposing a change to the structure of either DRG 103 or DRG 525 at this time. e. *Drug-Eluting Stents.* In the August 1, 2002 final rule, we created two new temporary DRGs to reflect cases involving the insertion of a drug-eluting coronary artery stent as signified by the presence of code 36.07 (Insertion of drug-eluting coronary artery stent): DRG 526 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With AMI); and DRG 527 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent Without AMI). We expect that when claims data are available that reflect the use of these stents, we will combine drug-eluting stent cases with other cases in DRGs 516 and 517. In the absence of MedPAR data reflecting the use of drug-eluting stents, it was necessary to undertake several calculations to establish the FY 2003 DRG relative weights for these two new DRGs. First, based on prices where drug-eluting stents are currently being used and the average price of currently available stents, we calculated a price differential of approximately $1,200. Assuming average hospital charge markups for this technology (based on weighted average cost-to-charge ratios), the anticipated charge differential between nondrug-eluting and drug-eluting stents would be approximately $2,664 per stent. However, we recognize that some cases involve more than one stent. Using an average of 1.5 stents per procedure, we estimate that the net incremental charge for cases that would receive drug-eluting stents is $3,996. In order to determine accurately the DRG relative weights for these two new DRGs relative to all other DRGs, we also must estimate the volume of cases likely to occur. We used the manufacturer's estimate that as many as 43 percent of current stent patients will receive drug-eluting stents during FY 2003 to calculate the FY 2003 DRG relative weights, although we prorated this percentage since the new DRGs did not become active until April 1, 2003. Even though the DRG will become active on April 1, 2003, we expect that hospitals did not use this technology before FDA approval. (We intend to identify and review any cases with the code 36.07 that occurred prior to FDA approval.) Therefore, no payments are expected to have been made under these DRGs for cases occurring before FDA approval. In determining the FY 2004 proposed DRG relative weights for DRGs 526 and 527, we assumed that 43 percent of coronary stent cases (those with code 36.06 (Insertion of nondrug-eluting coronary artery stent)) from DRGs 516 and 517 would be reassigned to new DRGs 526 and 527 (with code 36.07), and the charges of these cases would be increased $3,996 per case, to approximate the higher charges associated with the drug-eluting stents in DRGs 526 and 527. The relative weights for DRGs 516 and 517 are calculated based on the charges of the cases estimated to remain in these two DRGs. We are proposing to maintain DRGs 526 and 527 for FY 2004, and to adopt the same methodology to establish the relative weights as we used for FY 2003. The FDA issued a decision on April 24, 2003 approving drug-eluting stents. For the final rule, we will use the best available data at that time to establish the FY 2004 relative weights for DRGs 526 and 527. f. *Artificial Anal Sphincter.* The ICD-9-CM Coordination and Maintenance Committee created two new codes to describe procedures involving an artificial anal sphincter for use for discharges occurring on or after October 1, 2002. One code (49.75, Implantation or revision of artificial anal sphincter) is used to identify cases involving implantation or revision of an artificial anal sphincter. The second code (49.76, Removal of artificial anal sphincter) is used to identify cases involving the removal of the device. In Table 6B of the August 1, 2002 IPPS final rule (67 FR 50242), we assigned both codes to one of four MDCs based on principal diagnosis, and to one of six DRGs within those MDCs as follows: MDC 6, DRG 157 (Anal and Stomal Procedures With CC) and DRG 158 (Anal and Stomal Procedures Without CC); MDC 9 (Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast), DRG 267 (Perianal and Pilonidal Procedures); MDC 21 (Injuries, Poisonings, and Toxic Effect of Drugs), DRG 442 (Other O.R. Procedures for Injuries With CC) and DRG 443 (Other O.R. Procedures for Injuries Without CC); and MDC 24 (Multiple Significant Trauma), DRG 486 (Other O.R. Procedures for Multiple Significant Trauma). We have received a request that we review these DRG assignments. According to the requester, the artificial anal sphincter procedures are expensive and the payment does not adequately cover a hospital's costs in the most likely occurring DRGs 157 and 158. The requester submitted data showing cases involving artificial anal sphincters with average charges of $44,000, and suggested that we assign codes 49.75 and 49.76 in MDC 6 to DRG 170 (Other Digestive System O.R. Procedures With CC) and DRG 171) (Other Digestive System O.R. Procedures Without CC) because DRG 170 and DRG 171 are higher weighted than DRGs 157 and 158. At this time, we are not proposing to assign these cases to DRGs 170 and 171. Although we recognize the data submitted by the commenter appear to show this procedure is associated with above average costs in the DRGs to which these cases are assigned, we believe the current assignment is the most clinically appropriate at this time. As noted above, the procedure codes to identify the implantation, revision, or removal of these devices were effective beginning on October 1, 2002. Therefore, we propose to monitor the costs of these cases using actual Medicare cases with these codes included from the FY 2003 MedPAR that will be used for the FY 2004 DRG relative weights. C. Recalibration of DRG Weights We are proposing to use the same basic methodology for the FY 2004 recalibration as we did for FY 2003 (August 1, 2002 IPPS final rule (67 FR 50008). That is, we are proposing to recalibrate the DRG weights based on charge data for Medicare discharges using the most current charge information available (the FY 2002 MedPAR file). The MedPAR file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. FY 2002 MedPAR data include discharges occurring between October 1, 2001 and September 30, 2002, based on bills received by CMS through December 31, 2002, from all hospitals subject to the IPPS and short-term acute care hospitals in Maryland (which is under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2002 MedPAR file includes data for approximately 11,404,829 Medicare discharges. Discharges for Medicare beneficiaries enrolled in a Medicare+Choice managed care plan are excluded from this analysis. The data include hospitals that subsequently became CAHs, although no data are included for hospitals after the point they are certified as CAHs. The proposed methodology used to calculate the DRG relative weights from the FY 2002 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. • 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. • Statistical outliers were eliminated by removing all cases that are beyond 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. • 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. • The transplant cases that were used to establish the relative weight for heart and heart-lung, liver, and lung transplants (DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2000 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.) • Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the prospective payment rate, it is necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average 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 2004. Using the FY 2002 MedPAR data set, there are 42 DRGs that contain fewer than 10 cases. We computed the weights for these low-volume DRGs by adjusting the proposed FY 2003 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 (1.45510) 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 IPPS. As noted below in section IV.A.2., we are proposing to expand the transfer policy applicable to postacute care transfers from 10 DRGs currently to an additional 19 DRGs, beginning in FY 2004. Because we count a transfer case as a fraction of a case as described above in the recalibration process, any expansion of the postacute care transfer policy to 19 additional DRGs would affect the proposed relative weights for those DRGs. Therefore, we calculated the proposed FY 2004 normalization factor comparing the case-mix using the proposed FY 2004 DRG relative weights in which we treated postacute care transfer cases in the 19 DRGs proposed to be added to the postacute transfer policy for FY 2004 as a fraction of a case with the case-mix using the FY 2003 DRG relative weights without treating cases in these 19 additional DRGs as transfer cases. 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 LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2004 1. Background In the March 7, 2003 LTCH PPS proposed rule (68 FR 11234), we proposed to change the LTCH PPS annual payment rate update cycle to be effective July 1 through June 30 instead of October 1 through September 30. In addition, since the patient classification system utilized under the LTCH PPS is based directly on the DRGs used under the IPPS for acute care hospitals, in that same proposed rule, we proposed that the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights would continue to remain linked to the annual reclassification and recalibration of the CMS-DRGs under the IPPS. The annual update to the IPPS DRGs is based on the annual revisions to the ICD-9-CM codes and is effective each October 1. In the health care industry, annual changes to the ICD-9-CM codes are effective for discharges occurring on or after October 1 each year. The use of the ICD-9-CM coding system is also compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA), Pub. L. 104-191, under 45 CFR Parts 160 and 162. Therefore, the manual and electronic versions of the GROUPER software, which are based on the ICD-9-CM codes, are also revised annually and effective for discharges occurring on or after October 1 each year. Because the LTC-DRGs are based on the patient classification system used under the IPPS (CMS-DRGs), which is updated annually and effective for discharges occurring on or after October 1 through September 30 each year, in the March 7, 2003 LTCH PPS proposed rule (68 FR 11234), we proposed to continue to update the LTC-DRG classifications and relative weights to be effective for discharges occurring on or after October 1 through September 30 each year. As we explained in the March 7, 2003 LTCH PPS proposed rule (68 FR 11234), the FY 2004 DRGs and relative weights used under the IPPS had not yet been proposed, and we were unable to propose updated LTC-DRGs and relative weights at that time. Therefore, since the LTC-DRG classifications and relative weights would continue to be based on the annual updates to the IPPS DRGs, we proposed that proposed revisions to the LTC-DRG classifications and relative weights would be presented for public comment in the IPPS proposed rule and finalized in the IPPS final rule, to be effective October 1, 2003 through September 30, 2004. For FY 2003, version 20.0 of the DRG GROUPER is being utilized under both the IPPS and the LTCH PPS. The LTC-DRG classifications and relative weights are shown in Table 3 of the Addendum to the August 30, 2002 for FY 2003 final rule (67 FR 56076-56084) and in Table 3 of the Addendum to the March 7, 2003 LTCH PPS proposed rule (68 FR 11285 through 11292). Below we discuss the proposed LTC-DRGs and relative weights for FY 2004 based on the proposed changes to the hospital IPPS DRGs (GROUPER version 21.0) discussed in section II. of this preamble. 2. Proposed Changes in the LTC-DRG Classifications a. Background. Section 123 of Pub. L. 106-113 specifically requires that the PPS for LTCHs be a per discharge system with a DRG-based patient classification system reflecting the differences in patient resources and costs in LTCHs while maintaining budget neutrality. Section 307(b)(1) of Pub. Law 106-554 modified the requirements of section 123 of Pub. L. 106-113 by specifically requiring that the Secretary examine “the feasibility and the impact of basing payment under such a system [the LTCH PPS] on the use of existing (or refined) hospital diagnosis-related groups
(DRGs)that have been modified to account for different resource use of long-term care hospital patients as well as the use of the most recently available hospital discharge data.” In accordance with section 307(b)(1) of Pub. L. 106-554 and § 412.515 of our existing regulations, the LTCH PPS uses information from LTCH patient records to classify patient cases into distinct LTC-DRGs based on clinical characteristics and expected resource needs. The LTC-DRGs used as the patient classification component of the LTCH PPS correspond to the DRGs under the IPPS for acute care hospitals. Thus, in this proposed rule, we are proposing to use the proposed IPPS version 21.0 GROUPER for FY 2004 to process LTCH PPS claims. The proposed changes to the IPPS DRG classification system for FY 2004 (Grouper 21.0) are discussed in section II.B. of this preamble. Under the LTCH PPS, we determine relative weights for each of the IPPS DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCHs. In a departure from the IPPS, as we discussed in the August 30, 2002 final rule (67 FR 55985), we use low volume LTC-DRGs (less than 25 LTCH cases) in determining the LTC-DRG weights, since LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. In order to deal with the large number of low volume LTC-DRGs (DRGs with fewer than 25 cases), we group those low volume LTC-DRGs into 5 quintiles based on average charge per discharge. (A listing of the composition of low volume quintiles for the FY 2003 LTC-DRGs (based on FY 2001 MedPAR data) appears in the August 30, 2002 final rule at 67 FR 55986-55988). We also adjusted for cases in which the stay at the LTCH is five-sixths of the geometric average length of stay; that is, short-stay outlier cases (§ 412.529). (A detailed discussion of the application of the Lewin Group model that was used to develop the LTC-DRGs appears in the August 30, 2002 final rule at 67 FR 55978). b. Patient Classifications into DRGs. Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the LTC-DRG to which a beneficiary's stay is assigned. Similar to case classification for acute care hospitals under the IPPS ( *see* section II.B. of this preamble), cases are classified into LTC-DRGs for payment under the LTCH PPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the ICD-9-CM. As discussed above in section II.B. of this preamble, the DRGs are organized into 25 Major Diagnostic Categories (MDCs), most of which are based on a particular organ system of the body; the remainder involve multiple organ systems (such as MDC 22, Burns). Accordingly, the principal diagnosis determines MDC assignment. Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Some surgical and medical DRGs are further differentiated based on the presence or absence of CCs. ( *See* section II.B. of this preamble for further discussion of surgical DRGs and medical DRGs.) Because the assignment of a case to a particular LTC-DRG will help determine the amount that will be paid for the case, it is important that the coding is accurate. As is the case under the IPPS, classifications and terminology used in the LTCH PPS are consistent with the ICD-9-CM and the Uniform Hospital Discharge Data Set (UHDDS), as recommended to the Secretary by the National Committee on Vital and Health Statistics (“Uniform Hospital Discharge Data: Minimum Data Set, National Center for Health Statistics, April 1980”) and as revised in 1984 by the Health Information Policy Council
(HIPC)of the U.S. Department of Health and Human Services. We wish to point out again that the ICD-9-CM coding terminology and the definitions of principal and other diagnoses of the UHDDS are consistent with the requirements of the Administrative Simplification Act of 1996 of the HIPAA (45 CFR Parts 160 and 162). As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55981), the emphasis on the need for proper coding cannot be overstated. Inappropriate coding of cases can adversely affect the uniformity of cases in each LTC-DRG and produce inappropriate weighting factors at recalibration and result in inappropriate payments under the LTCH PPS. LTCHs are to follow the same coding guidelines used by the acute care hospitals to ensure accuracy and consistency in coding practices. There will be only one LTC-DRG assigned per long-term care hospitalization; it will be assigned at the discharge. Therefore, it is mandatory that the coders continue to report the same principal diagnosis on all claims and include all diagnostic codes that coexist at the time of admission, that are subsequently developed, or that affect the treatment received. Similarly, all procedures performed during that stay are to be reported on each claim. (For further information on the use of ICD-9-CM codes under the LTCH PPS, see the August 30, 2002 LTCH PPS final rule (67 FR 55979-55983).) Upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the ICD-9-CM. As of October 16, 2002, a LTCH that was required to comply with the HIPAA Administrative Simplification Standards and that had not obtained an extension in compliance with the Administrative Compliance Act (Pub. L. 107-105) is obligated to comply with the standards at 45 CFR 162.1002 and 45 CFR 162.1102. Completed claim forms are to be submitted to the LTCH's Medicare fiscal intermediary. Medicare fiscal intermediaries enter the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before assignment into a DRG can be made. (For more information on types of cases selected for further development, see the August 30, 2002 LTCH PPS final rule (67 FR 55979).) After screening through the MCE, each LTCH claim will be classified into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH GROUPER is specialized computer software based on the same GROUPER used under the IPPS. After the LTC-DRG is assigned, the Medicare fiscal intermediary determines the prospective payment by using the Medicare PRICER program, which accounts for LTCH hospital-specific adjustments. As provided for under the IPPS, we provide an opportunity for the LTCH to review the LTC-DRG assignments made by the fiscal intermediary and to submit additional information within a specified timeframe (§ 412.513(c)). The GROUPER is used both to classify past cases in order to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights during our annual update (as discussed in section II. of this preamble). The LTC-DRG weights are based on data for the population of LTCH discharges, reflecting the fact that LTCH patients represent a different patient mix than patients in short-term acute care hospitals. 3. Development of the Proposed FY 2004 LTC-DRG Relative Weights a. General Overview of Development of the LTC-DRG Relative Weights. As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55984), one of the primary goals for the implementation of the LTCH IPPS is to pay each LTCH an appropriate amount for the efficient delivery of care to Medicare patients. The system must be able to account adequately for each LTCH's case-mix in order to ensure both fair distribution of Medicare payments and access to adequate care for those Medicare patients whose care is more costly. To accomplish these goals, we adjust the LTCH PPS standard Federal prospective payment system rate by the LTC-DRG relative weights in determining payment to LTCHs for each case. Under the LTCH PPS, relative weights for each LTC-DRG are a primary element used to account for the variations in cost per discharge and resource utilization among the payment groups (§ 412.515). To ensure that Medicare patients classified to each LTC-DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each LTC-DRG that represents the resources needed by an average inpatient LTCH case in that LTC-DRG. For example, cases in a LTC-DRG with a relative weight of 2 will, on average, cost twice as much as cases in a LTC-DRG with a weight of 1. b. Data. To calculate the proposed LTC-DRG relative weights for FY 2004 in this proposed rule, we obtained total Medicare allowable charges from FY 2002 Medicare hospital bill data from the December 2002 update of the MedPAR file, and we used the proposed Version 21.0 of the CMS GROUPER used under the acute care hospital inpatient IPPS as discussed above in section II.B. of this preamble. Consistent with the methodology under the hospital IPPS, we are proposing to recalculate the FY 2004 LTC-DRG relative weights based on the best available data for the final rule. As we discussed in further detail in the August 30, 2002 LTCH PPS final rule (67 FR 55984), based on comments regarding the data used in the development of the LTCH prospective payment system, we have excluded the data from LTCHs that are all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Public Law 90-248 (42 U.S.C. 1395b-1) or section 222(a) of Public Law 92-603 (42 U.S.C. 1395b-1). Therefore, in the development of the proposed FY 2004 LTC-DRG relative weights we have excluded the data of the 22 all-inclusive rate providers and the 3 LTCHs that are paid in accordance with demonstration projects. In addition, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55989), a data problem regarding the proposed FY 2003 LTC-DRG relative weight values that were determined using MedPAR (claims) data for FYs 2000 and 2001 was brought to our attention. Following notification of this problem, we researched the commenter's claims and determined that, given the long stays at LTCHs, some providers had submitted multiple bills for payment under the TEFRA reimbursement system for the same stay. Based upon our research, we became aware of the following situation: In certain LTCHs, hospital personnel apparently reported a different principal diagnosis on each bill since, under the TEFRA system, payment was not dependent upon principal diagnosis as it is under a DRG-based system. These claims from the MedPAR file were run through the LTCH GROUPER and used in determining the proposed FY 2003 relative weights for each LTC-DRG. Since this issue was brought to our attention and we discovered that only data from the final bills were being extracted for the MedPAR file, it was possible that the original MedPAR file was not receiving the correct principal diagnosis. Therefore, in the August 30, 2002 final rule (67 FR 55989), we addressed the problem by identifying all LTCH cases in the FY 2001 MedPAR file for which multiple bills were submitted. For each of these cases, beginning with the first bill and moving forward consecutively through subsequent bills for that stay, we recorded the first unique diagnosis codes up to 10 and the first unique procedure codes up to 10. We then used these codes to appropriately group each LTCH case to a LTC-DRG for FY 2003. As we noted above, we are proposing to use LTCH claims data from the FY 2002 MedPAR file for the determination of the proposed FY 2004 LTC-DRG relative weights. Since at the time (FY 2002) LTCHs were still reimbursed under the TEFRA reasonable cost-based system, some LTCHs also had submitted multiple bills for Medicare payment for the same stay. Thus, in certain LTCHs, hospital personnel were apparently still reporting a different principal diagnosis on each bill since, under the TEFRA system in FY 2002, payment was not dependent upon principal diagnosis as it is under a DRG-based system. Therefore, we are proposing to follow the same methodology outlined above to determine the appropriate diagnosis and procedure codes for those multiple bill LTCH cases in the FY 2002 MedPAR files, and we are proposing to use these codes to group each LTCH case to a proposed LTC-DRG for FY 2004. Since the LTCH PPS was implemented for cost reporting periods beginning on or after October 1, 2002 (FY 2003), we believe that this problem will be self-correcting as LTCHs submit more completely coded data in the future. c. Hospital-Specific Relative Value Methodology. As we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55985), by nature LTCHs often specialize in certain areas, such as ventilator-dependent patients and rehabilitation and wound care. Some case types
(DRGs)may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. Such nonarbitrary distribution of cases with relatively high (or low) charges in specific LTC-DRGs has the potential to inappropriately distort the measure of average charges. To account for the fact that cases may not be randomly distributed across LTCHs, as explained in that same final rule (67 FR 55985), we use a hospital-specific relative value method to calculate the proposed LTC-DRG relative weights instead of the methodology used to determine the proposed DRG relative weights under the hospital IPPS described above in section II.C. of this preamble. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we reduce the impact of the variation in charges across providers on any particular LTC-DRG relative weight by converting each LTCH's charge for a case to a relative value based on that LTCH's average charge. Under the hospital-specific relative value method, as we explained in the August 30, 2002 LTCH PPS final rule (67 FR 55985), we standardize charges for each LTCH by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the LTCH's case-mix. The adjustment for case-mix is needed to rescale the hospital-specific relative charge values (which, by definition, averages 1.0 for each LTCH). The average relative weight for a LTCH is its case-mix, so it is reasonable to scale each LTCH's average relative charge value by its case-mix. In this way, each LTCH's relative charge value is adjusted by its case-mix to an average that reflects the complexity of the cases it treats relative to the complexity of the cases treated by all other LTCHs (the average case-mix of all LTCHs). In accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55985), we standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short-stay outliers under § 412.529 as described in section II.D.4. (step 3) of this preamble) by the average adjusted charge for all cases at the LTCH in which the case was treated. Short-stay outliers under § 412.529 are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the LTC-DRG. The average adjusted charge reflects the average intensity of the health care services delivered by a particular LTCH and the average cost level of that LTCH. The resulting ratio is multiplied by that LTCH's case-mix index to determine the standardized charge for the case. Multiplying by the LTCH's case-mix index accounts for the fact that the same relative charges are given greater weight in a LTCH with higher average costs than they would at a LTCH with low average costs which is needed to adjust each LTCH's relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case in a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case in a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Low Volume LTC-DRGs. In order to account for LTC-DRGs with low volume (that is, with fewer than 25 LTCH cases), in accordance with the methodology we established in the August 30, 2002 LTCH PPS final rule (67 FR 55985), we group those low volume LTC-DRGs into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights. For this proposed rule, using LTCH cases from the December 2002 update of the FY 2002 MedPAR file, we identified 163 proposed LTC-DRGs that contained between 1 and 24 cases. This list of proposed LTC-DRGs was then divided into one of the five proposed low volume quintiles, each containing a minimum of 32 proposed LTC-DRGs (163/5 = 32 with 3 proposed LTC-DRGs as the remainder). For FY 2004, we are proposing to make an assignment to a specific low volume quintile by sorting the 163 low volume proposed LTC-DRGs in ascending order by average charge. Since the number of proposed LTC-DRGs with less than 25 LTCH cases is not evenly divisible by five, the average charge of the low volume proposed LTC-DRG was used to determine which proposed low volume quintile received the additional proposed LTC-DRG. After sorting the 163 low volume proposed LTC-DRGs in ascending order, we are proposing that the first fifth
(32)of low volume proposed LTC-DRGs with the lowest average charge would be grouped into Quintile 1. Since the average charge of the 33rd proposed LTC-DRG in the sorted list is closer to the previous proposed LTC-DRG's average charge (assigned to proposed Quintile 1) than to the average charge of the 34th proposed LTC-DRG on the sorted list (to be assigned to proposed Quintile 2), we are proposing to place it into proposed Quintile 1. The highest average charge cases would then be grouped into proposed Quintile 5. This process would be repeated through the remaining low volume proposed LTC-DRGs so that 3 proposed low volume quintiles would contain 33 proposed LTC-DRGs and 2 proposed low volume quintiles would contain 32 proposed LTC-DRGs. In order to determine the proposed relative weights for the proposed LTC-DRGs with low volume for FY 2004, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55985), we would use the five proposed low volume quintiles described above. The proposed composition of each of the five low volume quintiles shown below in Table 1 would be used in determining the proposed LTC-DRG relative weights for FY 2004. We would determine a proposed relative weight and (geometric) average length of stay for each of the five proposed low volume quintiles using the formula that we are proposing to apply to the regular proposed LTC-DRGs (25 or more cases), as described below in section II.D.4. of this preamble. We are proposing to assign the same proposed relative weight and average length of stay to each of the proposed LTC-DRGs that make up that proposed low volume quintile. We note that as this system is dynamic, it is possible that the number and specific type of LTC-DRGs with a low volume of LTCH cases will vary in the future. We use the best available claims data in the MedPAR file to identify low volume LTC-DRGs and to calculate the relative weights based on our methodology. Table 1.—Proposed Composition of Low Volume Quintiles Proposed LTC-DRG Description Proposed Quintile 1 044 ACUTE MAJOR EYE INFECTIONS 047 OTHER DISORDERS OF THE EYE AGE >17 W/O CC 065 DYSEQUILIBRIUM 066 EPISTAXIS 069 OTITIS MEDIA & URI AGE >17 W/O CC 072 NASAL TRAUMA & DEFORMITY 128 DEEP VEIN THROMBOPHLEBITIS 149 MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC 178 UNCOMPLICATED PEPTIC ULCER W/O CC 192 PANCREAS, LIVER & SHUNT PROCEDURES W/O CC 262 BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY 273 MAJOR SKIN DISORDERS W/O CC 276 NON-MALIGNANT BREAST DISORDERS 305 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC 311 TRANSURETHRAL PROCEDURES W/O CC 319 KIDNEY & URINARY TRACT NEOPLASMS W/O CC 328 URETHRAL STRICTURE AGE >17 W CC 339 TESTES PROCEDURES, NON-MALIGNANCY AGE >17 342 CIRCUMCISION AGE >17 348 BENIGN PROSTATIC HYPERTROPHY W CC 349 BENIGN PROSTATIC HYPERTROPHY W/O CC 376 POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE 385 NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 399 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC 420 FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC 428 DISORDERS OF PERSONALITY & IMPULSE CONTROL 431 CHILDHOOD MENTAL DISORDERS 432 OTHER MENTAL DISORDER DIAGNOSES 455 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC 465 AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS 509 FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA 511 NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA 540 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC Proposed Quintile 2 021 VIRAL MENINGITIS 022 HYPERTENSIVE ENCEPHALOPATHY 031** CONCUSSION AGE >17 W CC 046 OTHER DISORDERS OF THE EYE AGE >17 W CC 053 SINUS & MASTOID PROCEDURES AGE >17 084 MAJOR CHEST TRAUMA W/O CC 177 UNCOMPLICATED PEPTIC ULCER W CC 193 BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC 194* BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC 200 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY 206 DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC 208 DISORDERS OF THE BILIARY TRACT W/O CC 211 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC 232 ARTHROSCOPY 234 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC 237 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH 275 MALIGNANT BREAST DISORDERS W/O CC 299 INBORN ERRORS OF METABOLISM 309 MINOR BLADDER PROCEDURES W/O CC 323 URINARY STONES W CC, &/OR ESW LITHOTRIPSY 324 URINARY STONES W/O CC 341 PENIS PROCEDURES 344 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY 367 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC 414 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC 421 VIRAL ILLNESS AGE >17 454 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC 473 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 497** SPINAL FUSION W CC 502 KNEE PROCEDURES W PDX OF INFECTION W/O CC 506 FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA 507* FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 508 FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA 510 NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA 529 VENTRICULAR SHUNT PROCEDURES WITH CC Proposed Quintile 3 031* CONCUSSION AGE >17 W CC 032 CONCUSSION AGE >17 W/O CC 063 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES 083 MAJOR CHEST TRAUMA W CC 117 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT 119 VEIN LIGATION & STRIPPING 158 ANAL & STOMAL PROCEDURES W/O CC 194** BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC 197 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 218 LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W CC 223 MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC 228 MAJOR THUMB OR JOINT PROC, OR OTH HAND OR WRIST PROC W CC 257 TOTAL MASTECTOMY FOR MALIGNANCY W CC 293 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC 295 DIABETES AGE 0-35 317 ADMIT FOR RENAL DIALYSIS 345 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY 347*** MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC 352 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES 369 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 402 LYMPHOMA & NON- ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC 408 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC 410 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 411 HISTORY OF MALIGNANCY W/O ENDOSCOPY 419 FEVER OF UNKNOWN ORIGIN AGE >17 W CC 443 OTHER O.R. PROCEDURES FOR INJURIES W/O CC 447 ALLERGIC REACTIONS AGE >17 449 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC 450 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC 497* SPINAL FUSION W CC 498* SPINAL FUSION W/O CC 503 KNEE PROCEDURES W/O PDX OF INFECTION 505 EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT 507** FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 518 PERCUTANEOUS CARDIVASCULAR PROC W/O CORONARY ARTERY STENT OR AMI Proposed Quintile 4 008 PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC 061 MYRINGOTOMY W TUBE INSERTION AGE >17 095*** PNEUMOTHORAX W/O CC 124 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG 125 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG 150 PERITONEAL ADHESIOLYSIS W CC 152 MINOR SMALL & LARGE BOWEL PROCEDURES W CC 157 ANAL & STOMAL PROCEDURES W CC 161 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC 191 PANCREAS, LIVER & SHUNT PROCEDURES W CC 195 CHOLECYSTECTOMY W C.D.E. W CC 210 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 226 SOFT TISSUE PROCEDURES W CC 227 SOFT TISSUE PROCEDURES W/O CC 230 LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR 268 SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES 306 PROSTATECTOMY W CC 308 MINOR BLADDER PROCEDURES W CC 310 TRANSURETHRAL PROCEDURES W CC 312 URETHRAL PROCEDURES, AGE >17 W CC 360 VAGINA, CERVIX & VULVA PROCEDURES 394 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS 427 NEUROSES EXCEPT DEPRESSIVE 479*** OTHER VASCULAR PROCEDURES W/O CC 486 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 493 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 494* LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC 498** SPINAL FUSION W/O CC 500 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC 517 PERCUTANEOUS CARDIVASCULAR PROC W NON-DRUG ELUTING STENT W/O AMI 519 CERVICAL SPINAL FUSION W CC 532 SPINAL PROCEDURES WITHOUT CC 538 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC Proposed Quintile 5 001 CRANIOTOMY AGE >17 W CC 055 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES 075 MAJOR CHEST PROCEDURES 077 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 108 OTHER CARDIOTHORACIC PROCEDURES 110 MAJOR CARDIOVASCULAR PROCEDURES W CC 115 PRM CARD PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GNRTR P 116 OTH PERM CARD PACEMAK IMPL OR PTCA W CORONARY ARTERY STENT IMPLNT 118 CARDIAC PACEMAKER DEVICE REPLACEMENT 154 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC 168 MOUTH PROCEDURES W CC 171*** OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC 201 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES 209 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF LOWER EXTREMITY 216 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 261 BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION 266*** SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC 288 O.R. PROCEDURES FOR OBESITY 304 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC 365 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES 401 LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 406 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC 412 HISTORY OF MALIGNANCY W ENDOSCOPY 441 HAND PROCEDURES FOR INJURIES 471 BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY 482 TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES 488 HIV W EXTENSIVE O.R. PROCEDURE 494** LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC 499 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 501 KNEE PROCEDURES W PDX OF INFECTION W CC 515 CARDIAC DEFIBRILATOR IMPLANT W/O CARDIAC CATH 534 EXTRACRANIAL VASCULAR PROCEDURES WITHOUT CC 536 CARDIAC DEFIB IMPLANT WITH CARDIAC CATH WITHOUT AMI/HF/SHOCK * One of the original 163 low volume proposed LTC-DRGs initially assigned to a different proposed low volume quintile; reassigned to this proposed low volume quintile in addressing nonmonotonicity (see step 5 below). ** One of the original 163 low volume proposed LTC-DRGs initially assigned to this proposed low volume quintile; reassigned to a different proposed low volume quintile in addressing nonmonotonicity (see step 5 below). *** One of the original 163 low volume proposed LTC-DRGs initially assigned to this proposed low volume quintile; removed from the proposed low volume quintiles in addressing nonmonotonicity (see step 5 below). 4. Steps for Determining the Proposed FY 2004 LTC-DRG Relative Weights As we noted previously, the proposed FY 2004 LTC-DRG relative weights are determined in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989-55991). In summary, LTCH cases must be grouped in the appropriate proposed LTC-DRG, while taking into account the low volume proposed LTC-DRGs as described above, before the proposed FY 2004 LTC-DRG relative weights can be determined. After grouping the cases in the appropriate proposed LTC-DRG, we are proposing to calculate the proposed relative weights for FY 2004 in this proposed rule by first removing statistical outliers and cases with a length of stay of 7 days or less. Next, we are proposing to adjust the number of cases in each proposed LTC-DRG for the effect of short-stay outlier cases under § 412.529. The short-stay adjusted discharges and corresponding charges would be used to calculate “relative adjusted weights” in each proposed LTC-DRG using the hospital-specific relative value method described above. Below we discuss in detail the steps for calculating the proposed FY 2004 LTC-DRG relative weights, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989-55991). *Step 1—Remove statistical outliers.* The first step in the calculation of the proposed FY 2004 LTC-DRG relative weights is to remove statistical outlier cases. We define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each proposed LTC-DRG. These statistical outliers would be removed prior to calculating the proposed relative weights. We believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate proposed relative weight that does not truly reflect relative resource use among the proposed LTC-DRGs. *Step 2—Remove cases with a length of stay of 7 days or less.* The proposed FY 2004 LTC-DRG relative weights should reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay 7 days or less do not belong in a LTCH, since such stays do not fully receive or benefit from treatment that is typical in a LTCH stay and full resources are often not used in the earlier stages of admission to a LTCH. If we were to include stays of 7 days or less in the computation of the proposed FY 2004 LTC-DRG relative weights, the value of many proposed relative weights would decrease and, therefore, payments would decrease to a level that may no longer be appropriate. We do not believe that it would be appropriate to compromise the integrity of the payment determination for those LTCH cases that actually benefit from and receive a full course of treatment at a LTCH, in order to include data from these very short-stays. Thus, in determining the proposed FY 2004 LTC-DRG relative weights, we remove LTCH cases with a length of stay of 7 days or less. *Step 3—Adjust charges for the effects of short-stay outliers.* The third step in the calculation of the proposed FY 2004 LTC-DRG relative weights is to adjust each LTCH's charges per discharge for short-stay outlier cases (that is, a patient with a length of stay that is less than or equal to five-sixths the average length of stay of the LTC-DRG as described in the August 30, 2002 LTCH PPS final rule (67 FR 55977). We make this adjustment by counting a short-stay outlier as a fraction of a discharge based on the ratio of the length of stay of the case to the average length of stay for the proposed LTC-DRG for nonshort-stay outlier cases. This has the effect of proportionately reducing the impact of the lower charges for the short-stay outlier cases in calculating the average charge for the proposed LTC-DRG. This process produces the same result as if the actual charges per discharge of a short-stay outlier case were adjusted to what they would have been had the patient's length of stay been equal to the average length of stay of the proposed LTC-DRG. As we explained in the August 30, 2002 LTCH PPS final rule (67 FR 55990), counting short-stay outlier cases as full discharges with no adjustment in determining the proposed LTC-DRG relative weights would lower the proposed LTC-DRG relative weight for affected proposed LTC-DRGs because the relatively lower charges of the short- stay outlier cases would bring down the average charge for all cases within a proposed LTC-DRG. This would result in an “underpayment” to nonshort-stay outlier cases and an “overpayment” to short-stay outlier cases. Therefore, in this proposed rule, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55990), we adjust for short-stay outlier cases under § 412.529 in this manner since it would result in more appropriate payments for all LTCH cases. *Step 4—Calculate the proposed FY 2004 LTC-DRG relative weights on an iterative basis.* The process of calculating the LTC-DRG relative weights using the hospital specific relative value methodology is iterative. First, for each LTCH case, we calculate a hospital-specific relative charge value by dividing the short-stay outlier adjusted charge per discharge (see step 3) of the LTCH case (after removing the statistical outliers (see step 1)) and LTCH cases with a length of stay of 7 days or less (see step 2) by the average charge per discharge for the LTCH in which the case occurred. The resulting ratio is then multiplied by the LTCH's case-mix index to produce an adjusted hospital-specific relative charge value for the case. An initial case-mix index value of 1.0 is used for each LTCH. For each proposed LTC-DRG, the proposed FY 2004 LTC-DRG relative weight is calculated by dividing the average of the adjusted hospital-specific relative charge values (from above) for the proposed LTC-DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these recalculated proposed LTC-DRG relative weights, each LTCH's average proposed relative weight for all of its cases (case-mix) is calculated by dividing the sum of all the LTCH's proposed LTC-DRG relative weights by its total number of cases. The LTCHs' hospital-specific relative charge values above are multiplied by these hospital specific case-mix indexes. These hospital-specific case-mix adjusted relative charge values are then used to calculate a new set of proposed LTC-DRG relative weights across all LTCHs. In this proposed rule, this iterative process is continued until there is convergence between the weights produced at adjacent steps, for example, when the maximum difference is less than 0.0001. *Step 5—Adjust the proposed FY 2004 LTC-DRG relative weights to account for nonmonotonically increasing relative weights.* As explained in section II.B. of this preamble, the proposed FY 2004 CMS DRGs, upon which the proposed FY 2004 LTC-DRGs are based, contain “pairs” that are differentiated based on the presence or absence of CCs. The proposed LTC-DRGs with CCs are defined by certain secondary diagnoses not related to or inherently a part of the disease process identified by the principal diagnosis, but the presence of additional diagnoses does not automatically generate a CC. As we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55990), the value of monotonically increasing relative weights rises as the resource use increases (for example, from uncomplicated to more complicated). The presence of CCs in a proposed LTC-DRG means that cases classified into a “without CC” proposed LTC-DRG are expected to have lower resource use (and lower costs). In other words, resource use (and costs) are expected to decrease across “with CC”/“without CC” pairs of proposed LTC-DRGs. For a case to be assigned to a proposed LTC-DRG with CCs, as we explained in the August 30, 2002 LTCH PPS final rule (67 FR 55990), more coded information is called for (that is, at least one relevant secondary diagnosis), than for a case to be assigned to a proposed LTC-DRG “without CCs” (which is based on only one principal diagnosis and no relevant secondary diagnoses). Currently, the LTCH claims data include both accurately coded cases without complications and cases that have complications (and cost more) but were not coded completely. Both types of cases are grouped to a proposed LTC-DRG “without CCs” since only one principal diagnosis was coded. Since LTCHs were previously paid under cost-based reimbursement, which is not based on patient diagnoses, LTCHs' coding for these cases may not have been as detailed as possible. Thus, in developing the FY 2003 LTC-DRG relative weights for the LTCH PPS based on FY 2001 claims data, as we explained in the August 30, 2002 LTCH PPS final rule (67 FR 55990), we found on occasion that the data suggested that cases classified to the LTC-DRG “with CCs” of a “with CC”/“without CC” pair had a lower average charge than the corresponding LTC-DRG “without CCs.” Similarly, based on FY 2002 claims data, we also found on occasion that the data suggested that cases classified to the proposed LTC-DRG “with CCs” of a “with CC”/“without CC” pair would have a lower average charge than the corresponding proposed LTC-DRG “without CCs” for FY 2004. We believe this anomaly may be due to coding that may not have fully reflected all comorbidities that were present. Specifically, LTCHs may have failed to code relevant secondary diagnoses, which resulted in cases that actually had CCs being classified into a “without CC” LTC-DRG. It would not be appropriate to pay a lower amount for the “with CC” LTC-DRG. Therefore, in this proposed rule, in accordance with the methodology established in that same final rule (67 FR 55990-55991), we grouped both the cases “with CCs” and “without CCs” together for the purpose of calculating the proposed FY 2004 LTC-DRG relative weights. We continue to employ this methodology to account for nonmonotonically increasing relative weights until we have adequate data to calculate appropriate separate weights for these anomalous LTC-DRG pairs. We expect that, as was the case when we first implemented the IPPS, this problem will be self-correcting, as LTCHs submit more completely coded data in the future. As we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55990), there are three types of “with CC” and “without CC” pairs that were nonmonotonic, that is, where the “without CC” proposed LTC-DRG would have a higher average charge than the “with CC” proposed LTC-DRG. For this proposed rule, using the LTCH cases in the December 2002 update of the FY 2002 MedPAR file, we identified two of the types of nonmonotonic LTC-DRG pairs. The first category of nonmonotonically increasing relative weights for proposed FY 2004 LTC-DRG pairs “with and without CCs” contains no pairs of proposed LTC-DRGs in which both the proposed LTC-DRG “with CCs” and the proposed LTC-DRG “without CCs” had 25 or more LTCH cases and, therefore, would not fall into one of the 5 proposed low volume quintiles. For that type of nonmonotonic LTC-DRG pair, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55990-55991), we would combine the LTCH cases and compute a new proposed relative weight based on the case-weighted average of the combined LTCH cases of the proposed LTC-DRGs. The case-weighted average charge is determined by dividing the total charges for all LTCH cases by the total number of LTCH cases for the combined proposed LTC-DRG. This new proposed relative weight would then be assigned to both of the proposed LTC-DRGs in the pair. However, as there are no pairs that fall into this category, in this proposed rule, we are proposing that, for FY 2004, there would be zero proposed LTC-DRGs in this category. The second category of nonmonotonically increasing relative weights for proposed LTC-DRG pairs with and without CCs consists of 5 pairs of proposed LTC-DRGs that has fewer than 25 cases, and each proposed LTC-DRG would be grouped to different proposed low volume quintiles in which the “without CC” proposed LTC-DRG would be in a higher-weighted proposed low volume quintile than the “with CC” proposed LTC-DRG. For those pairs, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55990-55991), we combine the LTCH cases and determine the case-weighted average charge for all LTCH cases. The case-weighted average charge is determined by dividing the total charges for all LTCH cases by the total number of LTCH cases for the combined proposed LTC-DRG. Based on the case-weighted average LTCH charge, we determine which proposed low volume quintile the “combined proposed LTC-DRG” would be grouped. Both proposed LTC-DRGs in the pair are then grouped into the same proposed low volume quintile, and thus would have the same proposed relative weight. For the FY 2004, in this proposed rule, we are proposing that the following proposed LTC-DRGs would be in this category: Proposed LTC-DRGs 31 and 32 (proposed low volume quintile 3); proposed LTC-DRGs 193 and 194 (proposed low volume quintile 2); proposed LTC-DRGs 493 and 494 (proposed low volume quintile 4); proposed LTC-DRGs 497 and 498 (proposed low volume quintile 3); and proposed LTC-DRGs 506 and 507 (proposed low volume quintile 2). The third category of nonmonotonically increasing relative weights for proposed LTC-DRG pairs with and without CCs consists of 5 pairs of proposed LTC-DRGs where one of the proposed LTC-DRGs has fewer than 25 LTCH cases and is grouped to a proposed low volume quintile and the other proposed LTC-DRG has 25 or more LTCH cases and has its own proposed LTC-DRG relative weight, and the proposed LTC-DRG “without CCs” has the higher proposed relative weight. In accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55990 and 55991), we remove the proposed low volume LTC-DRG from the proposed low volume quintile and combine it with the other proposed LTC-DRG for the computation of a new proposed relative weight for each of these proposed LTC-DRGs. This new proposed relative weight is assigned to both proposed LTC-DRGs, so they each have the same proposed relative weight. For FY 2004, in this proposed rule, we are proposing the following proposed LTC-DRGs would be in this category: Proposed LTC-DRGs 94 and 95; proposed LTC-DRGs 170 and 171; proposed LTC-DRGs 265 and 266; proposed LTC-DRGs 346 and 347; and proposed LTC-DRGs 478 and 479. *Step 6—Determine a proposed FY 2004 LTC-DRG relative weight for LTC-DRGs with no LTCH cases.* As we stated above, we determine the proposed relative weight for each proposed LTC-DRG using charges reported in the December 2002 update of the FY 2002 MedPAR file. Of the 518 proposed LTC-DRGs for FY 2004, we identified 164 proposed LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2002 MedPAR file used in this proposed rule, no patients who would have been classified to those proposed LTC-DRGs were treated in LTCHs during FY 2002 and, therefore, no charge data were reported for those proposed LTC-DRGs. Thus, in the process of determining the proposed LTC-DRG relative weights, we are unable to determine proposed weights for these 164 proposed LTC-DRGs using the methodology described in steps 1 through 5 above. However, since patients with a number of the diagnoses under these proposed LTC-DRGs may be treated at LTCHs beginning in FY 2004, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55991), we assign proposed relative weights to each of the 164 “no volume” proposed LTC-DRGs based on clinical similarity and relative costliness to one of the remaining 354 (518−164 = 354) proposed LTC-DRGs for which we are able to determine proposed relative weights, based on FY 2002 claims data. As there are currently no LTCH cases in these “no volume” proposed LTC-DRGs, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55991), we determine proposed relative weights for the 164 proposed LTC-DRGs with no LTCH cases in the FY 2002 MedPAR file used in this proposed rule by grouping them to the appropriate proposed low volume quintile. This methodology is consistent with our methodology used in determining proposed relative weights to account for the proposed low volume LTC-DRGs described above. As we described in the August 30, 2002 LTCH PPS final rule (67 FR 55991), our methodology for determining proposed relative weights for the “no volume” proposed LTC-DRGs is as follows: First, we crosswalk the no volume proposed LTC-DRGs by matching them to other similar proposed LTC-DRGs for which there were LTCH cases in the FY 2002 MedPAR file based on clinical similarity and intensity of use of resources as determined by care provided during the period of time surrounding surgery, surgical approach (if applicable), length of time of surgical procedure, post-operative care, and length of stay. We assign the proposed relative weight for the applicable proposed low volume quintile to the no volume proposed LTC-DRG if the proposed LTC-DRG to which it is crosswalked is grouped to one of the proposed low volume quintiles. If the proposed LTC-DRG to which the no volume proposed LTC-DRG is crosswalked is not one of the proposed LTC-DRGs to be grouped to one of the proposed low volume quintiles, we compare the proposed relative weight of the proposed LTC-DRG to which the no volume proposed LTC-DRG is crosswalked to the proposed relative weights of each of the five proposed quintiles and we assign the no volume proposed LTC-DRG the proposed relative weight of the proposed low volume quintile with the closest weight. For this proposed rule, a list of the no volume proposed FY 2004 LTC-DRGs and the proposed FY 2004 LTC-DRG to which it is crosswalked in order to determine the appropriate proposed low volume quintile for the assignment of a proposed relative weight for FY 2004 is shown below in Table 2. Table 2.—Proposed No Volume LTC-DRG Crosswalk and Proposed Quintile Assignment for FY 2004 LTC-DRG Description Cross walked LTC-DRG Low volume quintile assigned 2 CRANIOTOMY AGE > 17 W/O CC 1 Quintile 5. 3 CRANIOTOMY AGE 0-17 1 Quintile 5. 6 CARPAL TUNNEL RELEASE 251 Quintile 1. 26 SEIZURE & HEADACHE AGE 0-17 25 Quintile 2. 30 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 29 Quintile 3. 33 CONCUSSION AGE 0-17 25 Quintile 2. 36 RETINAL PROCEDURES 47 Quintile 1. 37 ORBITAL PROCEDURES 47 Quintile 1. 38 PRIMARY IRIS PROCEDURES 47 Quintile 1. 39 LENS PROCEDURES WITH OR WITHOUT VITRECTOMY 47 Quintile 1. 40 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 47 Quintile 1. 41 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 47 Quintile 1. 42 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS 47 Quintile 1. 43 HYPHEMA 47 Quintile 1. 45 NEUROLOGICAL EYE DISORDERS 46 Quintile 2. 48 OTHER DISORDERS OF THE EYE AGE 0-17 47 Quintile 1. 49 MAJOR HEAD & NECK PROCEDURES 64 Quintile 4. 50 SIALOADENECTOMY 63 Quintile 3. 51 SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY 63 Quintile 3. 52 CLEFT LIP & PALATE REPAIR 63 Quintile 3. 54 SINUS & MASTOID PROCEDURES AGE 0-17 63 Quintile 3. 56 RHINOPLASTY 72 Quintile 1. 57 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 63 Quintile 3. 58 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 63 Quintile 3. 59 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 63 Quintile 3. 60 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 63 Quintile 3. 62 MYRINGOTOMY W TUBE INSERTION AGE 0-17 63 Quintile 3. 67 EPIGLOTTITIS 63 Quintile 3. 70 OTITIS MEDIA & URI AGE 0-17 69 Quintile 1. 71 LARYNGOTRACHEITIS 97 Quintile 2. 74 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 69 Quintile 1. 81 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 69 Quintile 1. 91 SIMPLE PNEUMONIA & PLEURISY AGE 0-17 90 Quintile 2. 98 BRONCHITIS & ASTHMA AGE 0-17 97 Quintile 2. 104 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W CARDIAC CATH 110 Quintile 5. 105 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W/O CARDIAC CATH 110 Quintile 5. 106 CORONARY BYPASS W PTCA 110 Quintile 5. 107 CORONARY BYPASS W CARDIAC CATH 110 Quintile 5. 109 CORONARY BYPASS W/O PTCA OR CARDIAC CATH 110 Quintile 5. 111 MAJOR CARDIOVASCULAR PROCEDURES W/O CC 110 Quintile 5. 137 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 136 Quintile 2. 146 RECTAL RESECTION W CC 148 Quintile 5. 147 RECTAL RESECTION W/O CC 148 Quintile 5. 151 PERITONEAL ADHESIOLYSIS W/O CC 150 Quintile 4. 153 MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC 152 Quintile 4. 155 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC 171 Quintile 5. 156 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 171 Quintile 5. 159 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC 161 Quintile 4. 160 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC 161 Quintile 4. 162 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC 178 Quintile 1. 163 HERNIA PROCEDURES AGE 0-17 178 Quintile 1. 164 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 148 Quintile 5. 165 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC 149 Quintile 1. 166 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 148 Quintile 5. 167 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC 149 Quintile 1. 169 MOUTH PROCEDURES W/O CC 72 Quintile 1. 184 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 183 Quintile 2. 186 DENTAL ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17 185 Quintile 2. 187 DENTAL EXTRACTIONS & RESTORATIONS 185 Quintile 2. 190 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 189 Quintile 2. 196 CHOLECYSTECTOMY W C.D.E. W/O CC 197 Quintile 3. 198 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC 197 Quintile 3. 199 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY 200 Quintile 2. 212 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 211 Quintile 2. 219 LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W/O CC 218 Quintile 3. 220 LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE 0-17 218 Quintile 3. 224 SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC, W/O CC 234 Quintile 2. 229 HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC 234 Quintile 2. 252 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 234 Quintile 2. 255 FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT AGE 0-17 234 Quintile 2. 258 TOTAL MASTECTOMY FOR MALIGNANCY W/O CC 257 Quintile 3. 259 SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC 257 Quintile 3. 260 SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC 257 Quintile 3. 267 PERIANAL & PILONIDAL PROCEDURES 158 Quintile 1. 279 CELLULITIS AGE 0-17 78 Quintile 1. 282 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 281 Quintile 2. 286 ADRENAL & PITUITARY PROCEDURES 292 Quintile 4. 289 PARATHYROID PROCEDURES 293 Quintile 3. 290 THYROID PROCEDURES 293 Quintile 3. 291 THYROGLOSSAL PROCEDURES 293 Quintile 3. 298 NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 297 Quintile 2. 303 KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM 304 Quintile 5. 307 PROSTATECTOMY W/O CC 306 Quintile 4. 313 URETHRAL PROCEDURES, AGE >17 W/O CC 311 Quintile 1. 314 URETHRAL PROCEDURES, AGE 0-17 311 Quintile 1. 322 KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 326 Quintile 2. 327 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0-17 326 Quintile 2. 329 URETHRAL STRICTURE AGE >17 W/O CC 328 Quintile 1. 330 URETHRAL STRICTURE AGE 0-17 328 Quintile 1. 333 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 332 Quintile 1. 334 MAJOR MALE PELVIC PROCEDURES W CC 345 Quintile 3. 335 MAJOR MALE PELVIC PROCEDURES W/O CC 345 Quintile 3. 336 TRANSURETHRAL PROSTATECTOMY W CC 341 Quintile 2. 337 TRANSURETHRAL PROSTATECTOMY W/O CC 341 Quintile 2. 338 TESTES PROCEDURES, FOR MALIGNANCY 339 Quintile 1. 340 TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 339 Quintile 1. 343 CIRCUMCISION AGE 0-17 339 Quintile 1. 351 STERILIZATION, MALE 339 Quintile 1. 353 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY 365 Quintile 5. 354 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC 365 Quintile 5. 355 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC 365 Quintile 5. 356 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 360 Quintile 4. 357 UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY 360 Quintile 4. 358 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 360 Quintile 4. 359 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC 360 Quintile 4. 361 LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 149 Quintile 1. 362 ENDOSCOPIC TUBAL INTERRUPTION 149 Quintile 1. 363 D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY 367 Quintile 2. 364 D&C, CONIZATION EXCEPT FOR MALIGNANCY 367 Quintile 2. 370 CESAREAN SECTION W CC 369 Quintile 3. 371 CESAREAN SECTION W/O CC 367 Quintile 2. 372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 367 Quintile 2. 373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 367 Quintile 2. 374 VAGINAL DELIVERY W STERILIZATION &/OR D&C 367 Quintile 2. 375 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C 367 Quintile 2. 377 POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE 367 Quintile 2. 378 ECTOPIC PREGNANCY 369 Quintile 3. 379 THREATENED ABORTION 376 Quintile 1. 380 ABORTION W/O D&C 376 Quintile 1. 381 ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 376 Quintile 1. 382 FALSE LABOR 376 Quintile 1. 383 OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS 376 Quintile 1. 384 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS 376 Quintile 1. 386 EXTREME IMMATURITY 367 Quintile 2. 387 PREMATURITY W MAJOR PROBLEMS 367 Quintile 2. 388 PREMATURITY W/O MAJOR PROBLEMS 367 Quintile 2. 389 FULL TERM NEONATE W MAJOR PROBLEMS 367 Quintile 2. 390 NEONATE W OTHER SIGNIFICANT PROBLEMS 367 Quintile 2. 391 NORMAL NEWBORN 376 Quintile 1. 392 SPLENECTOMY AGE >17 194 Quintile 2. 393 SPLENECTOMY AGE 0-17 194 Quintile 2. 396 RED BLOOD CELL DISORDERS AGE 0-17 399 Quintile 1. 405 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 404 Quintile 2. 407 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC 408 Quintile 3. 417 SEPTICEMIA AGE 0-17 416 Quintile 3. 422 VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 420 Quintile 1. 446 TRAUMATIC INJURY AGE 0-17 445 Quintile 2. 448 ALLERGIC REACTIONS AGE 0-17 455 Quintile 1. 451 POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 455 Quintile 1. 481 BONE MARROW TRANSPLANT 394 Quintile 1. 484 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1 Quintile 5. 485 LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR 209 Quintile 5. 491 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY 209 Quintile 5. 492 CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 410 Quintile 3. 496 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 210 Quintile 4. 504 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 468 Quintile 5. 516 PERCUTANEOUS CARDIVASCULAR PROCEDURE W AMI 578 Quintile 3. 520 CERVICAL SPINAL FUSION W/O CC 498 Quintile 3. 525 HEART ASSIST SYSTEM IMPLANT 468 Quintile 5. 526 PERCUTANEOUS CARVIOVASCULAR PROC W DRUG-ELUTING STENT W AMI 517 Quintile 4. 527 PERCUTANEOUS CARVIOVASCULAR PROC W DRUG-ELUTING STENT W/O AMI 517 Quintile 4. 528 INTRACRANIAL VASCLUAR PROCEDURES WITH PDX HEMORRHAGE 1 Quintile 5. 530 VENTRICULAR SHUNT PROCEDURES WITHOUT CC 529 Quintile 2. 531 SPINAL PROCEDURES WITH CC 519 Quintile 4. 533 EXTRACRANIAL VASCULAR PROCEDURES WITH CC 534 Quintile 5. 535 CARDIAC DEFIB IMPLANT WITH CARDIAC CATH WITH AMI/HF/SHOCK 515 Quintile 5. 537 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC 253 Quintile 2. 539 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC 401 Quintile 5. To illustrate this methodology, which was established in the August 30, 2002 LTCH PPS final rule (67 FR 55991), for determining the proposed relative weights for the 164 proposed LTC-DRGs with no LTCH cases, we are providing the following examples, which refer to the no volume proposed LTC-DRGs crosswalk information for FY 2004 provided above in Table 2: Example 1: There were no cases in the FY 2002 MedPAR file used for this proposed rule for proposed LTC-DRG 163 (Hernia Procedures Age 0-17). Since the procedure is similar in resource use and the length and complexity of the procedures and the length of stay are similar, we determined that proposed LTC-DRG 178 (Uncomplicated Peptic Ulcer Without CC), which is assigned to proposed low volume quintile 1 for the purpose of determining the proposed FY 2004 relative weights, would display similar clinical and resource use. Therefore, we are proposing to assign the same proposed relative weight of LTC-DRG 178 of 0.5711 (proposed Quintile 1) for FY 2004 (Table 11 in the Addendum to this proposed rule) to proposed LTC-DRG 163. Example 2: There were no LTCH cases in the FY 2002 MedPAR file used in this proposed rule for proposed LTC-DRG 91 (Simple Pneumonia and Pleurisy Age 0-17). Since the severity of illness in patients with bronchitis and asthma is similar in patients regardless of age, we determined that proposed LTC-DRG 90 (Simple Pneumonia and Pleurisy Age >17 Without CC) would display similar clinical and resource use characteristics and have a similar length of stay to proposed LTC-DRG 91. There were over 25 cases in proposed LTC-DRG 90. Therefore, it would not be assigned to a proposed low volume quintile for the purpose of determining the proposed LTC-DRG relative weights. However, under our established methodology, proposed LTC-DRG 91, with no LTCH cases, would need to be grouped to a proposed low volume quintile. We identified that the proposed low volume quintile with the closest weight to proposed LTC-DRG 90 (0.7429; see Table 11 in the Addendum to this proposed rule) would be proposed low volume quintile 2 (0.7347; see Table 11 in the Addendum to this proposed rule). Therefore, we are proposing to assign proposed LTC-DRG 91 a proposed relative weight of 0.7347 for FY 2004. Furthermore, in accordance with the methodology established in the August 30, 2002 final rule (67 FR 55991), we are proposing LTC-DRG relative weights of 0.0000 for heart, kidney, liver, lung, pancreas, and simultaneous pancreas/kidney transplants (proposed LTC-DRGs 103, 302, 480, 495, 512, and 513, respectively) for FY 2004 because Medicare will only cover these procedures if they are performed at a hospital that has been certified for the specific procedures by Medicare and presently no LTCH has been so certified. Based on our research, as we discussed in that same final rule (67 FR 55995), we found that most LTCHs only perform minor surgeries, such as minor small and large bowel procedures, to the extent any surgeries are performed at all. Given the extensive criteria that must be met to become certified as a transplant center for Medicare, we believe it is unlikely that any LTCHs would become certified as a transplant center. In fact, in the nearly 20 years since the implementation of the IPPS, there has never been a LTCH that even expressed an interest in becoming a transplant center. However, if in the future a LTCH applies for certification as a Medicare-approved transplant center, we believe that the application and approval procedure would allow sufficient time for us to propose appropriate weights for the LTC-DRGs affected. At the present time, we would only include these six transplant proposed LTC-DRGs in the GROUPER program for administrative purposes. Since we use the same GROUPER program for LTCHs as is used under the acute care hospital IPPS, removing these LTC-DRGs would be administratively burdensome. Again, we note that as this system is dynamic, it is entirely possible that the number of proposed LTC-DRGs with a zero volume of LTCH cases based on the system will vary in the future. We used the best most recent available claims data in the MedPAR file to identify zero volume proposed LTC-DRGs and to determine the relative weights in this final rule. Table 11 in the Addendum to this proposed rule lists the proposed LTC-DRGs and their respective proposed relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (to assist in the determination of short-stay outlier payments under § 412.529) for FY 2004. E. Add-On Payments for New Services and Technologies 1. Background Sections 1886(d)(5)(K) and
(L)of the Act establish a process of identifying and ensuring adequate payment for new medical services and technologies under the IPPS. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that the process must apply to a new medical service or technology if, “based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate.” Section 1886(d)(5)(K)(vi) of the Act specifies that a medical service or technology will be considered “new” if it meets criteria established by the Secretary after notice and opportunity for public comment. Section 412.87(b)(1) of our existing regulations provides that a new technology will 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 (see the September 7, 2001 final rule (66 FR 46902)). Section 412.87(b)(3) provides that, to receive special payment treatment, new technologies meeting this clinical definition must be demonstrated to be inadequately paid otherwise under the DRG system. 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). Table 10 in the Addendum to this proposed rule lists the proposed qualifying criteria by DRG, based on the discharge data that we are using to calculate the proposed FY 2004 DRG weights. The thresholds that will be published in the final rule for FY 2004 will be used to evaluate applicants for new technology add-on payments during FY 2005. In addition to the clinical and cost criteria, we established that, in order to qualify for the new technology add-on payments, 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 2002 are used to calculate the proposed FY 2004 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 costs of the technology. After we have 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 2002 would be eligible to receive add-on payments as a new technology at least until FY 2005 (discharges occurring before October 1, 2004), when data reflecting the costs of the technology would be used to recalibrate the DRG weights. Because the FY 2005 DRG weights will be calculated using FY 2003 MedPAR data, the costs of such a new technology would likely be reflected in the FY 2005 DRG weights. Similar to the timetable for applying for new technology add-on payments during FY 2004, we are proposing that applicants for FY 2005 must submit a formal request, including a full description of the clinical applications of the technology and the results of any clinical evaluations demonstrating that the new technology represents a substantial clinical improvement, along with a significant sample of data to demonstrate the technology meets the high-cost threshold, no later than early October 2003. We are proposing that a complete database must be submitted no later than mid-December 2003. Complete application information is available at our Web site at: *http://www.cms.hhs.gov/providers /hipps/default.asp.* To allow interested parties to identify the technologies under review before the publication of the annual proposed rule, the Web site also lists the tracking forms completed by each applicant. The new technology add-on payment policy provides additional payments for cases with high costs involving eligible 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 pays a marginal cost factor of 50 percent for the costs of the new technology in excess of the full DRG payment. If the actual costs of a new technology case exceed the DRG payment by more than the estimated costs of the new technology, Medicare payment is 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., 2nd Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, we account for projected payments under the new technology provision 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 and the hospital-specific amounts. Because any additional payments directed toward new technology under this provision must be offset to ensure budget neutrality, it is important to consider carefully 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 would discuss in the annual proposed and final rules those technologies that were considered under this provision; our determination as to whether a particular technology meets our criteria to be considered new; 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 balance appropriately the 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 add-on payments for new technology under the provisions of sections 1886(d)(5)(K) and
(L)of the Act at 1.0 percent of estimated total operating prospective payments. If the target limit is exceeded, we 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 would be reduced, this reduction would be offset by large overall payments to hospitals for new technologies under this provision. 2. FY 2004 Status of Technology Approved for FY 2003 Add-On Payments: Drotrecogin Alfa (Activated)—Xigris® In the August 1, 2002 IPPS final rule, we stated that cases involving the administration of Xigris® (a biotechnology product that is a recombinant version of naturally occurring Activated Protein C (APC)) as identified by the presence of code 00.11 (Infusion of drotrecogin alfa (activated)) are eligible for additional payments of up to $3,400 (50 percent of the average cost of the drug)” (67 FR 50013). (The August 1, 2002 final rule contains a detailed discussion of this technology.) Although Xigris® was approved by the FDA in November 2001, it did not qualify for add-on payments until discharges on or after October 1, 2002. Consequently, FY 2002 discharges (between October 1, 2001 and September 30, 2002) may not reflect full utilization of the technology due to the absence of the add-on payment. Therefore, for FY 2004, we are proposing to continue to make add-on payments for cases involving the administration of Xigris® as identified by the presence of code 00.11. Based on preliminary analysis of the incidence of Xigris® in the first quarter FY 2003 MedPAR file, we are proposing to revise downward our estimate of total add-on payments for Xigris®. For FY 2003, we estimated that total add-on payments would be approximately $74.8 million (22,000 Medicare patients who would be eligible for a $3,400 add-on payment). For FY 2004, we are estimating the total add-on payments would be approximately $50 million (based on 14,000 Medicare patients who would be eligible for a $3,400 add-on payment). We are proposing that this additional payment would be included in the DRG reclassification and recalibration budget neutrality factor, which is applied to the standardized amounts and the hospital-specific amounts. However, we will reevaluate our assumptions regarding this estimate based on preliminary claims data from the FY 2003 MedPAR file before the publication of the FY 2004 IPPS final rule. 3. FY 2004 Applicants for New Technology Add-On Payments We received two applications for new technologies to be designated eligible for inpatient add-on payments for new technology for FY 2004. A discussion of these applications and our determinations on these applications appears below. a. Bone Morphogenetic Proteins
(BMPs)for Spinal Fusions. An application was submitted by Medtronic Sofamor Danek for the InFUSE TM Bone Graft/LT-CAGE®” Lumbar Tapered Fusion Device for approval as a new technology eligible for add-on payments. A similar application was submitted last year but was denied because, based on the available data, the technology did not exceed the one standard deviation threshold above the average charges for the DRGs to which the technology is assigned. 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 procedure is done in place of the more traditional use of autogenous iliac crest bone graft. For a more detailed discussion about InFUSE TM Bone Graft/LT-CAGE® Lumbar Tapered Fusion, see the August 1, 2002 IPPS final rule (67 FR 50016). On July 2, 2002, the FDA approved InFUSE TM Bone Graft/LT-CAGE® for spinal fusion procedures in skeletally mature patients at one level. Therefore, based on the FDA's approval, multilevel use of this technology would be off-label. In the August 1, 2002 IPPS final rule (67 FR 50017), we stated this technology would meet the cost threshold only if the added costs of multilevel fusions were taken into account. Because the FDA had not approved this technology for multilevel fusions, and the applicant had not submitted data to demonstrate this technology is a substantial clinical improvement for multilevel fusions (the clinical trial upon which the application was based was a single-level fusion trial), we could not issue a substantial clinical improvement determination for multilevel fusions and, consequently, did not consider the costs associated with multilevel fusions in our analysis of whether this technology met the cost threshold. Therefore, because the average charges for this new technology, when used for single-level spinal fusions, did not exceed the threshold to qualify for new technology add-on payment of $37,815, we denied this application for add-on payments for FY 2003. For similar reasons, we did not consider data on the charges for multilevel fusions in our analysis of whether this technology meets the cost threshold for FY 2004. In its application for add-on payments for FY 2004, Medtronic used data from CMS' FY 2001 Standard Analytical File for physicians and hospitals. The analysis linked a 5-percent sample of hospital spinal fusions cases with the corresponding physician claims. Because there were no ICD-9-M codes to identify multilevel fusions in 2001, multilevel fusions were identified using CPT codes on the physician claims. Average charges were taken from actual cases used in clinical trials. After grouping these cases into one, two, and three or more levels fused in DRGs 497 and 498 (Spinal Fusion Except Cervical With and Without CC, respectively), the applicant then calculated average charges assuming the use of the InFUSE TM Bone Graft/LT-CAGE® for these cases. For DRG 497, the estimated single-level fusion average charge was $41,321; for DRG 498, the estimated single-level fusion average charge was $37,200. Because these DRGs are not currently split for different numbers of fusion levels involved, Medtronic has calculated its own standard deviation of average charges to determine the threshold for these DRGs using the 5-percent sample data. For DRG 497, the threshold (calculated by Medtronic) was $45,646, which is greater than the estimated average charge of $41,321 for single-level fusions noted above. For DRG 498, the threshold (calculated by Medtronic) was $36,935, which is less than the average charges for single-level fusions in this DRG as noted above. However, we note the thresholds to qualify for the new technology add-on payments for FY 2003 published in Table 10 of the August 1, 2002 IPPS final rule for DRGs 497 and 498 were $58,040 and $41,923, respectively. These thresholds were computed based on all cases assigned to these DRGs, and do not differentiate between the number of spinal levels fused. Because we are not proposing to redefine these DRGs to differentiate cases on the basis of the number of levels of the spine fused in the manner suggested by the applicant's analysis, the thresholds published in last year's final rule are applicable for a new technology to qualify for add-on payments in these DRGs for FY 2004. Therefore, because the averages calculated by the applicant for single-level fusions do not exceed the published thresholds, we are proposing not to approve this technology on the basis of this analysis. The applicant also submitted data from actual cases involving the InFUSE TM Bone Graft/LT-CAGE® with single level fusions only. The data submitted included 31 claims from 4 hospitals (only one Medicare patient was included in the sample). All 31 cases were from DRG 498. The average standardized charge for these cases was $47,172. Based on these data, the average standardized charge exceeds the threshold for DRG 498. However, we note that this limited sample excludes any cases from DRG 497. We note that, effective for discharges occurring on or after October 1, 2002, ICD-9-CM codes 84.51 (Insertion of interbody spinal fusion device) and 84.52 (Insertion of recombinant bone morphogenetic protein) are effective to identify cases involving this technology. Therefore, in an effort to resolve the difficulties in obtaining sufficient data upon which to determine whether this technology exceeds the applicable threshold, we intend to review available MedPAR data for the first several months of FY 2003 to identify these cases and calculate their average standardized charges to compare with the thresholds. We anticipate some of these cases will involve multilevel spinal fusions, and it will be necessary to identify those cases in order to remove them from the calculation of the average charges. If the technology meets the cost threshold based on the MedPAR data, we will evaluate whether it qualifies as a substantial clinical improvement. According to the applicant: “InFUSE TM Bone Graft is more appropriate to use and has been proven more effective in its use than autogenous iliac crest bone graft, when either is placed in the LT-Cage TM Lumbar Tapered Fusion Device for anterior lumbar interbody fusion. Use of InFUSE TM Bone Graft instead of autogenous iliac crest bone graft: • Obviates iliac crest bone graft donor site morbidity. • Reduces operative time, blood loss and hospitalization. • Results in greater fusion success. • We found that the Oswestry Low Back Pain Disability score and SF-36 Physical Component and Pain Index score were consistently 10 percent better in the InFUSE TM Bone Graft group than the autogenous iliac bone graft group. • Enables earlier return to work.” Among the issues we will consider are: Does avoiding the complications associated with the iliac crest bone harvesting procedure constitute a substantial clinical improvement; and, with the increased rate of osteoarthritis and osteoporosis in the Medicare population, is there evidence that the technology represents a substantial clinical improvement in spinal fusions among this population? We are particularly interested in data on the results of aged Medicare patients who have been treated with BMP, and any basic biology bench data on the results of using BMP in osteoporotic bones. b. GLIADEL® Wafer. Glioblastoma Multiforme
(GBM)is the most common and most aggressive of the primary brain tumors. Standard care for patients diagnosed with GBM is surgical resection and radiation. According to the manufacturer (Guilford Pharmaceuticals), the GLIADEL® Wafer is indicated for use as an adjunct to surgery to prolong survival in patients with recurrent GBM. Implanted directly into the cavity that is created when a brain tumor is surgically removed, GLIADEL® delivers chemotherapy directly to the site where tumors are most likely to recur. The FDA approved GLIADEL® Wafer on September 23, 1996, for use as an adjunct to surgery to prolong survival in patients with recurrent GBM for whom surgical resection is indicated. In announcing its approval, the FDA indicated that GLIADEL® was approved: “ * * * based on the results of a multi-center placebo controlled study in 222 patients who had recurrent malignant glioma after initial treatment with surgery and radiation therapy. Following surgery to remove the tumor, half of the patients were treated with GLIADEL® implants and half with placebo. In patients with glioblastoma multiforme, the 6-month survival rate increased from 36 percent with placebo to 56 percent with GLIADEL®. Median survival increased from 20 weeks with placebo to 28 weeks with GLIADEL®. In patients with pathologic diagnoses other than glioblastoma multiforme, GLIADEL® had no effect on survival.” Guilford Pharmaceuticals has requested that GLIADEL® still be considered new because, until a new ICD-9-CM code (00.10 Implementation of Chemotherapeutic Agent) was established on October 1, 2002, it was not possible to identify specifically these cases in the MedPAR data. 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 GLIADEL® are currently reflected in the DRG weights (despite the absence of a specific code), GLIADEL® does not meet our criterion that a medical service or technology be “new”. That is, FY 2002 MedPAR data used to calculate the proposed DRG weights for FY 2004 include cases where GLIADEL® was administered (and the corresponding charges of these cases, include charges associated with GLIADEL®). On February 26, 2003, the FDA approved GLIADEL® for use in newly diagnosed patients with high-grade malignant glioma as an adjunct to surgery and radiation. However, our understanding is that many newly diagnosed patients were already receiving this therapy. To the extent this is true, the charges associated with this use of GLIADEL® are also reflected in the DRG relative weights. According to Guilford's application, the current average wholesale price of GLIADEL® is $10,985. Guilford submitted charge data for 23 Medicare patients at 7 hospitals from FY 2000. The charges were then standardized and adjusted for inflation using the hospital market basket inflation factor (from 2000 to 2003) in order to determine an inflated average standardized charge of $33,002. Guilford points out that this charge narrowly misses the DRG 2 threshold published in Table 10 of the August 1, 2002 IPPS final rule of $34,673. However, we note that, according to the manufacturer, as many as 60 percent of current GLIADEL® cases may be assigned to DRG 1 based on the presence of CCs. Based on this assumption, the qualifying threshold for GLIADEL® would be $54,312 (60 percent of the DRG 1 threshold of $67,404, and 40 percent of the DRG 2 threshold of $34,673). As mentioned above in section II.B.3.a. of this proposed rule, we examined the definitions of DRGs 1 and 2 to determine whether they could be improved, and we are proposing to create a new DRG for patients with an intracranial vascular procedure and an intracranial hemorrhage and two new DRGs for patients with only a vascular shunt procedure (splitting on the presence or absence of a CC). We also compared the data submitted in the application on the charges for GLIADEL® cases with the charges of other procedures in DRGs 1 and 2. We found that, although the $33,002 average standardized charge reported is just below the qualifying threshold in DRG 2, it is actually well below the mean average standardized charge for DRG 1 ($42,092). As noted previously, as many as 60 percent of current GLIADEL® cases may be assigned to DRG 1 based on the presence of CCs. Therefore, we do not believe that any change to the DRG assignment of cases receiving GLIADEL® is warranted at this time. However, we will continue to monitor our data to determine whether a change is warranted in the future. 4. Review of the High-Cost Threshold The current cost threshold for a new technology to qualify for add-on payments is that the average standardized charges of cases involving the new technology must be demonstrated to exceed one standard deviation beyond the mean standardized charges of the DRG to which the new technology will be assigned. When we established this threshold in the September 7, 2001 final rule, we expressed our belief that it is important to establish a threshold that recognizes the variability in costs per case within DRGs and maintains the fundamental financial incentives of the IPPS (66 FR 46917). In its comments on this approach, MedPAC supported the one standard deviation threshold. However, others, particularly representatives of the manufacturers of new technology, have argued this threshold is too high, and that virtually no new technology would qualify for the special payment provision. We are concerned that establishing higher payments for a great number of new technologies may be inflationary because the add-on payments reduce the efficiency incentives hospitals face when new technologies must otherwise be financed out of current payments for similar cases. Traditionally, new technologies were required to compete with existing treatment methods on clinical and cost criteria. Add-on payments are intended to give new technologies a competitive boost relative to existing treatment methods with the goal of encouraging faster and more widespread adoption of new technologies. Much of the current variation around the mean within any particular DRG is due to the range of procedures contained within each DRG. Generally, some of these procedures will be more expensive than the mean and some will be less expensive. The threshold should be set high enough to ensure that it identifies truly high-cost technologies. If the threshold were set too low (for example, at $2,500, as some have suggested), additional technologies may qualify merely by association with a procedure only slightly more costly than the mean for the DRG. For example, consider a DRG with five different procedures and mean charges of $15,000. The mean charges for each procedure are distributed around $15,000, as illustrated in the following table. A qualifying threshold of $2,500 would result in any new technology that is only used for the fifth procedure automatically qualifying for new technology add-on payments (unless the new technology had the unlikely effect of lowering the mean cost for cases with this procedure by at least $2,500). This is because the average charge of $20,000 for cases in this procedure already exceeds the mean charges for the DRG plus $2,500. Procedure Mean charge 1 $10,000 2 12,000 3 15,000 4 17,000 5 20,000 At the same time, we recognize that the very limited number of applications that have been submitted the past 2 years (five for FY 2003; two for FY 2004) may indicate that only a very small number of the new technologies that come onto the market every year are costly enough even to apply for new technology add-on payments. Therefore, for FY 2005 and subsequent Fiscal Years, we are proposing to reduce the threshold to 75 percent of one standard deviation beyond the geometric mean standardized charge for all cases in the DRG to which the new medical service or technology is assigned (proposed § 412.87(b)(3)). Based on our analysis of the thresholds for FY 2004, this proposed change would reduce the average threshold across all DRGs to qualify for the add-on payments from approximately $9,900 above the mean standardized charges for each DRG to approximately $7,400. This reduction would maintain the averaging principles of the IPPS while easing the requirement somewhat to allow more technologies to qualify. Furthermore, the situation illustrated above, where a technology qualifies on the basis of its association with a high cost procedure, is much less likely to occur as a result of this reduction than if the threshold were reduced dramatically. 5. Technical Changes Subpart H of part 412 describes payments to hospitals under IPPS. We have become aware of references to the calculation of IPPS payments in this subpart that inadvertently omit references to new technology add-on payments. For example, § 412.112(c) describes the basis for per case payments. This section refers to outlier payments under subpart F, but was not revised to reflect the implementation of the new technology add-on payments. Therefore, we are proposing to amend § 412.112(c) to add a new paragraph
(d)to include a reference to additional payments for new medical services or technologies under subpart F. Section 412.116(e) currently states that payments for outlier cases are not made on an interim basis. That is, for hospitals receiving payments under a biweekly, lump-sum payment methodology, outlier payments are not included in the calculation of the lump-sum payment amounts. Rather, outlier payments are calculated on a case-by-case basis. Similarly, due to the unique nature of the new technology add-on payments, we are proposing that they would also be calculated on a case-by-case basis rather than included in the calculation of interim payment amounts. Therefore, we are proposing to revise § 412.116(e) to include this policy. 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 IPPS, 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 IPPS. In a December 27, 2000 notice published in the **Federal Register** (65 FR 82228), the Office of Management and Budget
(OMB)issued its revised standards for defining MSAs. In that notice, OMB indicated that it plans to announce in calendar year 2003 new definitions of “Core Based Statistical Areas” (CBSAs) based on the new standards and the Census 2000 data. The new standards establish two categories of CBSAs:
(1)Metropolitan Statistical Areas (50,000 or more), and
(2)Micropolitan Statistical Areas (10,000 to 49,999). After these new CBSAs are announced, we will evaluate the new area designations and their possible effects on the Medicare hospital wage index. Therefore, the earliest these new CBSA definitions would be used is the FY 2005 wage index. 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 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. 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 April 4, 2003 **Federal Register** (68 FR 16516), we published a notice of intent to collect calendar year 2002 data from hospitals. There is a 60-day public comment period on that notice. After considering and responding to the comments we receive, we plan to send the surveys to all IPPS hospitals (and hospitals in Maryland that are under a waiver from the IPPS) through the fiscal intermediaries. We intend to collect these data to be incorporated in the FY 2005 wage index after notice and opportunity for public comment. B. Proposed FY 2004 Wage Index Update The proposed FY 2004 wage index values (effective for hospital discharges occurring on or after October 1, 2003 and before October 1, 2004) in section V. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2000 (the FY 2003 wage index was based on FY 1999 wage data). The proposed FY 2004 wage index includes the following categories of data associated with costs paid under the IPPS (as well as outpatient costs), which were also included in the FY 2003 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 2003, the proposed wage index for FY 2004 also excludes the direct and overhead salaries and hours for services not subject to IPPS payment, such as SNF services, home health services, costs related to GME (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), and other subprovider components that are not paid under the IPPS. C. FY 2004 Wage Index Proposals 1. Elimination of Wage Costs Associated With Rural Health Clinics and Federally Qualified Health Centers In the FY 2001 IPPS final rule, we discussed removing from the wage index the salaries, hours, and wage-related costs of hospital-based rural health clinics
(RHCs)and Federally qualified health centers (FQHCs) because Medicare pays for these costs outside of the IPPS (65 FR 47074). We noted that because RHC and FQHC costs were not separately reported on Worksheet S-3 of the Medicare cost report, we could not exclude these costs from the prior wage indexes. We further noted that we would evaluate the exclusion of RHC and FQHC wage data in developing the FY 2004 wage index. We now have revised Worksheet S-3 so that it allows for the separate reporting of RHC and FQHC wage costs and hours beginning with FY 2000. Therefore, as we now have the ability to exclude these costs from the wage index, beginning with the FY 2004 wage index, we are proposing to exclude the wage costs and hours data for RHCs and FQHCs from the hospital wage index calculation. An analysis of the effects of this change is included in the Appendix A of this proposed rule. 2. Paid Hours It has been the longstanding policy of CMS to calculate the wage index using paid hours rather than hours worked (58 FR 46299). This policy reflects our belief that paid hours more appropriately reflect a hospital's total wage costs, which include amounts paid for actual time worked and for covered leave periods (for example, annual, sick, and holiday leave). Therefore, the inclusion of paid lunch hours in the wage index is consistent with our inclusion of other paid nonworking hours. Several hospitals have requested that we exclude paid lunch or meal break hours from the wage index calculation. At these hospitals, the typical workday is 7 1/2 working hours, plus a 1/2 hour paid meal break, for a total of 8 paid hours. These hospitals, some of which are municipal-owned and required by their overarching union contracts to provide paid lunch hours, believe they are disadvantaged by wage index policy that requires paid lunch hours to be included in calculating the wage index. The hospitals argue that their practice of paying employees for meal breaks is not substantially different, in practice, from other hospitals whose employees do not receive paid lunch hours but who are on call during their lunch periods. These hospitals further argue that this policy causes them, in some cases due to union contracts beyond the hospital's control, to be the only hospitals with this category of nonproductive hours included in the wage index. We are soliciting comments on our policy that paid lunch hours should be excluded from the wage index. Specifically, we would like a broader understanding of the issue of whether some hospitals may, in fact, be truly disadvantaged by this policy through no fault of their own. Any change in our policy would not be implemented until, at the earliest, the FY 2005 wage index. Some hospitals and associations have also recommended that we exclude the paid hours associated with military and jury duty leave from the wage index calculation. They state that, unlike other paid leave categories for which workers are usually paid at their full hourly rates (for example, annual, sick, and holiday), hospitals typically pay employees on military or jury duty only a fraction of their normal pay. The amount that the hospital pays is intended to only supplement the earnings that the employee receives from the government, so that, while performing military or civic duties, the employee can continue to be paid the same salary level as if he or she were still working at the hospital. The hospitals and associations believe that including the lower pay rates associated with employees' military and jury duty leave unfairly decreases a hospital's average hourly wage and, therefore, its wage index value. Therefore, we are proposing to exclude from the wage index the paid hours associated with military and jury duty leave, beginning with the FY 2005 wage index. The associated salaries would continue to be reported on Worksheet S-3, Part II, Line 1 of the Medicare cost report. D. Verification of Wage Data From the Medicare Cost Reports The data for the proposed FY 2004 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2000 Medicare cost reports. The data file used to construct the proposed wage index includes FY 2000 data submitted to us as of February 18, 2003. 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 2004 wage index, pending their resolution before calculation of the final FY 2004 wage index. We instructed the intermediaries to complete their verification of questionable data elements and to transmit any changes to the wage data no later than April 4, 2003. We believe all unresolved data elements will be resolved by the date the final rule is issued. The revised data will be reflected in the final rule. Also, as part of our editing process, we removed data for 110 hospitals that failed edits. We identified 72 hospitals with incomplete or inaccurate data resulting in zero or negative, or otherwise aberrant, average hourly wages. Therefore, wage data from these hospitals were removed from the calculation. We have notified the fiscal intermediaries of these hospitals and will continue to work with the fiscal intermediaries to correct these data whenever possible. As a result, the proposed FY 2004 wage index is calculated based on FY 2000 wage data for 4,593 hospitals. In constructing the proposed FY 2004 wage index, we include the wage data for facilities that were IPPS hospitals in FY 2000, even for those facilities that have terminated their participation in the program as hospitals or have since been designated as a critical access hospital (CAH), as long as those data do not fail any of our edits for reasonableness. We believe that including the wage data for these hospitals is, in general, appropriate to reflect the economic conditions in the various labor market areas during the relevant past period. However, we received correspondence suggesting that the wage data for hospitals that have subsequently been redesignated as CAHs should be removed from the wage index calculation because CAHs are unique compared to other short-term, acute care hospitals. CAHs are limited to only 15 acute care beds. An additional 10 beds may be designated as swing-beds, but only 15 beds can be used at one time to serve acute care patients. CAHs tend to be located in isolated, rural areas. We solicit comment on whether we should exclude wage data from such hospitals from the wage index calculation. However, we have included the data for CAHs in the proposed FY 2004 wage index if the CAH was paid under the IPPS during FY 2000. E. Computation of the Proposed FY 2004 Wage Index The method used to compute the proposed FY 2004 wage index follows: Step 1—As noted above, we based the proposed FY 2004 wage index on wage data reported on the FY 2000 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, 1999 and before October 1, 2000. In addition, we included data from some hospitals that had cost reporting periods beginning before October 1999 and reported a cost reporting period covering all of FY 2000. 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 2000 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2000 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 1999 and before October 1, 2000), we included wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we included the wage data from the later period in the wage index calculation. We have removed the wage data of CAHs, after the effective date of the CAH designation, from the calculation of the proposed wage index. 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, 5 and 5.01, 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 IPPS). 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, 1999 through April 15, 2001 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 10/14/1999 11/15/1999 1.06794 11/14/1999 12/15/1999 1.06447 12/14/1999 01/15/2000 1.06083 01/14/2000 02/15/2000 1.05713 02/14/2000 03/15/2000 1.05335 03/14/2000 04/15/2000 1.04954 04/14/2000 05/15/2000 1.04571 05/14/2000 06/15/2000 1.04186 06/14/2000 07/15/2000 1.03786 07/14/2000 08/15/2000 1.03356 08/14/2000 09/15/2000 1.02898 09/14/2000 10/15/2000 1.02425 10/14/2000 11/15/2000 1.01953 11/14/2000 12/15/2000 1.01482 12/14/2000 01/15/2001 1.01004 01/14/2001 02/15/2001 1.00509 02/14/2001 03/15/2001 1.00000 03/14/2001 04/15/2001 0.99491 For example, the midpoint of a cost reporting period beginning January 1, 2000 and ending December 31, 2000 is June 30, 2000. An adjustment factor of 1.03786 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 2000 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 $24.5439. 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 $11.5431 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 Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. 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 2004, this change affects 141 hospitals in 44 MSAs. The MSAs affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule. F. Proposed 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 IPPS. 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 Pub. L. 106-554 provides that the Secretary must establish a mechanism under which a statewide entity may apply to have all of the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, for reclassifications beginning in FY 2003. The implementing regulations for this provision are at § 412.235. 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
(1)If the rural county would otherwise be considered part of an urban area under the standards published in the **Federal Register** for designating MSAs (and for designating NECMAs), and
(2)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 meet these criteria are deemed urban for purposes of the standardized amounts and for purposes of assigning the wage index. Revised MSA standards were published in the December 27, 2000 **Federal Register** (65 FR 82228). We are working with the Census Bureau to compile a list of hospitals that meet the new standards based on the 2000 census data; however, that work is not yet complete. Therefore, for purposes of calculating the proposed wage indexes in this proposed rule, we used the list of qualifying hospitals based on the 1990 MSA standards. However, if the updated list of hospitals meeting the new standards based on the 2000 census data is available in time, we will incorporate it in the final rule to be published by August 1, 2003. To the extent hospitals otherwise reclassified by the MGCRB for FY 2004 are adversely affected by their inclusion on or exclusion from the new list, we will address this in the final rule. Among the options we may consider in the final rule to address situations where hospitals may be adversely affected are: Assigning adversely affected hospitals the highest applicable wage index; or extending the opportunity for adversely affected hospitals to withdraw from a reclassification by the MGCRB for FY 2004. 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, 3 the wage index values were determined by considering the following: 3 Although section 1886(d)(8)(C)(iv)(I) of the Act also provides that the wage index for an urban area may not decrease as a result of redesignated hospitals if the urban area wage index is below the wage index for rural areas in the State in which the urban area is located, this was effectively made moot by section 4410 of Public Law 105-33, which provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. Also, section 1886(d)(8)(C)(iv)(II) of the Act provides that an urban area's wage index may not decrease as a result of redesignated hospitals if the urban area is located in a State that is composed of a single urban area. • 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. • Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred (otherwise, redesignated rural hospitals are excluded from the calculation of the rural wage index). • The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. If including the wage data for the redesignated hospitals increases the wage index value for the urban area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. Otherwise, the hospitals located in the urban area receive a wage index excluding the wage data of hospitals redesignated into the area. 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 2004 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, and those areas have hospitals from more than one State reclassified into them. 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 FYs 1998, 1999, and 2000 cost reporting periods. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital from the FY 1998 and FY 1999 cost reporting periods, as well as the FY 2000 period used to calculate the proposed FY 2004 wage index. The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period. At the time this proposed wage index was constructed, the MGCRB had completed its review of FY 2004 reclassification requests. We have included in this proposed rule Table 9, which shows hospitals that have been reclassified under either section 1886(d)(8) or section 1886(d)(10)(D) of the Act. This table includes hospitals reclassified for FY 2004 by the MGCRB (73 for wage index, 66 for the standardized amount, and 33 for both the wage index and the standardized amount), as well as hospitals that were reclassified for the wage index in either FY 2002
(476)or FY 2003
(56)and are, therefore, in either the second or third year of their 3-year reclassification. This table also includes hospitals located in urban areas that have been designated rural in accordance with section 1886(d)(8)(E) of the Act (14). In addition, it includes rural hospitals redesignated to an urban area under section 1886(d)(8)(B) of the Act for purposes of the standardized amount and the wage index (42). 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** . Similarly, 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 within 45 days of the publication of this proposed rule. If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision but prior to the above date, it may later cancel its withdrawal in a subsequent year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period (§ 412.273(b)(2)(i)). The request to cancel a prior withdrawal must be made in writing to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year (§ 412.273(d)). For further information about withdrawing, terminating, or canceling a previous withdrawal or termination of a 3-year reclassification for wage index purposes, we refer the reader to § 412.273, as well as the August 1, 2002 IPPS final rule (67 FR 50065) and the August 1, 2001 IPPS final rule (66 FR 39887). 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. Therefore, the final wage indexes will likely be different from those published in this proposed rule, and, in some cases, they may be quite different. Although, as described above, the statute provides that a reclassified rural hospital may not have a lower wage index after reclassification than before, there is no similar protection for urban hospitals. Therefore, hospitals should carefully evaluate the impacts of their reclassifications prior to the deadline for withdrawing from an approved reclassification. Applications and other information about MGCRB reclassifications may be obtained via the CMS internet Web site at *http://cms.hhs.gov/providers/prrb/mgcinfo.asp* , or by calling the MGCRB at
(410)786-1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. As noted previously, OMB plans to announce new definitions of CBSAs by the middle of this year, and the earliest these new CBSA definitions would be used for the wage index is FY 2005. Applications for reclassification by the MGCRB for FY 2005 will be due by September 2, 2003. However, by that time, we will not have completed our analysis of the new CBSAs. Therefore, hospitals submitting applications for reclassification by the MGCRB for FY 2005 should base those applications on the current MSAs. We will assess the implications of the new CBSAs on hospitals' reclassification requests in the FY 2005 proposed rule. G. Requests for Wage Data Corrections The preliminary wage data file was made available on January 10, 2003 (and subsequently on February 4, 2003), through the Internet on CMS's Web site at *http://www.cms.hhs.gov/providers/hipps/default.asp* . In a memorandum dated December 31, 2002, we instructed all Medicare fiscal intermediaries to inform the IPPS hospitals they service of the availability of the wage data file and the process and timeframe for requesting revisions (including the specific deadlines listed below). We also instructed the fiscal intermediaries to advise hospitals that these data are made available directly through their representative hospital organizations. If a hospital wished to request a change to its data as shown in that wage data file, the hospital was to submit corrections along with complete, detailed supporting documentation to its intermediary by February 17, 2003 (this deadline was initially announced as February 10, 2003, but was changed due to the need to repost some of the data). Hospitals were notified of this deadline and of all other possible deadlines and requirements, including the requirement to review and verify their data as posted on the preliminary wage data file on the Internet, through the December 31, 2002 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 by April 4, 2003. In addition, fiscal intermediaries were to notify hospitals of the changes or the reasons that changes were not accepted. 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 the development of the final FY 2004 prospective payment rates to be published by August 1, 2003. If a hospital disagreed with the fiscal intermediary's resolution of a policy issue (for example, whether a general category of cost is allowable in the wage data), the hospital could have contacted CMS in an effort to resolve the issue. We note that the April 4, 2003 deadline also applied to these requests. Requests were required to be sent to CMS at the address below (with a copy to the hospital's fiscal intermediary). The request must have fully documented all attempts by the hospital to resolve the dispute through the process described above, including copies of relevant correspondence between the hospital and the fiscal intermediary. During review, we do not consider issues such as the adequacy of a hospital's supporting documentation, as we believe that fiscal intermediaries are generally in the best position to make evaluations regarding the appropriateness of these types of issues (which should have been resolved earlier in the process). Hospitals should also examine Table 2 in the Addendum to this proposed rule to verify their data. Table 2 contains each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2000 data used to construct the proposed FY 2004 wage index. We note that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital's data and transmitted to CMS prior to February 18, 2003. We will release a final wage data file in May 2003 to hospital associations and the public on the Internet at *http://www.cms.hhs.gov/providers/hipps/default.asp* . The May 2003 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 (revisions submitted to CMS by the fiscal intermediaries by April 4, 2003). If, after reviewing the May 2003 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 that outlines why the hospital believes an error exists and provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries must receive these requests no later than June 6, 2003. Requests mailed to CMS should be sent to: Centers for Medicare & Medicaid Services, Center for Medicare Management, Attention: Wage Index Team, Division of Acute Care, C4-07-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. Each request also must 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, after the release of the May 2003 wage index file, 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 approve the following types of requests: • 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 4, 2003. • Requests for correction of errors that were not, but could have been, identified during the hospital's review of the January 2003 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 6, 2003) will be incorporated into the final wage index in the final rule to be published by August 1, 2003, and to be effective October 1, 2003. We have created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 2004 payment rates. Accordingly, hospitals that did 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 challenge later, before the Provider Reimbursement Review Board, the failure of CMS to make a requested data revision ( *See W. A. Foote Memorial Hospital* v. *Shalala* , No. 99-CV-75202-DT (E.D. Mich. 2001)). 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 early May 2003, 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 2004 wage index by August 1, 2003, and the implementation of the FY 2004 wage index on October 1, 2003. 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 for an area only if a hospital can show that the intermediary or CMS made an error in tabulating its data. 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 earlier, 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 publication of the FY 2004 wage index. 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 will be necessary. However, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is approved. H. Modification of the Process and Timetable for Updating the Wage Index Although the wage data correction process described in section III.G. of this preamble has proven successful in the past for ensuring that the wage data used each year to calculate the wage indexes are generally reliable and accurate, we continue to be concerned about the growing volume of wage data revisions initiated by hospitals after the release of the first public use file in February. This issue has been discussed previously in the FY 1998 IPPS proposed rule (62 FR 29918) and in the FY 2002 IPPS proposed rule (66 FR 22682). In each discussion, we describe the increasing number of revisions to wage data between the proposed rule and the final rule. Currently, the fiscal intermediaries are required to conduct initial desk reviews on or before November 15 in advance of the preparation of the preliminary wage data public use file in early January (see Program Memorandum A-02-94, October 4, 2002). Furthermore, they are required to address items that fall outside the established thresholds. This may involve further review of the supplementary documentation or contacting the hospital for additional documentation. In addition, fiscal intermediaries are required to notify State hospital associations regarding hospitals that fail to respond to issues raised during the desk review. These actions are to be completed in advance of sending the data to CMS to prepare the preliminary wage data public use file in early January. However, as we have indicated in prior **Federal Register** s, as much as 30 percent of hospitals subsequently request revisions to their data after the preliminary wage data file is made available. This high volume of revisions results in an additional workload for the fiscal intermediaries. In particular, much of a fiscal intermediary's efforts prior to submitting the data to prepare the preliminary public use file may be in vain if the hospital subsequently revises all of its data prior to the early February deadline (which is the hospital's right at that point). Therefore, we are proposing to modify the process to release the preliminary wage data file prior to requiring the fiscal intermediaries to conduct their initial desk reviews on the data. This unaudited data would be available on the Internet by early October rather than early January. Hospitals would review this file to ensure it contains their correct data as submitted on their cost reports and request any changes by early November. At that time, the fiscal intermediaries would review the revision requests and conduct desk reviews of the data including all approved changes. Under this proposed revised timetable, the fiscal intermediaries would notify the hospitals in early February of any changes to the wage data as a result of the desk reviews and the resolution of the hospitals' early November change requests. The fiscal intermediaries would also submit the revisions to CMS in early February. Hospitals would then have until early March to submit requests to the fiscal intermediaries for reconsideration of adjustments made by the fiscal intermediaries as a result of the desk review. Other than requesting reconsideration of desk review adjustments, hospitals would not be able to submit new requests for additional changes that were not submitted by early November. By early April, the fiscal intermediaries would notify all hospitals of their decisions regarding the hospitals' requests to reconsider desk review adjustments and submit all of the revised wage data to CMS. From this point (early April) until the publication of the final rule, the process would be identical to the current timetable. Similar to the current timetable, hospitals would also have the opportunity in early April to request CMS consideration of policy disputes. We believe that the proposed revision of the schedule would improve the quality of the wage index by initiating hospitals' review of their data sooner and allowing the fiscal intermediaries to focus their reviews on the final data submitted by hospitals to be included in the wage index. In addition, we would receive the revised data in time to incorporate them into the wage indexes published in the proposed rule, resulting in fewer changes from the proposed rule to the final rule. This will improve the ability of hospitals to assess whether they should request a withdrawal from a MGCRB reclassification. Because the decision of whether to withdraw a wage index reclassification must be made prior to publication of the final rule, this proposed schedule should decrease the likelihood that the final wage index will be dramatically different from the proposed wage index. The following table illustrates the proposed timetable that would be applicable for the development of the FY 2005 wage index: Timeframe Steps in wage index development process Early October Preliminary and unaudited wage data file published as a public use file
(PUF)on CMS Web site. Early November Deadline for hospitals to send requests for revisions to the fiscal intermediaries. Early February Fiscal intermediaries review revisions and desk review wage data; notify hospitals of changes and resolution of revision requests; and submit preliminary revised data to CMS. Early March Deadline for hospitals to request wage data reconsideration of desk review adjustments and provide adequate documentation to support the request. Early April Deadline for the fiscal intermediaries to submit additional revisions resulting from the hospitals' reconsideration requests. This is also the deadline for hospitals to request CMS intervention in cases where the hospital disagrees with the fiscal intermediary's policy interpretations. Early May * Release of final wage data PUF on CMS Web site. Early June * Deadline for hospitals to submit correction requests, to both CMS and their fiscal intermediary, for errors due to the mishandling of the final wage data by CMS or the fiscal intermediary. August 1 * Publication of the final rule. October 1 * Effective date of updated wage index. * Indicates no change from prior years. IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Transfer Payment Policy (§ 412.4) Existing regulations at § 412.4(a) define discharges under the IPPS as situations in which a patient is formally released from an acute care hospital or dies in the hospital. Section 412.4(b) defines transfers from one acute care hospital to another, 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. The per diem rate paid to a transferring hospital is calculated by dividing the full DRG payment by the geometric mean length of stay for the DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 45804), our policy provides for payment that is double the per diem amount for the first day (§ 412.4(f)(1)). Transfer cases are also eligible for outlier payments. The outlier threshold for transfer cases is equal to the fixed-loss outlier threshold for nontransfer cases, divided by the geometric mean length of stay for the DRG, multiplied by the length of stay for the case, plus one day. 1. Transfers to Another Acute Care Hospital (§ 412.4(b)) Medicare adopted its IPPS transfer policy because, if we were to pay the full DRG payment regardless of whether a patient is transferred or discharged, there would be a strong incentive for hospitals to transfer patients to another IPPS hospital early in their stay in order to minimize costs while still receiving the full DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases. Currently, when a patient chooses to depart from a hospital against the medical opinion of treating physicians, the case is treated as a left against medical advice
(LAMA)discharge and coded as discharge status “07-Left Against Medical Advice (LAMA)” on the inpatient billing claim form. Because, by definition, LAMA discharges are assumed not to involve the active participation of the hospital administration, our policy has been to treat LAMA cases as discharges. This policy applies even if the patient is admitted to another hospital on the date of the LAMA discharge. Consequently, we currently make a full DRG payment for any discharge coded as a LAMA case. However, we are concerned that some hospitals may be incorrectly coding transfers as LAMA cases. The Office of Inspector General
(OIG)issued a report in March 2002 (A-06-99-00045), asserting that of the approximately 60,000 LAMA discharges annually, 1,500 patients were subsequently admitted to another IPPS hospital the same day. The OIG performed a detailed review of the medical records at selected hospitals and found evidence that the hospitals actively participated in transferring the patients to a different IPPS hospital, yet the hospital coded the claim as a LAMA. OIG cited several examples of these cases: “In the first example, the transferring hospital did not have an inpatient room available for the patient, who had been in the emergency room for 24 hours. The medical record showed that the treating physician contacted another PPS hospital to determine whether the hospital could accept the patient. Specifically, the medical record stated: ‘Upon request of the patient, [hospital name] was contacted since there is a good possibility of transferring patient to [name of hospital]. At present, he has been in emergency room for 24 hours waiting for a bed.’ ” In this example, despite the overt participation of the physician in securing the admission to the other IPPS hospital and the fact that the transferring hospital did not have an inpatient room available for the patient, the claim was submitted as a LAMA discharge, rather than as a transfer to another IPPS hospital. “In the second example, the patient was brought to the first hospital by ambulance. Subsequently, the patient's family indicated that they wanted a neurologist at another hospital to render the treatment needed by the patient. The attending physician contacted the neurologist in order to determine if the neurologist would accept, admit, and treat the patient. The medical record contained ample evidence of knowledge and participation of the transferring hospital, and the discharge should have been reported as a PPS transfer. Specifically, the medical record stated: ‘Patient's family wanted to sign the patient out against medical advice and take her to [name of hospital]. The physician spoke with the neurologist at [name of hospital], who agreed to accept the patient. The patient's family signed the patient discharged against medical advice. All the risks of self-discharge were explained.’ ” In this case, although the medical record indicated the patient wanted to leave against medical advice, there is also evidence that the patient's attending physician at the hospital participated in the transfer to another IPPS hospital. While we do not wish to discourage such participation and cooperation in cases where a transfer occurs, this situation would seem almost indistinguishable from other transfer situations. For instance, we have long recognized situations where patients are transferred from a rural hospital to an urban hospital for a surgical procedure, then back to the rural hospital to complete the recuperative care, as appropriate transfer situations as long as the transfers are medically appropriate. In such a case, the rural hospital would receive a payment under the transfer policy for the first portion of the stay, the urban hospital would also receive payment under the transfer policy for the care it provided, and the rural hospital would receive a full DRG payment as the discharging hospital for the recuperative care it provided upon the patient's return from the urban hospital. In such situations, each portion of the stay may be assigned a different DRG. Therefore, we are proposing to expand our definition of a transfer under § 412.4(b) to include all patients who are admitted to another IPPS hospital on the same day that the patient is discharged from an IPPS hospital, unless the first (transferring) hospital can demonstrate that the patient's treatment was completed at the time of discharge from that hospital. In other words, unless the same-day readmission is to treat a condition that is unrelated to the condition treated during the original admission (for example, the beneficiary is in a car accident later that day), any situation where the beneficiary is admitted to another IPPS hospital on the same date that he or she is discharged from an IPPS hospital would be considered a transfer, even if the patient left against medical advice from the first hospital. Although we considered proposing a policy that would be based on whether the hospital actively participated in the transfer, and exempting from the transfer definition cases where the hospital had absolutely no knowledge that the patient intended to go to another hospital, we are not proposing such a policy for two reasons. First, it would be difficult to administer equitably a policy that required a determination as to whether the hospital or the physician had knowledge of the patient's intentions. Such a policy would require fiscal intermediaries to make a difficult judgment call in many cases. Second, if we were to base the determination of whether a case is a transfer on the level of involvement of the hospital and the physician caring for the patient, we would be creating a financial disincentive to hospitals for ensuring an efficient and cooperative transfer once a decision has been made by the patient or the patient's family to leave the hospital. We recognize that, in some cases, a hospital cannot know the patient will go to another hospital. However, we note the claims processing system can identify cases coded as discharges where the date of discharge matches the admission date at another hospital. In these cases, the fiscal intermediary will notify the hospital of the need to submit an adjustment claim. However, if the hospital can present documentation showing that the patient's care associated with the admission to the hospital was completed before discharge, consistent with our current policy, the transfer policy will not be applied. 2. Technical Correction Section 412.4(b)(2) defines a discharge from one inpatient area of the hospital to another area of the hospital as a transfer. Although this situation may be viewed as an intrahospital transfer, it does not implicate the transfer policy under the IPPS. Therefore, to avoid confusion and to be consistent with the proposed changes to § 412.4(b) described at section IV.A.3. of this preamble, we are proposing to delete existing § 412.4(b)(2) from the definition of a transfer. 3. Expanding the Postacute Care Transfer Policy to Additional DRGs (§§ 412.4(c) and (d)) Under section 1886(d)(5)(J) of the Act, 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 SNF (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 IPPS final rule (63 FR 40975 through 40976), we specified the appropriate time period during which we would consider a discharge to postacute home health services to constitute a transfer 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 care transfer cases patients transferred to a swing-bed for skilled nursing care (63 FR 40977). Section 1886(d)(5)(J) of the Act 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 (Intracranial Hemorrhage and Stroke with Infarction (formerly “Specific Cerebrovascular Disorders Except Transient Ischemic Attack”)); • DRG 113 (Amputation for Circulatory System Disorders Except Upper Limb and Toe); • DRG 209 (Major Joint Limb Reattachment Procedures of Lower Extremity); • DRG 210 (Hip and Femur Procedures Except Major Joint Procedures 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 With Mechanical Ventiliation 96+ Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnoses (formerly “Tracheostomy Except for Face, Mouth, and Neck Diagnoses”)). Similar to the policy for transfers between two acute care hospitals, the transferring hospital in a postacute care 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 before 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 care transfer situations. For these 3 DRGs, hospitals receive 50 percent of the full DRG payment plus the single per diem (rather than double the per diem) 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.” Section 1886(d)(5)(J)(iv) of the Act authorizes the Secretary to expand the postacute transfer policy beyond 10 DRGs. In the May 9, 2002 IPPS proposed rule, we discussed the possibility of expanding this policy to either all DRGs or a subset of additional DRGs (we identified 13 additional DRGs in that proposed rule) (67 FR 31455). However, as discussed further in the August 1, 2002 final rule (65 FR 50048), we did not expand the postacute transfer provision to additional DRGs for FY 2003. The commenters on the options in the May 9, 2002 proposed rule raised many issues regarding the impact of expanding this policy that we needed to consider further before proceeding. In particular, due to the limited time between the close of the comment period and the required publication date of August 1, we were unable to completely analyze and respond to all of the points that were raised. We indicated that we would continue to conduct research to assess whether further expansion of this policy may be warranted and, if so, how to design any such refinements. Many commenters on the May 9, 2002 proposed rule argued that, in a system based on averages, expansion of the postacute care transfer policy negatively influences, and in fact penalizes, hospitals for efficient care. They claimed that this policy indiscriminately penalizes hospitals for efficient treatment and for ensuring that patients receive the right care at the right time in the right place. They believed that the postacute care transfer provision creates an inappropriate incentive for hospitals to keep patients longer. Commenters also expressed concern that the expansion of the transfer provision violates the fundamental principle of the IPPS. The DRG system is based on payments that will, on average, be adequate. These commenters argued that expansion of the postacute care transfer policy would give the IPPS a per-diem focus and would mean that hospitals would be paid less for shorter than average lengths of stay, although they would not be paid more for the cases that are longer than average (except for outlier cases). We agree that the transfer policy should not hamper the provision of effective patient care, and any future expansion must consider both the need to reduce payments to reflect cost-shifting due to reductions in length of stay attributable to early transfers to postacute care and the need to ensure that payments, on average, remain adequate to ensure effective patient care. Therefore, we have assessed the extent to which the current postacute transfer policy balances these objectives. The table below displays the results of our analysis. We first examined whether the 10 DRGs included in the policy continue to exhibit a relatively high percentage of cases transferred to postacute care settings, particularly among cases with lengths of stay shorter than the geometric mean for the DRG (these cases would be affected by the reduced payments for transfers). The table shows that these DRGs continue to contain high percentages of cases transferred to postacute care settings similar to those we reported in the FY 1999 final rule (63 FR 40975). These results would appear to demonstrate that the postacute transfer policy has not greatly altered hospitals' treatment patterns for these cases. This similarity in treatment patterns is further evidenced by the fact that, for 6 of the 10 DRGs, the geometric mean length of stay has continued to decline in the 5 years since the policy was implemented. Accordingly, hospitals have continued to transfer many patients in these DRGs before the mean length of stay, despite the transfer policy. As we stated in the July 31, 1998 final rule, the transfer provision adjusts payments to hospitals to reflect the reduced lengths of stay arising from the shift of patient care from the acute care setting to the postacute setting (63 FR 40977). This policy does not require a change in physician clinical decisionmaking nor in the manner in which physicians and hospitals practice medicine: it simply addresses the appropriate level of payments once those decisions have been made. With respect to whether this policy alters the fundamental averaging principles of the IPPS, we believe the current policy, which targets specific DRGs where evidence shows hospitals have aggressively moved care to postacute care settings, does not alter the averaging principles of the system. In fact, it could be said to enhance those principles because a transfer case is counted as only a fraction of a case toward DRG recalibration based on the ratio of its transfer payment to the full DRG payment for nontransfer cases. This methodology ensures the DRG weight calculation is consistent with the payment policy for transfer cases. The last column of the table below indicates that all but three of these DRGs have experienced increases in DRG weights since the policy was implemented. By reducing the contribution of transfer cases to the calculation of the DRG average charge, the relative weights (the result of dividing the DRG average charge by the national average charge per case) are higher than they would otherwise be. This is because transfers, particularly short-stay transfers, have lower total charges, on average. DRG DRG title All transfer cases Percent of all cases transferred to postacute care setting Percent of all cases transferred prior to mean length of stay Percent change in mean length of stay FYs 92-98 Percent change in mean length of stay FYs 98-03 Percent change in DRG relative weight FYs 98-03 14 Intracranial Hemorrhage and Stroke with Infarction 143,649 48.88 11.74 −29.17 −5.88 8.53 113 Amputation for Circulatory System Disorders Except Upper Limb and Toe 24,470 66.57 30.12 −32.17 7.22 9.21 209 Major Joint and Limb Reattachment Procedures of Lower Extremity 244,969 66.66 19.76 −47.52 −15.09 −8.09 210 Hip and Femur Procedures Except Major Joint Age >17 With CC 87,253 76.26 35.67 −42.98 −6.15 0.1 211 Hip and Femur Procedures Except Major Joint Age >17 Without CC 20,239 72.38 15.89 −44.44 −8.00 1.39 236 Fractures of Hip and Pelvis 26,583 69.86 11.20 −34.85 −6.98 −1.43 263 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC 13,158 62.00 31.35 −41.45 4.49 9.36 264 Skin Graft and/or Debridement for Skin Ulcer or Cellulitis Without CC 1,759 49.97 18.81 −37.21 1.85 5.36 429 Organic Disturbances and Mental Retardation 30,349 53.25 15.22 −28.95 −12.96 −5.27 483 Tracheostomy With Mechanical Ventilation 96 + Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnoses 21,818 52.93 27.34 −15.29 2.37 1.38 After determining the current 10 DRG postacute care transfer policy appears to be appropriately balancing the objectives to reduce payments to reflect cost-shifting due to reductions in length of stay attributable to early postacute care transfers and to ensure that payments, on average, remain adequate to ensure effective patient care, we once again undertook the analysis to identify additional DRGs to which the policy may be expanded. However, it should be noted that, at this time, we have decided not to expand the policy to all DRGs. Although we still believe expanding the postacute care transfer policy to all DRGs might be the most equitable approach because a policy that is limited to certain DRGs may result in disparate payment treatment across hospitals, at this time, we believe an incremental expansion is appropriate. That is, we believe further analysis is necessary to assess whether it would be appropriate to apply a reduced payment for postacute care transfers across all DRGs. In particular, it is important to attempt to distinguish between DRGs where the care is increasingly being shifted to postacute care sites versus DRGs where some patients have always been discharged to postacute care early in the stay. For the latter DRGs, it may not be appropriate to reduce payment for these DRGs if the base payment already reflects a similar postacute care utilization rate (for example, in these cases there would be no cost shifting). As described below, we have identified an additional 19 DRGs, based on declining mean lengths of stay and high percentages of postacute transfers, for which an expansion of the current policy appears warranted. MedPAC has also conducted analysis on the current postacute care transfer policy. Most recently, in its March 2003 Report to Congress, MedPAC recommended adding 13 additional DRGs to the 10 DRGs covered under the current policy (page 46). The 13 DRGs were the same DRGs included in one of our proposals to expand the postacute care transfer policy in last year's IPPS proposed rule. MedPAC did not recommend expanding the policy to include all DRGs at this time, noting that this expansion might reduce payments to some hospitals by as much as 4 percent. Rather, it suggested evaluating the impact of a limited expansion before extending the policy to more DRGs. MedPAC's report cites several reasons for expanding the postacute care transfer policy beyond the current 10 DRGs. First, it notes the continuing shifts in services from the acute care setting to the postacute care setting. Second, the report points to different postacute care utilization for different hospitals, particularly based on geographic location. Third, the report states: “the expanded transfer policy provides a better set of incentives to protect beneficiaries from potential premature discharge to postacute care.” Fourth, MedPAC notes that the policy improves payment equity across hospitals by: Reducing payments to hospitals that transfer patients to postacute care while making full payments to hospitals that provide all of the acute inpatient services in an acute care setting; and maintaining more accurate DRG weights that reflect the true resource utilization required to provide the full course of acute inpatient care, as distinguished from the partial services provided to patients who are transferred to postacute care. Since the publication of last year's rule, we have conducted an extensive analysis to identify the best method by which to expand the postacute care transfer policy. Similar to the analysis used to identify the current 10 DRGs, we are proposing to identify DRGs with high postacute care transfer rates and at least 14,000 transfer cases. However, rather than ranking DRGs on the basis of the percentage of all postacute care transfers, we are proposing to rank DRGs on the basis of the percentage of postacute care transfers occurring before the DRG geometric mean length of stay. This is because only transfers that occur before the geometric mean length of stay, minus one day due to the policy that hospitals receive double the per diem for the first day, are impacted by the transfer policy. In order to focus on those DRGs where this policy would have the most impact, we are proposing to include only DRGs where at least 10 percent of all cases that were transferred to postacute care before the geometric mean length of stay. The next proposed criterion is to identify DRGs with at least a 7-percent decline in length of stay over the past 5 years (from FY 1998 to FY 2003). This criterion would focus on those DRGs for which hospitals have been most aggressively discharging patients sooner into postacute care settings. Finally, we are proposing to include only DRGs with a geometric mean length of stay of at least 3 days because the full payment is reached on the second day for a DRG with a 3-day length of stay. Using these criteria, we have identified 19 additional DRGs to include in the postacute care transfer policy. However, some of the 13 DRGs proposed last year (and included in MedPAC's proposed expansion) are not included in this proposed rule. For example, DRGs 79 and 80 (Respiratory Infections and Inflammations Age >17 With and Without CC, respectively) were included in last year's proposed expansion but are not included in this proposed rule for FY 2004. DRGs 79 and 80 are excluded from this proposed rule because they did not exhibit a decline in length of stay of at least 7 percent over the past 5 years. We note that 7 of these 19 DRGs are paired DRGs (that is, they contain a CC and no-CC split). Because these DRGs are paired DRGs (that is, the only difference in the cases assigned to DRG 130, for example, as opposed to DRG 131 is that the patient has a complicating or comorbid condition), we are proposing to include both DRGs under this expanded policy. If we were to include only DRG 130 in the transfer policy, there would be an incentive for hospitals not to include any code that would identify a complicating or comorbid condition, so that a transfer case would be assigned to DRG 131 instead of DRG 130. Using the selection criteria described above, we identified the following 19 DRGs that we are proposing to include under the postacute care transfer policy (in addition to the 10 DRGs already subject to the policy). DRG DRG title All transfer cases Percent of all cases transferred to postacute care setting Percent of cases transferred prior to mean length of stay Percent change in mean length of stay FYs 1992-1998 Percent change in mean length of stay FYs 1998-2003 12 Degenerative Nervous System Disorders 39,034 54.13 13.10 −21.74 −12.00 24 Seizure and Headache Age >17 With CC 19,239 35.67 11.63 −20.75 −7.69 25 Seizure and Headache Age >17 Without CC 4,738 19.15 2.15 −14.29 −10.71 89 Simple Pneumonia and Pleurisy Age > 17 With CC 175,441 34.86 11.37 −18.31 −11.11 90 Simple Pneumonia and Pleurisy Age >17 Without CC 9,544 20.86 2.82 −20.37 −15.00 121 Circulatory Disorders With AMI and Major Complication, Discharged Alive 79,242 52.52 20.46 −21.95 −11.67 122 Circulatory Disorders With AMI Without Major Complications Discharged Alive 33,028 48.91 24.09 −26.67 −23.08 130 Peripheral Vascular Disorders With CC 31,106 37.78 14.27 −13.11 −11.76 131 Peripheral Vascular Disorders Without CC 5,723 23.08 5.42 −4.44 −19.51 239 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy 23,188 53.54 21.96 −22.67 −7.55 243 Medical Back Problems 36,772 41.49 13.61 −14.00 −7.50 277 Cellulitis Age >17 With CC 35,015 37.77 14.03 −21.43 −7.84 278 Cellulitis Age >17 Without CC 6,526 22.05 3.11 −18.87 −10.00 296 Nutritional and Miscellaneous Metabolic Disorders Age >17 With CC 104,216 40.05 11.88 −21.67 −9.30 297 Nutritional and Miscellaneous Metabolic Disorders Age >17 Without CC 12,649 28.03 2.17 −17.50 −10.00 320 Kidney and Urinary Tract Infectious Age >17 With CC 77,669 44.64 12.40 −23.88 −8.51 321 Kidney and Urinary Tract Infections Age >17 Without CC 8,610 29.90 5.67 −20.41 −13.89 462 Rehabilitation 147,211 56.59 22.69 −22.54 −11.43 468 Extensive O.R. Procedure Unrelated to Principal Diagnosis 24,783 44.51 18.53 −20.30 −7.07 We are proposing to revise § 412.4(d) to incorporate these additional 19 DRGs as qualifying DRGs for transfer payments and to make a conforming change to § 412.4(c). We also examined whether any of these DRGs would qualify for the alternative payment methodology of 50 percent of the full DRG payment plus the per diem 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 specified in existing regulations under § 412.4(f). To identify the DRGs that might qualify, the average charges for all cases with a length of stay of 1 day were compared to the average charges of all cases in a particular DRG. To qualify for the alternative methodology, the average charges of 1-day discharge cases must be at least 50 percent of the average charges for all cases in the DRG. Based on this analysis, we determined that 5 out of the 19 DRGs would qualify for this payment method (DRGs 25, 122, 131, 297, and 321). However, the fact that the average charges of 1-day stays equal at least 50 percent of the average charges for all cases in these DRGs is due to the very short lengths of stay for these DRGs. Therefore, we do not believe that it is necessary to include them in the alternative payment methodology. For example, for a DRG with a 3-day geometric mean length of stay, full DRG payment will be met on the second day of the stay, regardless of which payment methodology is used. Therefore, we are proposing that none of the 19 additional DRGs that we are proposing to add to the postacute care transfer policy would be paid under the alternative payment methodology. We also have analyzed the 10 DRGs that are currently subject to the postacute care transfer policy. Of the three DRGs that are receiving payments under the special payment (transfers after 1 day incur charges equal to at least 50 percent of the average charges for all cases). Unlike the five DRGs that would otherwise meet this criterion, the geometric mean lengths of stay of both DRG 209 and 211 are over 4 days. In addition, DRG 210 is currently paid under the special payment methodology, but our current analysis indicates average charges for one day stays are less than 50 percent of the average charges for all cases in the DRG. Nonetheless, DRG 210 is a paired with DRG 211, which meets the criteria. Therefore, we are proposing DRG 210 will continue to be paid under the special payment methodology. Similar to our rationale for including both paired DRGs when one qualifies for inclusion in the postacute care transfer policy, we are including both DRGs in this pair under the special payment methodology. Accordingly, we are proposing that only DRGs 209, 210, and 211 that are currently paid under the alternative transfer payment methodology would continue to be paid under this methodology. Finally, we note that the OIG has prepared several reports that examined hospitals' compliance with proper coding of patients' discharge status as transferred under our guidelines, and has found substantial noncompliance leading to excessive payments. 4 Specifically, the OIG found hospitals submitting claims indicating the patient had been discharged when, in fact, the patient was transferred to a postacute care setting. As we indicated in the May 8, 1998 **Federal Register** (63 FR 25593), hospitals found to be intentionally engaging in such practices may be investigated for fraudulent or abusive billing practices. We intend to work with the OIG to develop the most appropriate response to ensure all hospitals become compliant with our guidelines. 4 The OIG report identification numbers are: A-04-00-02162, A-04-00-01220 and A-04-01210. A fourth report is expected out soon. B. 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 IPPS 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 are 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. Rural referral centers with a disproportionate share percentage of at least 30 percent are not subject to the 5.25 percent cap on DSH payments that is applicable to other rural hospitals (with the exception of rural hospitals with 500 or more beds). Rural referral centers are not subject to the proximity criteria when applying for geographic reclassification, and they do not have to meet the requirement that a hospital's average hourly wage must exceed 106 percent of the average hourly wage of the labor market area where the hospital is located. As discussed in **Federal Register** documents at 62 FR 45999 and 63 FR 26325, under section 4202 of Public Law 105-33, a hospital that was classified as a rural referral center for FY 1991 is to be considered as a rural referral center for FY 1998 and later years so long as that hospital continues to be located in a rural area and does not voluntarily terminate its rural referral center status. Effective October 1, 2000, if a hospital located in what is now an urban area was ever a rural referral center, it is reinstated to rural referral center status (65 FR 47089). Otherwise, a hospital seeking rural referral center status must satisfy the 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 (§ 412.96(b)(1)(ii)). 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 (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) (§ 412.96(c)(1) through (c)(5)). (See also the September 30, 1988 **Federal Register** (53 FR 38513).) With respect to the two mandatory prerequisites, a hospital may be classified as 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, as specified in section 1886(d)(5)(C)(i) of the Act.) 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 for FY 2004 includes all urban hospitals nationwide, and the proposed regional values for FY 2004 are the median values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in § 412.105). These proposed values are based on discharges occurring during FY 2002 (October 1, 2001 through September 30, 2002) and include bills posted to CMS' records through December 2002. We are proposing that, in addition to meeting other criteria, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2003, rural hospitals with fewer than 275 beds must have a case-mix index value for FY 2002 that is at least— • 1.3374; or • The median case-mix index value (not transfer-adjusted) 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 proposed 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) 1.2252 2. Middle Atlantic (PA, NJ, NY) 1.2270 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.3157 4. East North Central (IL, IN, MI, OH, WI) 1.2485 5. East South Central (AL, KY, MS, TN) 1.2511 6. West North Central (IA, KS, MN, MO, NE, ND, SD) 1.1841 7. West South Central (AR, LA, OK, TX) 1.2733 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.3511 9. Pacific (AK, CA, HI, OR, WA) 1.2834 The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2002 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 (not transfer-adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these 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 2002 (that is, October 1, 2001 through September 30, 2002). 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, 2003, must have as the number of discharges for its cost reporting period that began during FY 2002 a figure that is at least— • 5,000 (3,000 for an osteopathic hospital); or • The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table: Region Number of discharges 1. New England (CT, ME, MA, NH, RI, VT) 7,476 2. Middle Atlantic (PA, NJ, NY) 8,906 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 9,497 4. East North Central (IL, IN, MI, OH, WI) 8,439 5. East South Central (AL, KY, MS, TN) 6,894 6. West North Central (IA, KS, MN, MO, NE, ND, SD) 3,991 7. West South Central (AR, LA, OK, TX) 7,629 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 8,908 9. Pacific (AK, CA, HI, OR, WA) 7,021 These numbers will be revised in the final rule based on the latest available cost report data. C. Indirect Medical Education
(IME)Adjustment (§ 412.105) and Disproportionate Share Hospital
(DSH)Adjustment (§ 412.105) 1. Available Beds and Patient Days: Background (§ 412.105(b) and § 412.106(a)(1)(ii)) Section 1886(d)(5)(B) of the Act provides that subsection
(d)hospitals that have residents in approved graduate medical education
(GME)programs receive an additional payment for each discharge of Medicare beneficiaries to reflect the higher indirect patient care 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, calculated using hospitals' ratios of residents to beds. The determination of the number of beds, based on available bed days, is specified at § 412.105(b). This determination of the number of available beds is also applicable for other purposes, including the level of the disproportionate share hospital
(DSH)adjustment payments under § 412.106(a)(l)(i). Section 1886(d)(5)(F) of the Act specifies two methods for a hospital to qualify for the Medicare DSH adjustment. The primary method, which is the subject of a provision in this proposed rule, is for a hospital to qualify based on a complex statutory formula under which payment adjustments are based on the level of the DSH patient percentage. The first computation includes the number of patient days that are furnished to patients who were entitled to both Medicare Part A and Supplemental Security Income
(SSI)benefits. This number is divided by the total number of patient days that are associated with patients entitled to benefits under Medicare Part A. The second computation includes hospital patient days that are furnished to patients who, for those days, were eligible for Medicaid but were not entitled to benefits under Medicare Part A. This number is divided by the number of total hospital inpatient days in the same period. Hospitals whose DSH patient percentage exceeds 15 percent are eligible for a DSH payment adjustment (prior to April 1, 2001, the qualifying DSH patient percentage varied, in part, by the number of beds (66 FR 39882)). The DSH payment adjustment may vary based on the DSH patient percentage and the type of hospital: the statute provides for different adjustments for urban hospitals with 100 or more beds and rural hospitals with 500 or more beds, hospitals that qualify as rural referral centers or SCHs, and other hospitals. We are combining our discussion of proposed changes to the policies for counting beds and patient days, in relation to the calculations at §§ 412.105(b) and 412.106(a)(1)(ii) because the underlying concepts are similar, and we believe they should generally be interpreted in a consistent manner for both purposes. Specifically, we are proposing to clarify that beds and patient days that are counted for these purposes should be limited to beds or patient days in hospital units or wards that would be directly included in determining the allowable costs of inpatient hospital care payable under the IPPS on the Medicare cost reports. As a preliminary matter, beds and patient days associated with these beds that are located in units or wards that are excluded from the IPPS (for example, psychiatric or rehabilitation units), and thus from the determination of allowable costs of inpatient hospital care under the IPPS on the Medicare cost report, are not to be counted for purposes of §§ 412.105(b) and 412.106(a)(1)(ii). The remainder of this discussion pertains to beds and patient days associated with these beds that are located in units or wards that are not excluded from the IPPS and for which costs are included in determining the allowable costs of inpatient hospital care under the IPPS on the Medicare cost report. For example, neonatal intensive care unit beds are included in the determination of available beds because the costs and patient days associated with these beds are directly included in the determination of the allowable costs of inpatient hospital care under the IPPS. In contrast, beds and patient days associated with these beds that are located in excluded distinct-part psychiatric or rehabilitation units would not be counted for purposes of §§ 412.105(b) and 412.106(a)(1)(ii) under any circumstances, because the costs associated with those units or wards are excluded from the determination of the costs of allowable inpatient care under IPPS. This policy has been upheld in the past by various courts. (See, for example, *Little Co. of Mary Hospital and Health Care Centers* v. *Shalala,* 165 F.3d 1162 (7th Cir. 1999; *Grant Medical Center* v. *Shalala,* 905 F. Supp. 460 (S.D. Ohio 1995); *Sioux Valley Hospital* v. *Shalala* , No. 93-3741SD, 1994 U.S. App. LEXIS 17759 (8th Cir. July 20, 1996) (unpublished table decision); *Amisub* v. *Shalala* , No. 94-1883
(TFH)(D.D.C. December 4, 1995) (mem.).) In these cases, the courts agreed with the Secretary's position distinguishing between the treatment of neonatal intensive care unit beds and well-baby nursery beds based on the longstanding policy of CMS that neonatal intensive care unit days are considered intensive care days (part of inpatient routine care) rather than nursery days. Our policies on counting beds are applied consistently for both IME and DSH although the incentives for hospitals can be different for IME and DSH. For purposes of IME, teaching hospitals have an incentive to minimize their number of available beds in order to increase the resident-to-bed ratio and maximize the IME adjustment. On the other hand, for DSH purposes, urban hospitals with under 100 beds and rural hospitals with under 500 beds may have an incentive to increase their bed count in order to qualify for the higher DSH payments for urban hospitals with over 100 beds (or rural hospitals with over 500 beds). However, some courts have applied our current rules in a manner that is inconsistent with our current policy and that would result in inconsistent treatment of beds, patient days, and costs. For example, in *Clark Regional Medical Center* v. *United States Department of Health & Human Services* , 314 F.3d 241 (6th Cir. 2002), the court upheld the district court's ruling that all bed types not specifically excluded from the definition of available bed days in the regulations must be included in the count of available bed days. Similarly, in a recent decision in the Ninth Circuit Court of Appeals *Alhambra* v. *Thompson,* 259 F.3d 1071 (Ninth Cir. 2001), the court ruled that days attributable to groups of beds that are not separately certified as distinct part beds (that is, nonacute care beds in which care provided is at a level below the level of routine inpatient acute care) but are adjacent to or in an acute care “area” are included in the “areas of the hospital that are subject to the prospective payment system” and should be counted in calculating the Medicare DSH patient percentage. These courts considered subregulatory guidance (program instructions) in formulating their decisions. Although this proposed rule would clarify the underlying principles for our bed and patient days counting policies and would amend the relevant regulations to be consistent with these clarifications, we recognize the need to revise some of our program instructions to make them fully consistent with these clarifications and will act to do so as soon as possible. While some of the topics discussed below pertain only to counting available beds (unoccupied beds) and some only to counting patient days (section 1115 waiver days, dual-eligible days, and Medicare+Choice days), several important topics are applicable to both bed-counting and day-counting policies (nonacute care beds and days, observation beds and days, and swing-beds and days). Therefore, for ease of discussion, we have combined all topics pertaining to counting available beds and patient days together in the following discussion. 2. Unoccupied Beds The current policy for counting hospital beds for IME and DSH is specified at § 412.105(b). That count is based on total available bed days during the hospital's cost reporting period, divided by the number of days in the cost reporting period. The regulations specify certain types of beds to be excluded from this count (for example, beds or bassinets in the healthy newborn nursery, custodial care beds, and beds in excluded distinct part hospital units). Further instructions for counting beds are detailed in section 2405.3, Part I, of the Medicare Provider Reimbursement Manual (PRM). That section states that a bed must be permanently maintained for lodging inpatients and it must be available for use and housed in patient rooms or wards. Thus, beds in a completely or partially closed wing of the facility are considered available only if the hospital can put the beds into use when they are needed. Currently, if a bed can be staffed for inpatient care either by nurses on staff or from a nurse registry within 24 to 48 hours, the unoccupied bed is determined available. 5 In most cases, it is a straightforward matter to determine whether unoccupied beds can be staffed within this timeframe because they are located in a unit that is otherwise staffed and occupied (an unoccupied bed is available for patient care but it is not occupied by a patient on a particular day). The determination is not as simple in situations where a room in an otherwise occupied unit has been altered for other purposes, such as for a staff lounge or for storage. 5 This policy was first articulated in correspondence to the Blue Cross and Blue Shield Association (BCBSA) on November 2, 1988, and published in BCBSA's Administrative Bulletin #1841, 88.01, on November 18, 1988. Section 2405.3 of the PRM states that beds in unoccupied rooms or wards are to be excluded from the bed count if the associated costs are excluded from depreciable plant assets because the area is not available for patient use. However, issues continue to arise with regard to how to treat entire units or even entire floors that are unoccupied over a period of time. For example, in one recent Provider Reimbursement Review Board
(PRRB)decision, the hospital acknowledged that an entire floor was temporarily unoccupied for approximately 2 years. Rooms on the floor were used for office space, storage and outpatient services. The PRRB ruled that current rules allowed these beds to be counted. Specifically, the PRRB found the beds could reasonably be made ready for inpatient use within 24 to 48 hours, the rooms were counted on the hospital's cost report as depreciable plant assets available for patient care, and the hospital could adequately provide patient care in the beds using staff nurses or nurses from a nurse registry. Upon review, the Administrator also ultimately upheld this decision based on existing policies and instructions. We do not believe that an accurate bed count should include beds that are essentially hypothetical in nature; for example, when the beds are on a floor that is not used for inpatient care throughout the entire cost reporting period (and, indeed, may have been used for other purposes). Followed to the extreme, a hospital could count every bed in its facility, even if it had no intention of ever using a bed for inpatient care, as long as it would be theoretically possible to place an inpatient in the bed. We do not believe such a result would accurately reflect a hospital's inpatient bed capacity. Even though some teaching hospitals have an incentive to minimize the bed count for payment purposes, some DSH hospitals have an incentive to maximize the bed count for the same reason. Our current policy is intended to reflect a hospital's bed count as accurately as possible, achieving a balance between capturing short-term shifts in occupancy and long-term changes in capacity. Therefore, we believe further clarification and refinement of our policies relating to counting available beds is necessary. In the FY 2003 IPPS proposed rule published on May 9, 2002 (67 FR 31462), we proposed that, if a hospital's reported bed count results in an occupancy rate (average daily census of patients divided by the 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. However, at the time the FY 2003 IPPS final rule was published on August 1, 2002 (67 FR 50060), we decided not to proceed with the proposed changes as final and to reconsider the issue as part of a future comprehensive analysis of our bed and patient day counting policies. In this proposed rule, rather than establish a minimum standard occupancy rate, we are proposing to determine whether beds in a unit are available based upon whether the unit was used to provide patient care of a level generally payable under the IPPS (“IPPS level of care”) *at any time* during the 3 preceding months. If any of the beds in the unit were used to provide an IPPS level of care at any time during the preceding 3 months, all of the beds in the unit are counted for purposes of determining available bed days during the current month. If no patient care of a type generally payable under the IPPS was provided in that unit during the 3 preceding months, the beds in the unit are to be excluded from the determination of available bed days during the current month (proposed §§ 412.105(b)(2) and 412.106(a)(1)(ii)(C)). For example, our policy as to how to count beds during minor renovations of units, wards, or individual rooms has been that unless the space costs are treated as nonallowable, the beds would be counted. Under the policy we are proposing, beds in an otherwise unoccupied unit that are occupied (for purposes of providing IPPS-level care) at any time during the 3 preceding months would be counted as available for the current month. This would apply even if the rooms were undergoing renovation during a portion of that 3-month period. We believe a unit or ward can be defined as a group of rooms staffed by nurses assigned to a single nursing station. In most cases, the patients treated within a single unit or ward will receive a similar level of care (that is, acute, intensive, rehabilitation, psychiatric, or skilled nursing). However, we encourage comments on the most useful definition of a unit or ward. We believe this proposed policy would provide a clear standard for both hospitals and fiscal intermediaries to use to determine whether otherwise unoccupied beds should be counted. We note that if the required time period for excluding the unoccupied beds were to be set too low, hospitals could potentially manipulate their available bed count by not admitting any patients to a unit during low occupancy periods, thereby distorting the measure of hospital size. We believe 3 months, one quarter of a hospital's fiscal year, represents a reasonable standard for determining that a unit is not being used to provide patient care and may be excluded from the hospital's available bed count. It is also necessary to consider our policy with respect to individual beds within rooms located in an otherwise occupied unit when those beds are used for alternative purposes. For example, section 2405.3 of the PRM states that beds used for the following are excluded from the definition (of a bed): Postanesthesia or postoperative recovery rooms, outpatient areas, emergency rooms, ancillary departments nurses' and other staff residences, and other such areas as are regularly maintained and utilized for only a portion of the stay of patients or for purposes other than inpatient lodging. In some situations, beds used for these excluded purposes may be intermingled with acute care inpatient beds. Beds being used to provide specific categories of nonacute services, such as outpatient services in an observation bed or skilled nursing services in a swing-bed, are excluded from the count. As discussed later, this flows from our policy that the bed days are treated consistently with the assignment of the costs on the Medicare cost report of the services provided in the bed. In the case of individual rooms in an otherwise occupied unit that are altered to be used for other uses besides inpatient care, we are proposing the bed(s) should be counted if a patient could be admitted to the room within 24 hours (proposed § 412.105(b)(3)). This would apply even if the bed(s) were not currently located in the room, as long as a bed could be physically placed in the room and made available within 24 hours. We are proposing that it would no longer be necessary for the hospital to determine whether a bed could be staffed within 24 to 48 hours. For example, in the case of a room that has been altered for use as a staff lounge, if the room could be made available to house a patient merely by replacing the lounge furniture with a patient bed, the bed should be counted as available. Under this proposal, other than when an inpatient room is used to provide observation services, labor/delivery room services, or skilled nursing services in a swing-bed (all discussed later in this proposed rule), the alternative purpose of the room is only relevant if it impacts whether the room could be made available for patient occupancy within 24 hours. If the hospital was fully occupied (no other room was available), and the room still was not put into service when needed, that would provide evidence that the room could not be made available and beds in the room should be excluded from the bed count. Therefore, we are proposing to amend § 412.105(b) to indicate that the bed days in a unit that is unoccupied by patients receiving IPPS-level care for the 3 preceding months are to be excluded from the available bed day count for the current month. We are further proposing the beds in a unit that was occupied for IPPS-level care during the 3 preceding months should be counted unless they could not be made available for patient occupancy within 24 hours, or they are used to provide outpatient observation services or swing-bed skilled nursing care. 3. Nonacute Care Beds and Days As noted above, these policies are consistent with the reporting of the days, costs, and beds that are used to calculate the costs of hospital inpatient care in individual cost centers on the Medicare cost report. Furthermore, since the IME and DSH adjustments are part of the IPPS, we read the statute to apply only to inpatient beds and days. Under the existing provisions of § 412.105(b), the regulations specifically exclude beds or bassinets in the healthy newborn nursery, custodial care beds, or beds in excluded distinct part hospital units as types of beds excluded from the count of available beds. Existing regulations at § 412.106(a)(1)(ii) state that the number of patient days used in the DSH percentage calculation includes only those days attributable to areas of the hospital that are subject to the IPPS and excludes all others. This regulation was added after being proposed in the March 22, 1988 **Federal Register** (53 FR 9339), and made final in the September 30, 1988 **Federal Register** (53 FR 38479). At that time, we indicated that, “based on a reading of the language in section 1886(d)(5)(F) of the Act, which implements the disproportionate share provision, we are in fact required to consider only those inpatient days to which the prospective payment system applies in determining a prospective payment hospital's eligibility for a disproportionate share adjustment.” Using this reasoning, we stated that the DSH patient percentage calculation should only include patient days associated with the types of services paid under the IPPS. As noted previously, a recent decision in the Ninth Circuit Court of Appeals ( *Alhambra* v. *Thompson* ) ruled that days attributable to groups of beds that are not separately certified as distinct part beds (that is, nonacute care beds in which care provided is at a level below the level of routine inpatient acute care), but are adjacent to or in an acute care “area,” are included in the “areas of the hospital that are subject to the prospective payment system” and should be counted in calculating the Medicare DSH patient percentage. In light of the Ninth Circuit decision that our rules were not sufficiently clear to permit exclusion of bed days based on the area where the care is provided, we are proposing to revise our regulations to be more specific. Therefore, in this proposed rule, we are proposing to clarify that beds and patient days are excluded from the calculations at § 412.105(b) and § 412.106(a)(1)(ii) if the nature of the care provided in the unit or ward is inconsistent with what is typically furnished to acute care patients, regardless of whether these units or wards are separately certified or are located in the same general area of the hospital as a unit or ward used to provide an acute level of care. Although the intensity of care may vary within a particular unit, such that some patients may be acute patients while others are nonacute, we understand that a patient-by-patient review of whether the care received would be paid under the IPPS would be unduly burdensome. Therefore, we believe it is more practical to permit the application of this principle based upon the location at which the services were furnished. In particular, we are proposing to revise our regulations to clarify that the beds and patient days attributable to a nonacute care unit or ward should not be included in the calculations at § 412.105(b) and § 412.106(a)(1)(ii), even if the unit is not separately certified by Medicare as a distinct-part unit and even if the unit or ward is within the same general location of the hospital as areas that are subject to the IPPS. Exceptions to this policy are outpatient observation and swing-bed days, which are excluded from the count of available bed days even if the care is provided in an acute care unit. Our policies pertaining to these beds are discussed further below. Another exception is healthy newborn nursery days. The costs, days, and beds of a healthy newborn nursery are excluded from inpatient calculations for Medicare purposes. Meanwhile, for the purpose of computing the Medicaid patient share computation of the DSH patient percentages, these days are included both as Medicaid patient days and as total patient days. Nursery costs are not directly included in calculating Medicare hospital inpatient care costs because Medicare does not generally cover services for infants. However, Medicaid does offer extensive coverage to infants, and nursery costs would be directly included in calculating Medicaid hospital inpatient care costs. Therefore, these costs, days, and beds are excluded for Medicare purposes, but included for determining the Medicaid DSH percentage. (This policy was previously communicated through a memorandum to CMS Regional Offices on February 27, 1997.) Generally, as discussed previously, if the nature of the care provided in the unit or ward is consistent with what is typically furnished to acute care patients, and, therefore, would be characteristic of services paid under the IPPS, the patient days, beds, and costs of that unit or ward would be classified as inpatient acute care (except for observation bed days and swing bed days, as discussed later in this preamble). Conversely, if the intensity and type of care provided in the unit or ward are not typical of a service that would be paid under the IPPS (for example, nonacute care), we are proposing that the beds and patient days attributable to a nonacute care unit or ward should not be included in the calculations of beds and patient days at § 412.105(b) and § 412.106(a)(1)(ii). This proposed policy is not intended to focus on the level or type of care provided to individual patients in a unit, but rather on the level and type of care provided in the unit as a whole. For example, the bed days for a patient participating in an experimental procedure that is not covered under the IPPS should be counted as long as the patient is treated in a unit of the hospital that generally provides acute inpatient care normally payable under the IPPS. The expectation is that a patient located in an acute care unit or ward of the hospital is receiving a level of care that is consistent with what would be payable under the IPPS. There are instances where services that are provided in units excluded from the IPPS (such as rehabilitation and psychiatric distinct-part units) are consistent with the level of care that would qualify for payment under the IPPS. However, §§ 412.105(b) and 412.106(a)(1)(ii) specifically exclude the beds and patient days associated with these excluded units. That exclusion is because the costs of care provided in these units are paid outside the IPPS, even though some of the care provided is of a type that would be payable under the IPPS if the care was provided in an IPPS unit. We are proposing to revise § 412.105(b) to clarify that beds in units or wards established or used to provide a level of care that is not consistent with what would be payable under the IPPS cannot be counted (proposed paragraph (b)(1)). We also are proposing to revise the DSH regulations at § 412.106(a)(1)(ii) to clarify that the number of patient days includes only those attributable to patients that receive care in units or wards that furnish a level of care that would generally be payable under the IPPS (proposed paragraph (a)(1)(ii)(C)). We note these proposed revisions are clarifications of our regulations to reflect our longstanding interpretation of the statutory intent, especially relating to the calculation of the Medicare DSH patient percentage. 4. Observation Beds and Swing-Beds Observation services are those services furnished by a hospital on the hospital's premises that include use of a bed and periodic monitoring by a hospital's nursing or other staff in order to evaluate an outpatient's condition or to determine the need for a possible admission to the hospital as an inpatient. When a hospital places a patient under observation but has not formally admitted him or her as an inpatient, the patient initially is treated as an outpatient. Consequently, the observation bed days are not recognized under the IPPS as part of the inpatient operating costs of the hospital. Observation services may be provided in a distinct observation bed area, but they may also be provided in a routine inpatient care area. In either case, our policy is the bed days attributable to beds used for observation services are excluded from the counts of available bed days and patient days at §§ 412.105(b) and 412.106(a)(1)(ii). This policy was clarified in a memorandum that was sent to all CMS Regional Offices (for distribution to fiscal intermediaries) dated February 27, 1997, which stated that if a hospital provides observation services in beds that are generally used to provide hospital inpatient services, the equivalent days that those beds are used for observation services should be excluded from the count of available bed day count (even if the patient is ultimately admitted as an acute inpatient). A swing-bed is a bed otherwise available for use to provide acute inpatient care that is also occasionally used to provide SNF care. The criteria to qualify as a swing-bed hospital are located under § 482.66, and for a swing-bed CAH under § 485.645. Under § 413.114(a)(1), payment for posthospital SNF care furnished in swing-beds is in accordance with the provisions of the prospective payment system for SNF care (effective for services furnished in cost reporting periods beginning on and after July 1, 2002). Similar to observation beds and patient days, swing-beds and patient days are excluded from the counts of available bed days and patient days at §§ 412.105(b) and 412.106(a)(1)(ii) when the swing-bed is used to furnish SNF care. 6 6 *Ibid.* Observation beds and swing-beds are both special, frequently temporary, alternative uses of acute inpatient care beds. That is, only the days an acute inpatient care unit bed is used to provide outpatient observation services are to be deducted from the available bed count under § 412.105(b). Otherwise, the bed is considered available for acute care services (as long as it otherwise meets the criteria to be considered available). This same policy applies for swing-beds. The policies to exclude observation bed days and swing-bed days stem from the fact that these bed days are not payable under the IPPS (unless the patient is ultimately admitted, in the case of observation bed days). Some hospitals have contested our policy excluding swing-beds and patient days and observation beds and patient days under existing §§ 412.105(b) and 412.106(a)(1)(ii). For example, in *Clark Regional Medical Center* v. *United States Department of Health & Human Services,* 314 F.3d 241 (6th Cir. 2002), the court upheld the district court's ruling that all bed types not specifically excluded from the definition of available bed days in the regulations must be included in the count of available bed days. The hospitals involved in this decision wanted to include observation and swing-bed days in their bed count calculation in order to qualify for higher DSH payments as 100 bed hospitals. The Court found that “the listing of beds to be excluded from the count restricts the class of excluded beds only to those specifically listed.” Because observation beds and swing-beds are not currently specifically mentioned in § 412.105(b) as being excluded from the bed count, the Court ruled that these beds must be included in the count. The list of the types of beds excluded from the count under existing § 412.105(b) was never intended to be an exhaustive list of all of the types of beds to be excluded from the bed count under this provision. In fact, over the years, specific bed types have been added to the list as clarifications of the types of beds to be excluded, not as new exclusions (see the September 1, 1994 **Federal Register** (59 FR 45373) and September 1, 1995 **Federal Register** (60 FR 45810), where we clarified exclusions under our policy that were not previously separately identified in the regulation text). Courts also have recently found that observation and swing-bed days are included under the ‘plain meaning’ of § 412.106(a)(1)(ii), which reads: “The number of patient days includes only those days attributable to areas of the hospital that are subject to the prospective payment system and excludes all others.” However, the preamble language when this provision was promulgated clarified its meaning (53 FR 38480): • “Although previously the Medicare regulations did not specifically define the inpatient days for use in the computation of a hospital's disproportionate share patient percentage, we believe that, based on a reading of the language in section 1886(d)(5)(F) of the Act, which implements the disproportionate share provision, we are in fact required to consider only those inpatient days to which the prospective payment system applies in determining a prospective payment hospital's eligibility for a disproportionate share adjustment.” Our policy excluding outpatient observation and swing-bed days is consistent with this regulatory interpretation of days to be counted under § 412.106(a)(1)(ii). That is, the services provided in these beds are not payable under the IPPS (unless the patient is admitted, in the case of observation bed days). As outlined previously, our consistent and longstanding policy, which has been reviewed and upheld previously by several courts, including the United States District Court for the District of Columbia, is based on the principle of counting beds in the same manner as the patient days and costs are treated. Our policy to exclude observation and swing-bed days under the regulations at § 412.105(b) and § 412.106(a)(1)(ii) stems from this policy. However, we are proposing to amend our policy with respect to observation bed days of patients who ultimately are admitted. As noted previously, our current policy is that these bed days are excluded from the available bed day and the patient day counts. This policy was communicated in a memorandum to all CMS Regional Offices on February 27, 1997. Specifically, we are proposing that, if a patient is admitted as an acute inpatient subsequent to receiving outpatient observation services, because the charges of the observation ancillary services the patient receives are currently treated as inpatient charges on the cost report, in order to be consistent with our policy to treat the costs and patient days consistently, we will begin to include the patient bed days associated with the observation services in the inpatient bed day count. In order to avoid any potential future misunderstandings about our policies regarding the exclusion of observation and swing-bed days under the regulations at § 412.105(b) and § 412.106(a)(1)(ii), we are proposing to revise our regulations to specify our policy that observation and swing-bed bed days are to be excluded from the counts of both available beds and patient days, unless a patient treated in an observation bed is ultimately admitted, in which case the beds and days would be included in those counts. 5. Labor, Delivery, Recovery, and Postpartum Beds and Days Prior to December 1991, Medicare's policy on counting days for maternity patients required an inpatient day to be counted for an admitted maternity patient in the labor/delivery room at the census taking hour. This is consistent with Medicare policy for counting days for admitted patients in any other ancillary department at the census-taking hour. However, based on decisions adverse to the government regarding this policy in a number of Federal courts of appeal, including the United States Court of Appeals for the District of Columbia Circuit, the policy regarding the counting of inpatient days for maternity patients was revised. Therefore, our current policy regarding the treatment of labor and delivery bed days was initially described in Section 2205.2 of the PRM. Section 2205.2. of the PRM states that a maternity inpatient in the labor/delivery room at midnight is not included in the census of inpatient routine care if the patient has not occupied an inpatient routine bed at some time since admission. For example, if a Medicaid patient is in the labor room at the census and has not yet occupied a routine bed, the bed day is not counted as a routine bed day of care in Medicaid or total days and, therefore, is not included in the counts under existing §§ 412.105(b) and 412.106(a)(1)(ii). If the patient is in the labor room at the census but had first occupied a routine bed, a routine bed day is counted, in Medicaid and total days, for DSH purposes and for apportioning the cost of routine care on the cost report (consistent with our longstanding policy to treat days, costs, and beds similarly). Increasingly, hospitals are redesigning their maternity areas from separate labor and delivery rooms apart from the postpartum rooms, to single labor, delivery room, and postpartum
(LDRP)rooms. In order to appropriately track the days and costs of LDRP rooms, it is necessary to apportion them between the labor and delivery ancillary cost center and the routine adults and pediatrics cost center. This is done by determining the proportion of the patient's stay in the LDRP room that the patient was receiving ancillary services (labor and delivery) as opposed to routine adult and pediatric services (recovery and postpartum). An example of this would be if 25 percent of the patient's time in the LDRP room was for labor/delivery services and 75 percent for routine care, over the course of a 4-day stay in the LDRP room. In that case, 75 percent of the time the patient spent in the LDRP room is applied to the total bed days and costs (resulting in 3 routine adults and pediatrics bed days for this patient, 75 percent of 4 total days). The resulting days (or portion of days) are included in total days and in Medicaid days for all purposes. For purposes of determining hospital bed count, the time when the beds are unoccupied should be counted as available bed days using an average percentage (for example, 75 percent adults and pediatrics and 25 percent ancillary) based on all patients. In other words, 75 percent of the days the bed is unoccupied would be counted in the available bed count. We realize that it may be burdensome for a hospital to determine for each patient in this type of room the amount of time spent in labor/delivery and the amount of time spent receiving routine care. Alternatively, the hospital could calculate an average percentage of time patients receive ancillary services, as opposed to routine inpatient care during a typical month, to apply the rest of the year. 6. Days Associated with Demonstration Projects Under Section 1115 of the Act Some States extend medical benefits to a given population that could not have been made eligible for Medicaid under a State plan amendment under section 1902(r)(2) or section 1931(b) of the Act, under a demonstration under a section 1115(a)(2) demonstration project (also referred to as a section 1115 waiver). These populations are specific, finite populations identifiable in the award letters and special terms and conditions for the demonstrations. On January 20, 2000, we issued an interim final rule with comment period (65 FR 3136), followed by a final rule issued on August 1, 2000 (65 FR 47086 through 47087), to allow hospitals to include the patient days of all populations that receive benefits under a section 1115 demonstration project in calculating the Medicare DSH adjustment. Previously, hospitals were to include only those days for populations under the section 1115 demonstration project who were, or could have been made, eligible under a State plan. Patient days of those expansion waiver groups who could not be made eligible for medical assistance under the State plan were not to be included for determining Medicaid patient days in calculating the Medicare DSH patient percentage. Under the January 20, 2000 interim final rule with comment period (65 FR 3137), hospitals could include in the numerator of the Medicaid fraction those patient days for individuals who receive benefits under a section 1115 expansion waiver demonstration project (effective with discharges occurring on or after January 20, 2000). In the January 20, 2000 interim final rule with comment period, we explained that including the section 1115 expansion populations “in the Medicare DSH calculation is fully consistent with the Congressional goals of the Medicare DSH adjustment to recognize the higher costs to hospitals of treating low-income individuals covered under Medicaid.” Since that revision, we have become aware that there are certain section 1115 demonstration projects that serve expansion populations with benefit packages so limited that the benefits are not similar to the medical assistance available under a Medicaid State plan. These section 1115 demonstration projects extend coverage only for specific services and do not include inpatient care in the hospital. Because of the limited nature of the coverage offered, the population involved may have a significantly higher income than traditional Medicaid beneficiaries. In allowing hospitals to include patient days related to section 1115 expansion waiver populations, our intention was to include patient days of section 1115 expansion waiver populations who receive benefits under the demonstration project that are similar to those available to traditional Medicaid beneficiaries, including inpatient benefits. Because of the differences between expansion populations in these limited benefit demonstrations and traditional Medicaid beneficiaries, we are proposing that the Medicare DSH calculation should exclude from treatment as Medicaid patient days those patient days attributable to limited benefit section 1115 expansion waiver populations (proposed § 412.106(b)(4)(i)). For example, a State may extend a family planning benefit to an individual for 2 years after she has received the 60-day postpartum benefit under Medicaid, or a State may choose to provide a family planning benefit to all individuals below a certain income level, regardless of having previously received the Medicaid postpartum benefit. This is a limited, temporary benefit that is generally administered in a clinic setting (see section 1905(a)(4)(C) of the Act). Also, a number of States are developing demonstrations that are limited to providing beneficiaries an outpatient prescription drug benefit. Generally, these limited benefits under a demonstration project do not include inpatient benefits. If a hospital were to include the days attributable to patients receiving benefits under such a limited benefit, the hospital would be able to receive higher DSH payments, perhaps substantially, for patients who may otherwise be insured for inpatient care. For example, these limited demonstrations provide benefits that may be needed to supplement private insurance coverage for individuals who do not have incomes low enough to qualify for Medicaid under the State plan. We do not believe such patients should be counted in the DSH patient percentage as eligible for title XIX. As we have noted previously, at the time the Congress enacted the Medicare DSH adjustment provision, there were no approved section 1115 demonstration projects involving expansion populations and the statute does not address the treatment of these days. Although we did not initially include patient days for individuals who receive extended benefits only under a section 1115 demonstration project, we nevertheless expanded our policy in the January 20, 2000 revision to these rules to include such patient days. We now believe that this reading is warranted only to the extent that those individuals receive inpatient benefits under the section 1115 demonstration project. Therefore, we are proposing to revise § 412.106(b)(4)(i) to clarify that patients must be eligible for medical assistance inpatient hospital benefits under an approved State Medicaid plan (or similar benefits, including inpatient hospital benefits, under a section 1115 demonstration project) in order for their hospital inpatient days to be counted as Medicaid days in the calculation of a hospital's DSH patient percentage. Under this proposed clarification, hospital inpatient days attributed to patients who do not receive coverage for inpatient hospital benefits either under the approved State plan or through a section 1115 demonstration would not be counted in the calculation of Medicaid days for purposes of determining a hospital's DSH patient percentage. Under this reading, in the examples given above, the days associated with a hospital inpatient who receives coverage of prescription drugs or family planning services on an outpatient basis, but no inpatient hospital coverage, through either a Medicaid State plan or a section 1115 demonstration, would not be counted as Medicaid days for purposes of determining the DSH patient percentage. This proposed revision would address an unintended potential consequence of our interpretation that hospitals may include in the DSH calculation patient days associated with section 1115 demonstration populations (65 FR 3136). As discussed above, that interpretation was based on our finding that individuals receiving a comprehensive benefit package under a section 1115 demonstration project could appropriately be included in the numerator of the Medicaid fraction even though the statute does not require such an inclusion, but did not address individuals who were receiving limited benefit packages under a section 1115 demonstration project. 7. Dual-Eligible Patient Days As described above, the DSH patient percentage is equal to the sum of the percentage of Medicare inpatient days attributable to patients entitled to both Medicare Part A and SSI benefits, and the percentage of total inpatient days attributable to patients eligible for Medicaid but not entitled to Medicare Part A benefits. If a patient is a Medicare beneficiary who is also eligible for Medicaid, the patient is considered dual-eligible and the patient days are included in the Medicare fraction of the DSH patient percentage but not the Medicaid fraction. This is consistent with the language of section 1886(d)(5)(F)(vi)(II) of the Act, which specifies that patients entitled to benefits under Part A are excluded from the Medicaid fraction. This policy currently applies even after the patient's Medicare coverage is exhausted. In other words, if a dual-eligible patient is admitted without any Medicare Part A coverage remaining, or the patient exhausts Medicare Part A coverage while an inpatient, his or her patient days are counted in the Medicare fraction before and after Medicare coverage is exhausted. This is consistent with our inclusion of Medicaid patient days even after the patient's Medicaid coverage is exhausted. We are proposing to change our policy, to begin to count in the Medicaid fraction of the DSH patient percentage the patient days of dual-eligible Medicare beneficiaries whose Medicare coverage has expired. We note the statute referenced above stipulates that patient days attributable to patients entitled to benefits under Medicare Part A are to be excluded from the Medicaid fraction, while the statute specifies the Medicaid fraction is to include patients who are eligible for Medicaid. As noted above, our current policy regarding dual-eligible patient days is that they are counted in the Medicare fraction and excluded from the Medicaid fraction, even if the patient's Medicare Part A coverage has been exhausted. We believe this interpretation is consistent with the statutory intent of section 1886(d)(5)(F)(vi)(II) of the Act. However, we recognize there are other plausible interpretations. In addition, on a more practical level, we recognize it is often difficult for fiscal intermediaries to differentiate the days for dual-eligible patients whose Part A coverage has been exhausted. The degree of difficulty depends on the data provided by the States, which may vary from one State to the next. Some States identify all dual-eligible beneficiaries in their lists of Medicaid patient days provided to the hospitals, while in other States the fiscal intermediary must identify patient days attributable to dual-eligible beneficiaries by matching Medicare Part A bills with the list of Medicaid patients provided by the State. The latter case is problematic when Medicare Part A coverage is exhausted because no Medicare Part A bill may be submitted for these patients. Thus, the fiscal intermediary has no data by which to readily verify any adjustment for these cases in the Medicaid data provided by the hospital. Currently, the fiscal intermediaries are reliant on the hospitals to identify the days attributable to dual-eligible beneficiaries so these days can be excluded from the Medicaid patient days count. Therefore, in order to facilitate consistent handling of these days across all hospitals, we are proposing that the days of patients who have exhausted their Medicare Part A coverage will no longer be included in the Medicare fraction. Instead, we are proposing these days should be included in the Medicaid fraction of the DSH calculation. (We note that not all SSI recipients are Medicaid eligible. Therefore, it will not be automatic that the patient days of SSI recipients will be counted in the Medicaid fraction when their Part a coverage expires.) Under this proposed change, before a hospital could count patient days attributable to dual-eligible beneficiaries in the Medicaid fraction, the hospital must submit documentation to the fiscal intermediary that justifies including the days in the Medicaid fraction after the Medicare Part A benefits have been exhausted. That is, if the State provides data on all the days associated with all dual-eligible patients treated at a hospital, regardless of whether the beneficiary had Medicare Part A coverage, the hospital is responsible for providing documentation showing which days should be included in the Medicaid fraction because Medicare Part A coverage was exhausted. 8. Medicare+Choice (M+C) Days Under § 422.1, an M+C plan “means health benefits coverage offered under a policy or contract by an M+C organization that includes a specific set of health benefits offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area of the M+C plan.” Generally, each M+C plan must provide coverage of all services that are covered by Medicare Part A and Part B (or just Part B if the M+C plan enrollee is only entitled to Part B). We have received questions whether patients enrolled in an M+C Plan should be counted in the Medicare fraction or the Medicaid fraction of the DSH patient percentage calculation. The question stems from whether M+C plan enrollees are entitled to benefits under Medicare Part A since M+C plans are administered through Medicare Part C. We note that, under § 422.50, an individual is eligible to elect an M+C plan if he or she is entitled to Medicare Part A and enrolled in Part B. However, once a beneficiary has elected to join an M+C plan, that beneficiary's benefits are no longer administered under Part A. Therefore, we are proposing to clarify that once a beneficiary elects Medicare Part C, those patient days attributable to the beneficiary should not be included in the Medicare fraction of the DSH patient percentage. These patient days should be included in the count of total patient days in the Medicaid fraction (the denominator), and the patient's days for the M+C beneficiary who is also eligible for Medicaid would be included in the numerator of the Medicaid fraction. D. Medicare Geographic Classification Review Board (MGCRB) Reclassification Process (§ 412.230) 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 for purposes of the wage index or the average standardized amount, or both, 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. Effective with reclassifications for FY 2003, section 1886(d)(10)(D)(vi)(II) of the Act provides that the MGCRB must use the average of the 3 years of hourly wage data from the most recently published data for the hospital when evaluating a hospital's request for reclassification. The regulations at § 412.230(e)(2)(ii) stipulate that the wage data are taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes. To evaluate applications for wage index reclassifications for FY 2004, the MGCRB used the 3-year average hourly wages published in Table 2 of the August 1, 2002 IPPS final rule (67 FR 50135). These average hourly wages are taken from data used to calculate the wage indexes for FY 2001, FY 2002, and FY 2003, based on cost reporting periods beginning during FY 1997, FY 1998, and FY 1999, respectively. Last year, we received a comment suggesting that we allow for the correction of inaccurate data from prior years as part of a hospital's bid for geographic reclassification (67 FR 50027). The commenter suggested that not to allow corrections to the data results in inequities in the calculation in the average hourly wage for purposes of reclassification. In the August 1, 2002 IPPS final rule, we responded: “Hospitals have ample opportunity to verify the accuracy of the wage data used to calculate their wage index and to request revisions, but must do so within the prescribed timelines. We consistently instruct hospitals that they are responsible for reviewing their data and availing themselves to the opportunity to correct their wage data within the prescribed timeframes. Once the data are finalized and the wage indexes published in the final rule, they may not be revised, except through the mid-year correction process set forth in the regulations at § 412.63(x)(2). Accordingly, it has been our consistent policy that if a hospital does not request corrections within the prescribed timeframes for the development of the wage index, the hospital may not later seek to revise its data in an attempt to qualify for MGCRB reclassification. “Allowing hospitals the opportunity to revise their data beyond the timelines required to finalize the data used to calculate the wage index each year would lessen the importance of complying with those deadlines. The likely result would be that the data used to compute the wage index would not be as carefully scrutinized because hospitals would know they may change it later, leading to inaccuracy in the data and less stability in the wage indexes from year to year.” Since responding to this comment in the FY 2003 IPPS final rule, we have become aware of a situation in which a hospital does not meet the criteria to reclassify because its wage data were erroneous in prior years, and these data are now being used to evaluate its reclassification application. In addition, in this situation, the hospital's wage index was subject to the rural floor because the hospital was located in an urban area with an actual wage index below the statewide rural wage index for the State, and it was for a time period preceding the requirement for using 3 years of data. Therefore, the hospital contends, it had no incentive to ensure its wage data were completely accurate. (However, we would point out that hospitals are required to certify that their cost reports submitted to CMS are complete and accurate. Furthermore, inaccurate or incomplete reporting may have other payment implications beyond the wage index.) While we continue to have all of the concerns we expressed in last year's final rule, we now more fully understand this particular hospital's situation. Although we do have administrative authority to establish a policy allowing corrections for this particular set of circumstances, we are concerned about establishing a precedent that could reduce the importance of ensuring that the final wage data published in the annual IPPS final rule are complete and accurate. As we indicated in our response last year, we are concerned this could lead to less accuracy and stability in the wage indexes from year to year. However, we are soliciting comments on whether it may be appropriate to establish a policy whereby, for the limited purpose of qualifying for reclassification based on data from years preceding the establishment of the 3-year requirement (that is, cost reporting years beginning before FY 2000), a hospital in an urban area that was subject to the rural floor for the period during which the wage data the hospital wishes to revise were used to calculate the wage index, a hospital may request that its wage data be revised. E. Costs of Approved Nursing and Allied Health Education Activities (§ 413.85) 1. Background Medicare has historically paid providers for the share of the costs that providers incur in connection with approved educational activities. The activities may be divided into the following three general categories to which different payment policies apply: • Approved graduate medical education
(GME)programs in medicine, osteopathy, dentistry, and podiatry. Medicare makes direct and indirect medical education payments to hospitals for residents training in these programs. Existing policy on direct GME payment is found at 42 CFR 413.86, and for indirect GME payment at 42 CFR 412.105. • Approved nursing and allied health education programs operated by the provider. The costs of these programs are excluded from the definition of inpatient hospital operating costs and are not included in the calculation of payment rates for hospitals paid under the IPPS or in the calculation of payments to hospitals and hospital units excluded from the IPPS that are subject to the rate-of-increase ceiling. These costs are separately identified and “passed through” (that is, paid separately on a reasonable cost basis). Existing regulations on nursing and allied health education program costs are located at 42 CFR 413.85. • All other costs that can be categorized as educational programs and activities are considered to be part of normal operating costs and are included in the per discharge amount for hospitals subject to the IPPS, or are included as reasonable costs that are subject to the rate-of-increase limits for hospitals and hospital units excluded from the IPPS. In this section, we are proposing to clarify our policy governing payments to hospitals for provider-operated nursing and allied health education programs. Under the regulations at § 413.85 (“Cost of approved nursing and allied health educational activities”), Medicare makes reasonable cost payment to hospitals for provider-operated nursing and allied health education programs. A program is considered to be provider-operated if the hospital meets the criteria specified in § 413.85(f), which means the hospital directly incurs the training costs, controls the curriculum and the administration of the program, employs the teaching staff, and provides and controls both clinical training and classroom instruction (where applicable) of a nursing or allied health education program. In the January 12, 2001 **Federal Register** (66 FR 3358), we published a final rule that clarified the policy for payments for approved nursing and allied health education activities in response to section 6205(b)(2) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) and sections 4004(b)(1) and
(2)of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508). Section 6205(b)(2) of Public Law 101-239 directed the Secretary to publish regulations clarifying the rules governing allowable costs of approved educational activities. The Secretary was directed to publish regulations to specify the conditions under which those costs are eligible for pass-through, including the requirement that there be a relationship between the approved nursing or allied health education program and the hospital. Section 4004(b)(1) of Public Law 101-508 provides an exception to the requirement that programs be provider-operated to receive pass-through payments. The section provides that, effective for cost reporting periods beginning on or after October 1, 1990, if certain conditions are met, the costs incurred by a hospital (or by an educational institution related to the hospital by common ownership or control) for clinical training (as defined by the Secretary) conducted on the premises of the hospital under an approved nursing or allied health education program that is *not* operated by the hospital are treated as pass-through costs and paid on the basis of reasonable cost. Section 4004(b)(2) of Public Law 101-508 sets forth the conditions that a hospital must meet to receive payment on a reasonable cost basis under section 4004(b)(1). 2. Continuing Education Issue for Nursing and Allied Health Education Since publication of the January 12, 2001 final rule on nursing and allied health education, we have encountered questions concerning the substantive difference between provider-operated continuing education programs for nursing and allied health education (which would *not* be reimbursable under Medicare on a reasonable cost basis) and provider-operated approved programs that are eligible to receive Medicare reasonable cost payment. In that final rule, we stated that Medicare would generally provide reasonable cost payment for “programs of long duration designed to develop trained practitioners in a nursing or allied health discipline, such as professional nursing or occupational therapy. This is contrasted with a continuing education program of a month to a year in duration in which a practitioner, such as a registered nurse, receives training in a specialized skill such as enterostomal therapy. While such training is undoubtedly valuable in enabling the nurse to treat patients with special needs and in improving the level of patient care in a provider, the nurse, upon completion of the program, continues to function as a registered nurse, albeit one with special skills. Further distinction can be drawn between this situation and one in which a registered nurse undergoes years of training to become a CRNA. For these reasons, the costs of continuing education training programs are not classified as costs of approved educational activities that are passed-through and paid on a reasonable cost basis. Rather, they are classified as normal operating costs covered by the prospective payment rate or, for providers excluded from the IPPS, as costs subject to the target rate-of-increase limits” (66 FR 3370). Accordingly, upon publication of the final rule, we revised § 413.85(h)(3) to include continuing education programs in the same category as “educational seminars and workshops that increase the quality of medical care or operating efficiency of the provider.” Costs associated with continuing education programs, as stated above, are recognized as normal operating costs and are paid in accordance with applicable principles. We received an inquiry requesting further clarification on what is meant by continuing education. It is our belief that provider-operated programs that do not lead to any specific certification in a specialty would be classified as continuing education. By certification, we do not mean certification in a specific skill, such as when an individual is certified to use a specific piece of machinery or perform a specific procedure. Rather, we believe certification would mean the ability to perform in the specialty as a whole. Although, in the past, we believe we have allowed hospitals to be paid for operating a pharmacy “residency” program, it has come to our attention that those programs do not meet the criteria for approval as a certified program. Once individuals have finished their undergraduate degree in pharmacy, there are *some* individuals who go on to participate in 1-year hospital-operated postundergraduate programs. It is our understanding that many individuals complete the 1-year postundergraduate program practice pharmacy inside the hospital setting. However, we also understand that there are pharmacists who *do not* complete the 1-year postundergraduate program, but have received the undergraduate degree in pharmacy, who also practice pharmacy inside the hospital setting. Because pharmacy students need not complete the 1-year residency program to be eligible to practice pharmacy in the hospital setting, the 1-year programs that presently are operated by hospitals would be considered continuing education, and therefore, would be ineligible for pass-through reasonable cost payment. We understand that *all* individuals who wish to be nurses practicing in a hospital must either complete a 4-year degree program in a university setting, a 2-year associate degree in a community or junior college setting, or a diploma program traditionally offered in a hospital setting. Since participants that complete a provider-operated diploma nursing program could not practice as nurses without that training, the diploma nursing programs are *not* continuing education programs and, therefore, may be eligible for pass-through treatment. Because of the apparent confusion concerning continuing education programs in the nursing and allied health reasonable cost context, we are proposing to revise § 413.85(h)(3) to state that educational seminars, workshops, and continuing education programs in which the employees participate that enhance the quality of medical care or operating efficiency of the provider and, effective October 1, 2003, do not lead to certification required to practice or begin employment in a nursing or allied health specialty, would be treated as educational activities that are part of normal operating costs. We also are proposing to add a conforming definition of “certification” for purposes of nursing and allied health education under § 413.85(c) to mean “the ability to practice or begin employment in a specialty as a whole.” 3. Programs Operated by Wholly Owned Subsidiary Educational Institutions of Hospitals Another matter that has come to CMS’ attention since publication of the January 12, 2001 final rule (66 FR 3363) on nursing and allied health education concerns the preamble language of the rule, which states: “Concerning those hospitals that have established their own educational institution to meet accrediting standards, we believe that, in some cases, these providers can be eligible to receive payment for the classroom and clinical training of students in approved programs. If the provider demonstrates that the educational institution it has established is wholly within the provider's control and ownership and that the provider continues to incur the costs of both the classroom and clinical training portions of the program, the costs would continue to be paid on a reasonable cost basis. An independent college would not meet these criteria. “An example of a program that could be considered provider-operated would be one in which the hospital is the sole corporate member of the college, elects the board of trustees, has board members in common, employs the faculty and pays the salaries, controls the administration of the program and the curriculum, and provides the site for the clinical and classroom training on the premises of the hospital. We believe that, in these situations, the community has not undertaken to finance the training of health professionals; the provider has merely restructured its provider-operated program to meet certain State or accrediting requirements. In most cases, providers have aligned themselves with already established educational institutions. We note that a program operated by an educational institution that is related to the provider through common ownership or control would not be considered to meet the criteria for provider operated.” (66 FR 3363) We have received a question from a hospital that pertains to the cited preamble language in the narrow circumstance where the hospital previously received Medicare reasonable cost payment for direct operation of nursing or allied health education programs and then established its own wholly owned subsidiary college to operate the programs, in order to meet accreditation standards. The hospital has continued to receive Medicare payments after the hospital moved operation of the programs to the wholly owned subsidiary college. The hospital believes that, based on the cited preamble language regarding wholly owned subsidiary colleges and the lack of prior specific guidance on this particular organizational structure (as well as its continued receipt of pass-through payments) and because the hospital continues to pay all of the costs of the nursing and allied health education programs, the hospital is still the direct operator of the programs and should continue to receive pass-through treatment. However, we believe that once the hospital moved the direct operation of its nursing and allied health education programs to the college, the programs no longer met our provider-operated criteria at § 413.85(f). At the very least, it appears that the hospital did not hire the faculty for the program(s) and did not have direct control of the curriculum of the program(s) after operation was transferred to the wholly owned subsidiary college. As we stated in the preamble language quoted above: “a program operated by an educational institution that is related to the provider through common ownership or control would not be considered to meet the criteria for provider operated” (66 FR 3363). However, we understand that some hospitals, including this hospital, may have interpreted the preamble language that stated, “if the provider demonstrates that the educational institution it has established is wholly within the provider's control and ownership and that the provider continues to incur the costs of both the classroom and clinical training portions of the program, the costs would continue to be paid on a reasonable cost basis” (Ibid.), to mean that hospitals that establish wholly owned subsidiary colleges or educational institutions would continue to receive Medicare reasonable cost payment if the hospitals incur the costs of the classroom instruction and clinical training. We are proposing to clarify that transferring operation of previously provider-operated programs to educational institutions, even if the institutions are wholly owned by the hospital, does *not* necessarily mean that the programs continue to meet our provider-operated criteria under § 413.85(f). In order to remain provider operated, the hospital must have *direct control* of the program; the hospital itself must employ the teaching staff, have direct control of the program curriculum, and meet other requirements, as stated at § 413.85(f). While we are proposing to clarify that merely operating programs through a wholly owned subsidiary college does not constitute direct operation of nursing or allied health education programs unless the hospital itself meets the requirements of the regulations at § 413.85(f), we believe it would be unfair to recoup Medicare payments that have already been made to hospitals that meet this very narrow fact pattern. Therefore, we are proposing that Medicare would not recoup reasonable cost payment from hospitals that have received pass-through payments for portions of cost reporting periods occurring on or before October 1, 2003 (the effective date of finalizing this proposed rule) for the nursing or allied health education program(s) where the program(s) had originally been operated by the hospital, and then operation of the program(s) had been transferred by the hospital to a wholly owned subsidiary educational institution in order to meet accreditation standards prior to October 1, 2003, and where the hospital had continuously incurred the costs of both the classroom and clinical training portions of the programs at the educational institution. In addition, we are proposing that, for portions of cost reporting periods occurring on or after October 1, 2003, such a hospital would continue to receive reasonable cost payments for the clinical training costs incurred by the hospital for the program(s) described above that were previously provider operated. However, we are further proposing that, with respect to classroom costs, only those classroom costs incurred by the hospital for the courses that were paid by Medicare on a reasonable cost basis and included in the hospital's provider-operated program(s) could continue to be reimbursed on a reasonable cost basis. That is, Medicare would pay on a reasonable cost basis for the classroom costs associated with the courses provided as part of the nursing and allied health education programs (for example, the courses relating to the theory and practice of the particular nursing and allied health discipline(s)) that were offered by the hospital when the hospital was the direct operator of the program(s). We believe this proposed policy is appropriate since continued pass-through payment will allow these hospitals to maintain equal footing with other hospitals that receive pass-through payments and have maintained their provider-operated programs. In addition, it would not be equitable to discontinue longstanding Medicare pass-through payment to these hospitals (in fact, reasonable cost payment to at least one of these hospitals for nonprovider-operated programs preceded the publication of the January 12, 2001 final rule on nursing and allied health education payments by many years) that restructured operation of their nursing and allied health education program(s) as wholly owned subsidiaries in order to meet accreditation standards while relying on their understanding of CMS' prior expressions of provider-operated requirements and the recent preamble language. If these providers were now forced to restructure in order to meet the requirements of § 413.85(f), they would not be able to maintain their accreditation. We note that Congress has specifically expressed its intent that providers that have restructured their programs to be operated by a wholly owned subsidiary educational institution in order to meet accreditation standards should continue to receive Medicare reasonable cost payment. In the conference report accompanying the Consolidated Appropriations Resolution for FY 2003, Congress stated: “The conferees are particularly concerned about nursing and allied health educational programs that cannot meet the regulations set forth at 42 CFR 413.85(f) solely as a result of regional educational accrediting criteria. Given the shortage of nursing and allied health professionals, the conferees support the payment of costs on a reasonable cost basis for a hospital that has historically been the operator of nursing and allied health education programs(s) that qualified for Medicare payments under 42 CFR 413.85, but, solely in order to meet educational standards, subsequently relinquishes some control over the program(s) to an educational institution, which meets regional accrediting standards; is wholly owned by the provider; and is supported by the hospital, that is, the hospital is incurring the costs of both the classroom and clinical training of the program.” (H.R. Rep. No. 108-10, 108th Cong., 1st Sess., 1115 (2003).) However, the proposed policy does not allow these hospitals to be paid for additional classroom costs for courses that were not paid on a reasonable cost basis to the hospitals in conjunction with their provider-operated programs (for example, additional classes needed to meet degree requirements). We believe that to allow pass-through payment for those additional costs would provide these hospitals with an unfair advantage over other hospitals with provider-operated programs. We note that any hospital that chooses to restructure its programs to be operated by a wholly owned subsidiary educational institution on or after the effective date of this proposal when finalized (October 1, 2003) would not be eligible for pass-through payments under this proposed provision unless the hospital continues to meet the requirements of § 413.85(f). We believe it is appropriate to limit the proposed payments to hospitals that restructured before this proposed rule is made final because our policy with respect to programs by a wholly owned subsidiary of a hospital will have been clarified in that final rule. We are proposing to revise § 413.85 by adding new paragraphs (d)(1)(iii) and (g)(3) to reflect this proposed payment policy. F. 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)(4)(F) of the Act caps the number of allopathic and osteopathic residents that hospitals may count for direct GME. Section 1886(h) of the Act, as added by section 9202 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 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 added 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. 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. Prohibition Against Counting Residents Where Other Entities First Incur the Training Costs a. General Background on Methodology for Determining FTE Resident Count. As we explain earlier in this preamble, Medicare makes both direct and indirect GME payments to hospitals for the training of residents. Direct GME payments are reimbursed in accordance with section 1886(h) of the Act, based generally on hospital-specific PRAs, the number of FTE residents a hospital trains, and the hospital's Medicare patient share. The indirect costs of GME are reimbursed in accordance with section 1886(d)(5)(B) of the Act, based generally on the ratio of the hospital's FTE residents to the number of hospital beds. It is well-established that the calculation of both direct GME and IME payments is affected by the number of FTE residents that a hospital is allowed to count; generally, the greater the number of FTE residents a hospital counts, the greater the amount of Medicare direct GME and IME payments the hospital will receive. In an attempt to end the implicit incentive for hospitals to increase the number of FTE residents, Congress instituted a cap on the number of allopathic and osteopathic residents a hospital is allowed to count for direct GME and IME purposes under the provisions of section 1886(h)(4)(F) (direct GME) and section 1886(d)(5)(B)(v)
(IME)of the Act. Dental and podiatric residents were not included in this statutorily mandated cap. With respect to reimbursement of direct GME costs, since July 1, 1987, hospitals have been allowed to count the time residents spend training in sites that are not part of the hospital (referred to as “nonprovider” or “nonhospital sites”) under certain conditions. Section 1886(h)(4)(E) of the Act requires that the Secretary's rules concerning computation of FTE residents for purposes of separate reimbursement of direct GME costs “provide that only time spent in activities relating to patient care shall be counted and that all the time so spent by a resident under an approved medical residency training program shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs all, or substantially all, of the costs for the training program in that setting.” (Section 1886(h)(4)(E) of the Act, as added by section of 9314 of the Omnibus Budget Reconciliation Act of 1986, Pub. L. 99-509.) Regulations on time spent by residents training in nonhospital sites for purposes of direct GME payment were first implemented in the September 29, 1989 final rule (54 FR 40286). We stated in that rule (under § 413.86(f)(3)) that a hospital may count the time residents spend in nonprovider settings for purposes of direct GME payment if the residents spend their time in patient care activities and there is a written agreement between the hospital and the nonprovider entity stating that the hospital will incur all or substantially all of the costs of the program. The regulations at that time defined “all or substantially all” of the costs to include the residents’ compensation for the time spent at the nonprovider setting. Prior to October 1, 1997, for IME payment purposes, hospitals could only count the time residents spend training in areas subject to the IPPS and outpatient areas of the hospital. Section 4621(b)(2) of the Balanced Budget Act of 1997 (Pub. L. 105-33) revised section 1886(d)(5)(B) of the Act to allow providers to count time residents spend training in nonprovider sites for IME purposes, effective for discharges occurring on or after October 1, 1997. Specifically, section 1886(d)(5)(B)(iv) of the Act was amended to provide that “all the time spent by an intern or resident in patient care activities under an approved medical residency program at an entity in a non-hospital setting shall be counted towards the determination of full-time equivalency if the hospital incurs all, or substantially all, of the costs for the training program in that setting.” In the regulations at §§ 412.105(f)(1)(ii)(C) and 413.86(f)(4) (as issued in the July 31, 1998 **Federal Register** ), we specify the requirements a hospital must meet in order to include a resident training in a nonhospital site in its FTE count for Medicare reimbursement for portions of cost reporting periods occurring on or after January 1, 1999 for both direct GME and for IME payments. The regulations at § 413.86(b) redefine “all or substantially all of the costs for the training program in the nonhospital setting” as the residents' salaries and fringe benefits (including travel and lodging where applicable), and the portion of the cost of teaching physicians' salaries and fringe benefits attributable to direct GME. A written agreement between the hospital and the nonhospital site is required before the hospital may begin to count residents training at the nonhospital site; the agreement must provide that the hospital will incur the costs of the resident's salary and fringe benefits while the resident is training in the nonhospital site. The hospital must also provide reasonable compensation to the nonhospital site for supervisory teaching activities, and the written agreement must specify that compensation amount. b. Inappropriate Counting of FTE Residents. As we stated above, dental residents, along with podiatric residents, are excepted from the statutory cap on the count of FTE residents for both direct GME and IME payment purposes. We have become aware of a practice pertaining to the counting of FTE residents at a nonhospital site, particularly dental residents, that we see as inappropriate under Medicare policy. Most often, the situation involves dental schools that, for a number of years, have been training dental residents in programs at the dental schools of universities affiliated with teaching hospitals, and the schools have been directly incurring the costs of the dental residents training at the dental schools (for example, the teaching faculty costs, the resident salary costs, the office space costs, and any overhead expenses of the programs). We also understand that there are dental clinics at these dental schools that treat patients (that is, are involved in “patient care activities”). As a result of the provisions that Congress added to allow hospitals to count FTE residents and receive IME payment, as well as direct GME payment, if the hospital incurs “all or substantially all” the costs of training residents in nonhospital settings, a significant number of dental schools are shifting the resident training costs of the dental programs from the schools to the hospital, and thus to the Medicare program, when the hospitals count the FTE dental residents training in these dental schools (that is, “nonhospital sites”) under the regulations at § 413.86(f)(4). Furthermore, in the case of training dentists at dental school clinics, as a result of this cost-shifting and because dental residents are excepted from the cap, hospitals are receiving significant amounts of Medicare direct GME and IME payments when they have incurred relatively small costs of the residents training in a dental school. The following actual situations are illustrative of the inappropriate application of Medicare direct GME and IME policy that we have found: • An academic medical center hospital associated with a university has been training allopathic residents for at least 20 years. Prior to 1999, the university s affiliated dental school had always incurred the costs of dental residency programs at the dental school. Beginning with the hospital's cost report for its fiscal year ending in 1999, for the first time ever, the hospital has requested direct GME and IME payment for an additional 67 FTE residents because the hospital claims it has begun to incur “all or substantially all” of the costs of the dental residents training in the university's affiliated dental school, in accordance with the regulations at § 413.86(f)(4). • A university dental school in one State has been incurring the costs of dental residency programs at its dental school for several years. Beginning in FY 1999, a teaching hospital in a neighboring State decided to begin incurring “all or substantially all” of the costs of the dental residents training in the dental clinics in the program (which is located in a different State from the hospital) in order to receive Medicare direct GME and IME payment for an additional 60 FTE residents. • In another situation, a teaching hospital on the East Coast of the United States has requested direct GME and IME payment for an additional 60 FTE dental residents, some of whom are training in dental programs at nonhospital sites located in Hawaii, New Mexico, and the Netherlands, because it has begun to incur “all or substantially all” of the costs of dental residents training in those remote “nonhospital sites”. Prior to 1999, the costs for these dental programs were funded by nonhospital sources. We note that such inappropriate cost-shifting practices are by no means limited to the dental school context. Indeed, we understand that there are some hospitals with resident counts below their direct GME and IME FTE resident caps that have recently (as of October 1, 1997, when it became possible to receive significant IME payments under the amendment made by Pub. L. 105-33) started to incur “all or substantially all” of the costs of residents who had been training at sites outside of the hospital without any financial assistance from the hospital, in order for the hospital to count those FTE residents and receive Medicare direct GME and IME payments for the additional residents. The actual costs of the programs that are being shifted from nonhospital entities to hospitals are relatively small, compared to the direct GME and IME payments that hospitals receive as a result of incurring “all or substantially all” of the training costs. • In another example, an academic medical center hospital in one State asked Medicare to allow it to count an additional 10 FTEs for both direct GME and IME payment, beginning with its fiscal year ending 1999 cost report, because the hospital claims it is incurring all or substantially all of the costs of training osteopathic family practice residents in a walk-in clinic. The osteopathic family practice residency program had previously been sponsored by this clinic for several years and the residents do not participate in any training at the hospital. c. Congressional Intent. Congress has delegated broad authority to the Secretary to implement a policy on the count of FTE residents for purposes of calculating direct GME and IME payments. For IME payment, section 1886(d)(5)(B) of the Act simply states that “the Secretary shall provide for an additional payment amount” which includes “the ratio of the hospital's full-time equivalent interns and residents to beds.” The methodology to compute the count of FTE residents for IME is not established in the statute. Similarly, for direct GME, section 1886(h)(4)(A) of the Act states that “the Secretary shall establish rules consistent with this paragraph for the computation of the number of full-time equivalent residents in an approved medical residency training program.” Although not in the context of the general rules for counting FTE residents, Congress similarly acknowledged its intent to defer to the Secretary with respect to the rules for implementing “limits” or caps on the number of FTE residents hospitals may count for purposes of direct GME and IME payment. The conference agreement that accompanied Pub. L. 105-33, which established a cap on the number of allopathic and osteopathic residents a hospital may count, states— “[T]he Conferees recognize that such limits raise complex issues, and provide for specific authority for the Secretary to promulgate regulations to address the implementation of this provision. The Conferees believe that rulemaking by the Secretary would allow careful but timely consideration of this matter, and that the record of the Secretary's rulemaking would be valuable when Congress revisits this provision.” (H.R. Conf. Rep. No. 105-217, 105th Cong., 1st Sess., 821 (1997). The absence of statutory specificity on determining FTE counts in these situations and the declared Congressional delegations of authority to the Secretary on the subject are clear indications that Congress has given the Secretary broad discretion to promulgate reasonable regulations in order to implement the policy on the counting of residents for direct GME and IME payments. When Congress enacted the nonhospital site provisions for both direct GME and IME, Congress intended to address application of the FTE count policy to situations where the training site had been the hospital. The intent was to create incentives for hospitals to move resident training from the hospital to nonhospital settings. We believe that Congress did *not* intend for hospitals to be able to add to their FTE counts residents that had historically trained outside the hospital in other settings. Training in those nonhospital settings had historically occurred without Congress offering any financial incentive to hospitals to move the training out of the hospital. This Congressional intent is evident in the legislative history of both the direct GME and the IME provisions on nonhospital settings. First, legislative history associated with passage of the direct GME provision (as part of Pub. L. 99-509) indicates that Congress intended to broaden the scope of settings in which a hospital could train its residents and still receive separate direct GME cost reimbursement, and to provide incentives to hospitals for training residents in primary care programs. The Conference committee report indicates that “[s]ince it is difficult to find sufficient other sources of funding [than hospitals and Medicare] for the costs of such training, [that is, training in freestanding primary care settings such as family practice clinics or ambulatory surgery centers] *assignments to these settings* are discouraged. It is the Committee's view that training in these settings is desirable, because of the growing trend to treat more patients *out of the inpatient hospital setting* and because of the encouragement it gives to primary care.” (Emphasis added.) (H.R. Rep. No. 99-727, 99th Cong., 1st Sess., 70 (1986).) Thus, from the start of the policy allowing payment for training in nonprovider sites, we believe Congress intended to create a monetary incentive for hospitals to rotate residents from the hospital to the nonhospital settings. We believe Congress did not intend for hospitals to be paid for residents who had previously been training at nonhospital sites without hospital funding. Further, in the Conference committee report accompanying the provision of Pub. L. 105-33 on IME payment for training in nonhospital settings, Congress stated that “[t]he conference agreement includes new permission for *hospitals to rotate residents through nonhospital settings,* without reduction in indirect medical education funds.” (Emphasis added.) (H.R. Conf. Rep. No. 105-217, 105th Cong., 1st Sess., 817 (1997).) We note that, prior to enactment of Pub. L. 105-33, if a hospital rotated a resident to train at a nonhospital site, the hospital could not count the time the resident spent at the nonhospital site for purposes of Medicare IME payments. As a result, the lack of IME payments acted as a disincentive and discouraged hospitals from rotating residents out of the hospital. Therefore, Congress authorized hospitals to count residents in nonhospital sites for IME purposes as a specific incentive to encourage hospitals to rotate their residents to nonhospital sites (and not to encourage hospitals to incur the costs of a program at a nonhospital site that had already been funded by other sources). This legislative intent becomes more apparent when the nature of the Medicare IME payment is considered. The Medicare IME payment is inherently a payment that reflects the increased operating costs of treating inpatients as a result of the hospital having a residency program. For example, as explained in the September 29, 1989 final rule (54 FR 40286), the indirect costs of medical education might include added costs resulting from an increased number of tests ordered by residents as compared to the number of tests normally ordered by more experienced physicians. The IME payment is an adjustment that is made for each Medicare discharge from the areas subject to the IPPS in a teaching hospital. The authorization by Congress for IME payments relating to nonhospital services while residents are training at nonhospital sites would be absurd if not viewed as an incentive to transfer existing residency training from the hospital to the nonhospital setting. We do not believe Congress intended to permit such IME payments to be allowable to the hospital that is incurring “all or substantially all the costs” of residents training in nonhospital sites except in the situation where the hospital rotated residents from the hospital to the nonhospital settings. The illustrative situations described above in which nonhospital sites, such as dental schools, are shifting the costs of existing programs to the hospitals are not consistent with the intent of Congress to encourage hospitals to rotate residents from the hospital setting to nonhospital sites. Thus, we believe Congress intended both cited provisions of the Act on counting residents in nonhospital sites for purposes of direct GME and IME payments to be limited to situations in which hospitals rotate residents from the hospital to the nonhospital settings, and *not* situations in which nonhospital sites transfer the costs of an existing program at a nonhospital site to the hospital. d. Medicare Principles on Redistribution of Costs and Community Support. It is longstanding Medicare policy that if the community has undertaken to bear the costs of medical education, these costs are not to be assumed by the Medicare program. In addition, medical education costs that have been incurred by an educational institution may not be redistributed to the Medicare program. Indeed, these concepts, community support and redistribution of costs, have been a part of Medicare GME payment policy since the inception of the Medicare program. Both the House and Senate Committee reports accompanying Pub. L. 89-97 (the authorizing Medicare statute) indicate that Congress intended Medicare to share in the costs of medical education *only* in situations in which the community has not stepped in to incur them: “Many hospitals engage in substantial education activities, including the training of medical students, internship and residency programs, the training of nurses and the training of various paramedical personnel. Educational activities enhance the quality of care in an institution and it is intended, *until the community undertakes to bear such education costs in some other way,* that a part of the net cost of such activities * * * should be considered as an element in the cost of patient care, to be borne to an appropriate extent by the hospital insurance program. (Emphasis added.) (S. Rep. No. 404, 89th Cong., 1st Sess., 36 (1965); H.R. Rep. No. 213, 89th Cong., 1st Sess., 32 (1965).) The principle behind the congressional committee report language for Pub. L. 89-97 that Medicare would share in the costs of educational activities until communities bore them in some other way has guided Medicare policy on educational activities from the inception of the Medicare program. The principles of community support and redistribution of costs associated with payment for GME have been continually reiterated in various regulations, manual provisions, and implementing instructions to fiscal intermediaries. As recently as the final rule published in the **Federal Register** on January 12, 2001, we stated: “We note that the proposed revisions in the proposed rule inadvertently did not include community support as the basis for an offset from the allowed cost of a GME or nursing and allied health program. In this final rule, we restate our longstanding policy that Medicare will share in the costs of educational activities of providers where communities have not assumed responsibility for financing these programs. Medicare's policy is to offset from otherwise allowable education costs, community funding for these activities.” (66 FR 3368) We note the instructions that CMS (then HCFA) gave to its Regional Offices in the 1990 audit instructions for purposes of calculating the direct GME base period PRA specifically addressed redistribution of costs and community support in the GME context: “Where costs for services related to medical education activities have historically been borne by the university, it is assumed the community has undertaken to support these activities, and subsequent allocation of these costs to a hospital constitutes a redistribution of costs from an educational institution to a patient care institution. In such a situation, these costs are not allowable under the Medicare program. ( *See* 42 CFR 413.85(c) and HCFA Pub. L. 15-1, § 406). For example, if in the past the hospital did not identify and claim costs attributable to the time teaching physicians spent supervising I&Rs [interns and residents] working at the hospital, it is assumed that these costs were borne by the university. Therefore, the hospital may not claim these costs in subsequent cost reports.” (Instructions for Implementing Program Payments for Graduate Medical Education to ARAs for Medicare, Director of Office of Financial Operations of the Health Care Financing Administration, BPO-F12, February 12, 1990.) Furthermore, the regulation at § 413.85(c) that was originally issued in the **Federal Register** on September 30, 1986 (51 FR 34793) (which was further refined, but conceptually left unchanged, as of March 12, 2001) addressed the Congressional intent not to increase program costs, as well. That paragraph
(c)stated: “ *Educational Activities* . Many providers engage in education activities including training programs for nurses, medical students, interns and residents, and various paramedical specialties * * * . Although the intent of the program is to share in the support of educational activities customarily or traditionally carried on by providers in conjunction with operations, it is not intended that this program should participate in increased costs resulting from redistribution of costs from educational institutions or units to patient care institutions or units.” The Secretary of Health and Human Services interpreted this provision to deny reimbursement of educational costs that were borne in prior years by a hospital's affiliated medical school. The U.S. Supreme Court affirmed the Secretary's interpretation of the redistribution of costs regulation in *Thomas Jefferson University* v. *Shalala* (“ *Thomas Jefferson* ”), 512 U.S. 504 (1994). The Court found of § 413.85(c) that: “The regulation provides, *in unambiguous terms,* that the ‘costs’ of these educational activities will not be reimbursed when they are the result of a ‘redistribution,' or shift, of costs of an ‘educational' facility to a ‘patient care’ facility.” (Emphasis added.) ( *Thomas Jefferson,* 512 U.S. at 514). Thus, the Supreme Court in *Thomas Jefferson* held that it is well within the Secretary's discretion to interpret the language at § 413.85(c), which was specifically derived from the legislative history of the original enacting Medicare legislation quoted above, to impose a substantive limitation on medical education payment. The Supreme Court's opinion in *Thomas Jefferson* lends substantial support and credibility to CMS’ longstanding policy on community support and redistribution of costs in the GME context. e. Application of Redistribution of Costs and Community Support Principles. As we have described above, we have discovered an inappropriate application of Medicare direct GME and IME payment policies relating to the counting of FTE residents in nonhospital settings. As stated previously, we believe that:
(1)Congress has given the Secretary broad discretion to implement policy on FTE resident counts;
(2)Congress intended that the nonhospital site policy for both direct GME and IME would encourage hospitals to move resident training from the hospital to nonhospital settings, not to enable nonhospital sites to shift the costs of already established residency programs in the nonhospital site to the hospital; and
(3)since the inception of the Medicare program, CMS’ policy has been consistent with the intent of Congress that Medicare would only share in the costs of medical education until the community assumes the costs. The Supreme Court has specifically found that CMS’ implementation of the redistribution of costs and community support principles is “reasonable.” ( *Thomas Jefferson* , 512 U.S. at 514.) Accordingly, we are proposing that residents training at nonhospital sites may be counted in a hospital's FTE resident count only where the principles of redistribution of costs and community support are not violated. We are proposing this policy at this time to address the inappropriate practice of nonhospital sites shifting costs to hospitals solely to allow the hospitals to count residents training in the nonhospital sites. However, we believe the concepts of redistribution of costs and community support are equally relevant to the counting of FTEs residents by a hospital in general. We note again that the Medicare program has a long tradition of applying redistribution of costs and community support principles to medical education payments. As we have stated above, both the House and Senate Committee reports accompanying Pub. L. 89-97 (the 1965 authorizing Medicare statute) indicate that Congress intended Medicare to share in the costs of medical education only where the community has not stepped in to incur them. We believe it is appropriate to employ the principles of redistribution of costs and community support to specifically address the inappropriate scenarios described above whereby hospitals attempt to inflate their FTE resident counts by assuming payment of training costs for residents in nonhospital sites that were previously funded by a nonhospital entity. Therefore, we are proposing to specify the application of the redistribution of costs and community support principles by adopting the definitions (with some modification to reflect the methodology for counting FTE residents applicable to GME) of “community support” and “redistribution of costs” at § 413.85(c), which relate to nursing and health education program costs, for use at § 413.86(b), which relates to GME. In addition, we are proposing a general rule at proposed § 413.86(i) on the application of community support and redistribution of costs principles to the counting of FTE residents for GME. We are proposing to
(1)make the provisions under § 413.86(f) relating to determining the number of FTE residents subject to the provisions of the proposed § 413.86(i);
(2)add a proposed § 413.86(f)(4) in order to clarify that the principles of redistribution of costs and community support are applicable to the counting of FTE residents, including when the residents are training in nonhospital settings; and
(3)making the provisions of the proposed § 413.86(i) specifically applicable to determining the number of FTE residents under § 413.86(g)(4) through
(6)and (g)(12). The general rule at proposed § 413.86(i) contains two provisions. Proposed § 413.86(i)(1) states the principles of community support and redistribution of costs: In relation to community support, we are proposing that if the community has undertaken to bear the costs of medical education through community support, the training costs of residents that are paid through community support are not considered GME costs to the hospital for purposes of Medicare payment. In relation to redistribution of costs, we are proposing that the costs of training residents that constitute a redistribution of costs from an educational institution to the hospital are not considered GME costs to the hospital for purposes of Medicare payment. In applying the redistribution of costs and community support principles, we are proposing under § 413.86(i)(2) to state that a hospital must continuously incur direct GME costs of residents training in a particular program at a training site since the date the residents first began training in that site in order for the hospital to count the FTE residents in accordance with the provisions of paragraphs
(f)and (g)(4) through (g)(6), and (g)(12) of § 413.86. We note that our reasons for specifically referencing the applicability of the principles of community support and redistribution of costs at § 413.86(f)(4), the paragraph concerning counting residents training in nonhospital settings for direct GME purposes, are twofold. First, although we are already making the proposed § 413.86(i) applicable to § 413.86(f), which would make the principles applicable to each paragraph under § 413.86(f), in consideration of the inappropriate applications we have identified of the GME FTE-counting policy with respect to counting residents in nonhospital sites, we believe it is appropriate to also specifically address the applicability of the redistribution of costs and community support principles to § 413.86(f)(4). In addition, we note that the proposed reference at § 413.86(f)(4) has implications for IME payment as well, as explained below. Under existing § 412.105(f)(1)(ii)(C), the rule for the counting of FTE residents training in nonhospital settings for IME payment, there is a specific reference indicating that the criteria set forth in § 413.86(f)(4) must be met in order for a hospital to count the FTE residents training in nonhospital settings for purposes of IME payments. Thus, if under proposed § 413.86(f)(4)(iv) (the paragraph making redistribution of costs and community support principles applicable) a hospital is not permitted to count the FTE residents training in a nonhospital site because of redistribution of costs or community support, the hospital would not be permitted to count the FTE residents for purposes of IME payment as well, because the IME regulation at § 412.105(f)(1)(ii)(C) requires the criteria under § 413.86(f)(4) to be met. As we have stated above, payment for IME is based on the concept that, as a direct result of the hospital's resident training program, the costs the hospital incurs for patient care are increased. When Congress included section 1886(d)(5)(B)(iv) of the Act as part of Public Law 105-33, the statute expanded the circumstances under which IME payments to a hospital could be made by allowing the hospital to count the number of residents training outside the hospital setting under certain conditions. Even though it is clear that those residents training outside the hospital cannot have any impact on patient care costs to the hospital, Congress nevertheless allowed the hospital to receive IME payments when the hospital counts FTE residents training in a nonhospital setting in accordance with section 1886(d)(5)(B)(iv) of the Act, where those residents would otherwise have trained in the hospital setting. As we have stated, Congress created an incentive (or removed a disincentive) with the provisions of Public Law 105-33 for hospitals to rotate residents to nonhospital settings by allowing hospitals to continue to receive IME payment as if the residents continued to train in the hospital setting. If there is a redistribution of costs or community support, we believe IME payment to the hospital would be contrary to Congressional intent to encourage the hospital to rotate residents from the hospital to the nonhospital site. In addition, when Congress included section 1886(d)(5)(B)(iv) of the Act as part of Public Law 105-33, the statutory authority for IME payment was premised on the hospital incurring the direct GME costs of the residents: “all the time spent by an intern or resident in patient care activities under an approved medical residency program at an entity in a nonhospital setting shall be counted towards the determination of full-time equivalency *if the hospital incurs all, or substantially all, of the costs for the training program* in that setting.” (Emphasis added.) (Section 4621(b)(2) of Public Law 105-33; section 1886(d)(5)(B)(iv) of the Act.) We believe Congress intended the hospital to incur direct GME costs of the program in the nonhospital site in order to count the FTE residents training in nonhospital settings for purposes of IME payment. Thus, in the situation where a hospital incurred direct GME costs but there was redistribution of costs or community support, a disallowance of direct GME payments as well as a disallowance of IME payments is appropriate. Although we are stating generally that the principles of community support and redistribution of cost have applied since the inception of Medicare to graduate medical education payment, as we have stated above, we have identified relatively recent inappropriate application of the nonhospital site policy for counting FTE residents. Therefore, we believe it is appropriate to propose to identify January 1, 1999, as the date our fiscal intermediaries should use to determine whether a hospital or another entity has been incurring the costs of training in a particular program at a training setting for purposes of determining whether there has been a redistribution of costs or community support. We are proposing that January 1, 1999 be used as the date the fiscal intermediaries should use for determinations, since it may be difficult for our fiscal intermediaries to obtain from hospitals contemporaneous documentation that the hospitals have appropriately been incurring the direct GME costs in earlier fiscal years. We believe the January 1, 1999 date should simplify confirmation by our fiscal intermediaries and hospitals of whether the hospital or another entity had been incurring the costs of the program in particular training settings and whether redistribution of costs or community support had occurred. We have chosen the January 1, 1999 date because of administrative convenience and feasibility, so that necessary data are both valid and available, and in recognition of the fact that our fiscal intermediaries must prioritize their limited audit resources. While we are not requiring our fiscal intermediaries to determine whether a hospital had been incurring the training costs of a program prior to the January 1, 1999 date, if the fiscal intermediaries determine that there is a redistribution of costs or community support exists with respect to certain residents prior to January 1, 1999, a disallowance of direct GME and IME payments with respect to those FTE residents would certainly be required. Since calculation of a hospital's FTE resident count is dependent upon whether the hospital incurred the training costs, we are proposing to require each teaching hospital and its fiscal intermediary to determine which entity had been incurring the training costs at least since January 1, 1999. For example, if a nonhospital entity, such as a school of medicine or dentistry, had incurred the costs of training the residents anytime on or after January 1, 1999, and a hospital subsequently begins to incur direct GME costs of training those FTE residents, the hospital would not qualify to count those FTE residents for purposes of direct GME and IME payments. We note that the proposal states that a hospital must have been *continuously* incurring the costs of the training since the date the residents first began training in that program. Accordingly, if a hospital had at one time incurred the costs of training residents in a particular program, whether at the hospital or in a nonhospital setting, but a nonhospital institution later assumed the costs of training in that setting, even if the hospital assumed payment for the training costs again, the hospital could not then count those residents for purposes of direct GME and IME payments. We note that if a hospital incurs the direct GME costs, whether training takes place inside the hospital or in a nonhospital setting, in a new residency program, the hospital may be eligible to count the FTE residents as specified by the regulations under § 413.86(g)(6). Consistent with the policy on redistribution of costs and community support discussed above, if a hospital incurs the direct GME costs of *additional* FTE residents training in an existing program in a hospital setting where the costs of the existing program had been incurred by a nonhospital entity and the hospital has continuously funded the *additional* residents in the existing program in the hospital setting since the date the residents first began training there, the redistribution of costs or community support principles would not prohibit the hospital from counting the additional FTE residents for purposes of direct GME and IME payments. We note that, under existing policy, to count residents in a nonhospital setting, a hospital is required to incur for “all or substantially all of the costs of the *program* ” in that setting. In other words, a hospital is required to assume financial responsibility for the *full* complement of residents training in a nonhospital site in a particular program in order to count any FTE residents training there for purposes of IME payment. A hospital cannot count any FTE residents if it incurs “all or substantially all of the costs” for only a portion of the FTE residents in that program training setting. This policy is derived from the language of the IME and direct GME provisions of the statute on counting residents in nonhospital settings; both sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act state that the hospital must incur “all, or substantially all, of the costs for the training *program* in that setting.” (Emphasis added.) In contrast, as explained earlier, it is permissible under the proposed policy on the application of the redistribution of costs and community support principles for the hospital to count FTE residents where the hospital incurs direct GME costs of FTE residents that are *added* to an existing program, even though the hospital may not count the existing FTE residents due to the application of the redistribution of costs or community support rules. In the nonhospital setting, as a result of the interaction of these two separate FTE counting requirements—(1) that the hospital must not violate the redistribution of costs and the community support principles in order to count the resident FTEs in the nonhospital settings, and
(2)that the hospital must incur “all or substantially all” of the costs for the training program in that setting—a hospital would be prohibited from counting FTE residents added to an existing program at a nonhospital site unless the hospital incurs all or substantially all of the costs of training *all* of the residents in that program at that setting. That is, even if the hospital incurs all or substantially of the costs for all of the training program at the nonhospital site, the hospital would only be able to count the additional FTE residents who were not excluded by application of the redistribution of costs or community support principles. For example, training in a general dentistry program with 10 FTE residents has taken place at a school of dentistry for 20 years. The school of dentistry has been incurring the training costs of the general dentistry residents since the inception of the program. Beginning in 2003, the school of dentistry has decided to add an additional 5 FTE residents to the program, and Hospital A decides to incur “all or substantially all” the costs of those 5 additional FTE residents only. Applying the policy concerning redistribution of costs and community support in combination with the policy on incurring all or substantially all of the costs, the hospital could not count the additional 5 FTE residents in the dental school since it is not paying for all or substantially all of the costs of the program. Even if the hospital were to incur all or substantially all of the costs for the training program for all 15 FTE residents, the hospital could not count the 10 FTEs that were part of the existing general dentistry program because of the redistribution of costs and community support principles; it would be a redistribution of costs for the hospital to begin to incur direct GME costs of the 10 FTE residents when the dental school had previously been incurring those costs. We note that such a result does not occur when a *new program* is established in the nonhospital site. If, from the outset of the program, the hospital incurs direct GME costs and also incurs “all or substantially all” of the costs for the training program for all the new residents training at the site, there would be no redistribution of costs or community support, and the hospital could count all of those residents in the new program in its FTE count (subject, of course, to the hospital's 1996 FTE resident cap). We also note that the interaction of the two provisions discussed above—redistribution of costs and community support, and “all or substantially all”—does not occur when counting FTE residents training inside the hospital, since a hospital is not required to incur “all or substantially all” of the costs for the training program inside the hospital. Furthermore, if one hospital had incurred the direct GME costs of training residents in a particular program in a nonhospital site from one point in time, for example, 1995 through 1999, and then another hospital consecutively incurs the costs from 2000 and thereafter, the second hospital may be eligible to receive direct GME and IME payments for training the FTE residents from the point in time where the second hospital incurred the direct GME costs, and the redistribution and community support exclusions would not apply. The second hospital may be eligible to receive Medicare direct GME and IME payments because the costs were incurred previously by a hospital, and not either the community or the university. Therefore, there was neither community support nor redistribution of costs. The following are some examples to clarify how these proposed policies would be implemented: Example 1 Since 1995, 10 FTE residents in an internal medicine program have been training in the Community Clinic. In accordance with the current provisions of § 413.86(f), Hospital A has incurred all or substantially all of the costs of training the 10 FTE residents since 1995. Assuming the current provisions of the regulations at §§ 412.105(f)(1)(ii)(C) and 413.86(f)(3) and (f)(4) are met, Hospital A may continue to receive IME and direct GME payments for 10 FTE residents because Hospital A had incurred direct GME costs continuously (as evidenced by contemporaneous documentation since January 1, 1999), as specified in our proposed regulation. Beginning July 1, 2004, in addition to continuing to incur all or substantially all of the costs of the first 10 FTE internal medicine residents training in the nonhospital site, Hospital A also incurs all or substantially all of the costs of training an additional 3 FTE internal medicine residents at that site. Accordingly, beginning July 1, 2004, Hospital A may count all 13 FTE residents training in the Community Clinic for purposes of direct GME and IME payments, assuming Hospital A does not exceed its FTE cap for IME and direct GME. Example 2 Since 1995, 2.25 dental FTE residents in a dental school program were training in a dental clinic at the dental school. While the 2.25 FTEs were training at the clinic, the dental school paid for all of the costs of the dental program. Prior to July 1, 2000, Hospital A signed a written agreement with the clinic to incur all or substantially all of the costs of training the 2.25 FTE residents, from July 1, 2000 and onward. Thus, beginning with July 1, 2000, the dental school no longer incurred the costs of the program at this nonhospital site. In this scenario (even if Hospital A inappropriately received direct GME and IME payments for the 2.25 FTEs since July 1, 2000), Hospital A may not receive direct GME or IME payment for the 2.25 FTE residents training in the clinic because there would have been a redistribution of costs associated with training these 2.25 FTE residents from the dental school to the hospital. Example 3 Since 1995, 2.25 FTE residents in a family practice program were training in a physicians' group practice. While the 2.25 FTEs were training at the physicians' practice, a school of medicine paid for the costs of the family practice residency program. Prior to July 1, 2000, Hospital A signed a written agreement with the physicians' practice to send 1 additional family practice FTE resident to the physicians' practice and to incur all or substantially all of the costs of training the original 2.25 FTE residents *and* the 1 additional FTE, from July 1, 2000 and onward. Thus, beginning with July 1, 2000, the school of medicine no longer incurred the costs of the program at this nonhospital site. Hospital A may not count the 2.25 FTE residents that had been training since 1995 in that physicians' practice for purposes of direct GME and IME payments because the training costs were shifted from the school of medicine to the hospital. However, Hospital A may count the 1 FTE resident the hospital began to rotate for training in the physicians' practice because there was no cost-shifting for that resident and Hospital A incurred “all or substantially all” of the costs of the entire family practice program in the physicians' office setting. Example 4 Residents in a surgery program have been rotating from a hospital to two nonhospital clinics, Clinic A and Clinic B, since 1996. The training of the surgery residents in Clinic A has been supported by a nonhospital institution since 1996, while the hospital has incurred all or substantially all of the costs of the surgery residents in Clinic B since 1996. The hospital cannot count the surgery FTE residents training in Clinic A, even if it begins to pay for all of the costs of the program at that site, since a nonhospital institution had supported the training in Clinic A since 1996 (in other words, the redistribution of costs and community support principles would prohibit the hospital from counting these FTE residents). However, if the hospital continues to incur all or substantially all of the costs of the surgery residents in Clinic B, the hospital may count the FTE residents training in Clinic B for purposes of direct GME and IME payments because there would be no cost-shifting to the hospital for these residents and the hospital would incur all or substantially all of the costs for the training program in that setting. 3. Rural Track FTE Limitation for Purposes of Direct GME and IME for Urban Hospitals that Establish Separately Accredited Approved Medical Programs in a Rural Area (§§ 412.105(f)(1)(x) and 413.86(g)(12)) a. Change in the Amount of Rural Training Time Required for an Urban Hospital to Qualify for an Increase in the Rural Track FTE Limitation. To encourage the training of physicians in rural areas, section 407(c) of Pub. L. 106-113 amended sections 1886(d)(5)(B) and 1886(h)(4)(H) of the Act to add a provision that, in the case of an urban hospital that establishes separately accredited approved medical residency training programs (or rural tracks) in a rural area or has an accredited training program with an integrated rural track, an adjustment shall be made to the urban hospital's cap on the number of residents. For direct GME, the amendment applies to payments to hospitals for cost reporting periods beginning on or after April 1, 2000; for IME, the amendment applies to discharges occurring on or after April l, 2000. Section 407(c) of Pub. L. 106-113 did not define a “rural track” or an “integrated rural track,” nor are these terms defined elsewhere in the Act or in any applicable regulations. Currently, there are a number of accredited 3-year primary care residency programs in which residents train for 1 year of the program at an urban hospital and are then rotated for training for the other 2 years of the 3-year program to a rural facility(ies). These separately accredited “rural track” programs are recognized by the Accreditation Council of Graduate Medical Education (ACGME) as “1-2” rural track programs. As far as CMS is able to determine, ACGME is the only accrediting body to “separately accredit” rural track residency programs, a requirement specified in Pub. L. 106-113. We implemented the rural track program provisions of section 1886(d)(5)(B) and 1886(h)(4)(H) of the Act to address these “1-2” programs and to account for other programs that are not specifically “1-2” programs but that include rural training components. As stated above, since there is no existing definition of “rural track” or “integrated rural track,” we define at § 413.86(b) a “rural track” and an “integrated rural track” as an approved medical residency training program established by an urban hospital in which residents train for a portion of the program at the urban hospital and then rotate for a portion of the program to a rural hospital(s) or to a rural nonhospital site(s). We have previously noted that the terms “rural track” and “integrated rural track,” for purposes of this definition, are synonymous. To implement these provisions, we revised § 413.86 to add paragraph (g)(11) (since redesignated as (g)(12)), and § 412.105 to add paragraph (f)(1)(x) to specify that, for direct GME, for cost reporting periods beginning on or after April 1, 2000, or, for IME, for discharges occurring on or after April 1, 2000, an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may, under certain circumstances, include in its FTE count residents in those rural tracks, in addition to the residents subject to the FTE cap at § 413.86(g)(4). (See the August 1, 2000 interim final rule with comment period (65 FR 47033) and the August 1, 2001 IPPS final rule (66 FR 39902)). These regulations specify that an urban hospital may count the residents in the rural track in excess of the hospital's FTE cap up to a “rural track FTE limitation” for that hospital. We defined this rural track FTE limitation at § 413.86(b) as the maximum number of residents (as specified in § 413.86(g)(12)) training in a rural track residency program that an urban hospital may include in its FTE count, in addition to the number of FTE residents already included in the hospital's FTE cap. Generally, the rural track policy is divided into two categories: rural track programs in which residents are rotated to a rural area for at least two-thirds of the duration of the program; and rural track programs in which residents are rotated to a rural area for less than two-thirds of the duration of the program. Currently, family practice is the only specialty that has separately accredited rural track programs. As previously noted, to account for other specialties that have program lengths greater than or less than 3 years, or that are not “1-2” programs, but may establish separately accredited rural track residency programs that are longer than 3 years, our regulations specify that residents must train in the rural area for “two-thirds of the duration of the program,” rather than “2 out of 3 program years,” in order for the urban hospital to count FTEs in the rural track (up to the rural track FTE limitation) in addition to the residents included in the hospital's FTE limitation. Thus, for example, under current policy, if a surgery program, which is a 5-year program, were to establish a separately accredited rural track, the urban hospital must rotate the surgery residents to the rural area for at least two-thirds of the duration of the 5-year program in order to qualify to count those FTEs in excess of the hospital's FTE cap, as provided in § 413.86(g)(12) and § 412.105(f)(1)(x). Accordingly, our policy for determining whether an urban hospital qualifies for an adjustment to the FTE cap for training residents in rural areas is dependent upon the proportion of time the residents spend training in the rural areas. If the time spent training in rural areas (either at a rural hospital or a rural nonhospital site) constitutes *at least two-thirds* of the duration of the program, then the urban hospital may include the time the residents train *at that urban hospital* in determining GME payments. However, if the urban hospital rotates residents to rural areas for a period of time that is *less than two-thirds* of the duration of the program, although the rural hospital may count the time the residents train at the rural hospital if the program is new, the urban hospital may *not* include the time the residents train at the urban hospital for GME payment purposes (unless it can do so within the hospital's FTE cap). When we first implemented this policy on rural tracks, it was consistent with our understanding of how the ACGME accredits rural track “1-2” programs, in which residents train for 1 year of the program at an urban hospital and are then rotated for training years 2 and 3 to a rural facility. We believed that the ACGME did not separately accredit an approved program as a rural track program unless it met this “1-2” condition; that is, the residents were spending one-third of program training in the urban area and two-thirds of the program training in the rural area. However, we have recently learned that there are a few rural track programs that are separately accredited by the ACGME as “1-2” rural track programs, but the residents in these programs are not training in rural areas for at least two-thirds of the duration of the program. We understand that in certain instances in which the case-mix of the rural facilities might not be sufficiently broad to provide the residents with an acceptable range of training opportunities, the ACGME allows the residents in program years 2 and 3 to return to the urban hospital for some training in both years. However, because the training in years 2 and 3 is predominantly occurring at the rural locations, the ACGME still separately accredits the urban and rural portions as a “1-2” program. The existing regulations at §§ 412.105(f)(1)(x) and 413.86(g)(12) specify two main criteria for an urban hospital to count the time spent by residents training in a rural track while at the urban hospital in excess of the hospital's FTE limitation:
(1)The program must be separately accredited by the ACGME; *and*
(2)the time spent training in rural areas (either at a rural hospital or a rural nonhospital site) must constitute *at least two-thirds* of the duration of the program. We believe that an urban hospital that operates a program that is separately accredited by the ACGME as a “1-2” program, but in which residents train in rural areas for more than half but less than two-thirds of the duration of the program, should still be allowed to count those FTE residents for GME payment purposes. Therefore, to be consistent with the ACGME accreditation practices, we are proposing to revise our regulations. Proposed § 413.86(g)(12) would still address our policy that an urban hospital qualifies for an adjustment to the FTE cap for training in rural areas based upon the proportion of time the residents spend training in the rural areas. However, instead of using a “two-thirds” model to specify the amount of time residents are training in the rural areas, as the framework exists under current policy, the proposal would use, at §§ 413.86(g)(12)(i) through (iv), a “one-half of the time” model to specify the amount of time residents are training in rural areas. This proposal would address the limited cases where ACGME separately accredits programs as “1-2” rural tracks but residents in those programs train in the rural areas less than two-thirds of the time, although greater than one-half of the time. Specifically, we are proposing at § 413.86(g)(12) to state: • If an urban hospital rotates residents to a separately accredited rural track program at a rural hospital(s) for two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for more than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count for the time the rural track residents spend at the urban hospital. • If an urban hospital rotates residents to a separately accredited rural track program at a rural nonhospital site(s) for two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000, and before October 1, 2003, or for more than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count, subject to the requirements under § 413.86(f)(4). • If an urban hospital rotates residents in the rural track program to a rural hospital(s) for less than two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2002, and before October 1, 2003, or for one-half or less than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the rural hospital may not include those residents it its FTE count (if the rural track is not a new program under § 413.86(g)(6)(iii), or if the rural hospital's FTE count exceeds that hospital's FTE cap), nor may the urban hospital include those residents when calculating its rural track FTE limitation. • If an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for a period of time that is less than two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2002, and before October 1, 2003, or for one-half or less than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count, subject to the requirements under § 413.86(f)(4). We also are proposing to make a conforming change to § 412.105(f)(1)(x) to make these proposed provisions applicable to IME payments for discharges occurring on or after October 1, 2003. We believe this proposal produces a more equitable result than the existing policy; the proposal encompasses what we believe to be all situations in which the ACGME separately accredits rural track programs and in which residents in the programs spend a majority of the time training in rural settings, fulfilling the intent of Congress for Medicare to provide GME payments for significant rural residency training. b. Inclusion of Rural Track FTE Residents in the Rolling Average Calculation. Section 1886(h)(4)(G) of the Act, as added by section 4623 of Public Law 105-33, provides that, for a hospital's first cost reporting period beginning on or after October 1, 1997, the hospital's FTE resident count for direct GME payment purposes equals the average of the actual FTE resident count for that cost reporting period and the preceding cost reporting period. Section 1886(h)(4)(G) of the Act requires that, for cost reporting periods beginning on or after October 1, 1998, a hospital's FTE resident count for direct GME payment purposes equals the average of the actual FTE resident count for the cost reporting period and the preceding two cost reporting periods (that is, a 3-year rolling average). This provision phases in over a 3-year period any reduction in direct GME payments to hospitals that results from a reduction in the number of FTE residents below the number allowed by the FTE cap. We first implemented this provision in the August 29, 1997 final rule with comment period (62 FR 46004) and revised § 413.86(g)(5) accordingly. Because hospitals may have two PRAs, one for residents in primary care and obstetrics and gynecology (the “primary care PRA”), and a lower PRA for nonprimary care residents, we revised our policy for computing the rolling average for direct GME payment purposes ( *not* for IME) in the August 1, 2001 final rule (66 FR 39893) to create two separate rolling averages, one for primary care and obstetrics and gynecology residents (the “primary care rolling average”), and one for nonprimary care residents. Effective for cost reporting periods beginning on or after October 1, 2001, direct GME payments are calculated based on the sum of:
(1)The product of the primary care PRA and the primary care rolling average; and
(2)the product of the nonprimary care PRA and the nonprimary care FTE rolling average. (This sum is then multiplied by the Medicare patient load to determine Medicare direct GME payments). Section 407(c) of Public Law 106-113, which amended sections 1886(d)(5)(B) and 1886(h)(4)(H) of the Act to create the rural track provision, provided that, in the case of an urban hospital that establishes a separately accredited rural track, “* * * the Secretary shall *adjust the limitation under subparagraph (F)* in an appropriate manner insofar as it applies to such programs in such rural areas in order to encourage the training of physicians in rural areas” (emphasis added). Subparagraph
(F)of the Act is the provision that establishes a cap on the number of allopathic and osteopathic FTE residents that may be counted at each hospital for Medicare direct GME payment purposes. Thus, the provision authorizes the Secretary to allow for an increase to an urban hospital's FTE cap on allopathic and osteopathic residents in certain instances when an urban hospital establishes a rural track program. Although the rural track provision effectively allows an increase to the urban hospital's FTE cap by adjusting the FTE limitation under subparagraph (F), the statute makes no reference to subparagraph (G), the provision concerning the rolling average count of residents. That is, the statute does not provide for an exclusion from the rolling average for the urban hospital for those FTE residents training in a rural track. Since we implemented this rural track provision in the August 1, 2000 interim final rule with comment period (65 FR 47033), we have interpreted this provision to mean that, except for new rural track programs begun by urban teaching hospitals that are establishing an FTE cap for the first time under § 413.86(g)(6)(i), when an urban hospital establishes a new rural track program or expands an existing rural track program, FTE residents in the rural track that are counted by the urban hospital are included in the hospital's rolling average calculation immediately. Although we have not specified in the regulations that rural track FTE residents counted by an urban hospital are included in the hospital's rolling average FTE resident count, this has been our policy. The Medicare cost report, Form CMS-2552-96 (line 3.05 on Worksheet E, Part A, for IME payments, and on line 3.02 on Worksheet E-3, Part IV, for direct GME payments), reflects this policy. Accordingly, FTE residents in a rural track program are to be included in the urban hospital's rolling average count for IME and direct GME for cost reporting periods beginning on or after April 1, 2000. We are proposing to revise the regulations at § 413.86(g)(5) to add a new paragraph
(vii)to clarify that, subject to regulations at § 413.86(g)(12), except for new rural track programs begun by urban hospitals that are first establishing an FTE cap under § 413.86(g)(6)(i), when an urban hospital with an existing FTE cap establishes a new program with a rural track (or an integrated rural track), or expands an existing rural track (or an integrated rural track) program, the FTE residents in that program that are counted by the urban hospital are included in the urban hospital's rolling average FTE resident count immediately. We also are proposing to revise §§ 413.86(g)(12)(i)(A), (g)(12)(ii)(B), and (g)(12)(iv)(A) to indicate that for the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents, subject to the rolling average, training in the rural track at the urban hospital. 4. Technical Change Relating to Affiliated Groups and Affiliation Agreements Section 1886(h)(4)(H)(ii) of the Act permits, but does not require, the Secretary to prescribe rules that allow institutions that are members 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 give hospitals flexibility in structuring rotations within a combined cap when they share a resident's time. Consistent with the broad authority conferred by the statute, we established criteria for defining an “affiliated group” and an “affiliation agreement” in both the August 29, 1997 final rule (62 FR 45965) and the May 12, 1998 final rule (63 FR 26317). We further clarified our policy concerning affiliation agreements in the August 1, 2002 final rule (67 FR 50069). We are aware that there has been some confusion at times among members of the provider community when using the term “affiliation agreement,” since the term is used in contexts other than for Medicare GME payment purposes. For example, an “affiliation agreement” is a term historically used in the academic community that generally relates to agreements made between hospitals and medical schools or among sponsors of medical residency education programs. To help prevent further confusion, we are proposing to change the term in the regulations to “Medicare GME affiliation agreement.” We believe this will help to distinguish these agreements used for purposes of GME payments from agreements used for other purposes in the provider community. We are proposing to revise the regulations at § 413.86(b) to state “Medicare GME affiliated group,” and “Medicare GME affiliation agreement,” and we are making similar revisions to § 413.86(g)(4)(iv), (g)(7)(i) through (v), and § 412.105(f)(1)(vi) for IME payment purposes. G. Notification of Updates to the Reasonable Compensation Equivalent
(RCE)Limits (§ 415.70) 1. Background Under the Medicare program, payment for services furnished by a physician is made under either the Hospital Insurance Program (Part A) or the Supplementary Medical Insurance Program (Part B), depending on the type of services furnished. In accordance with section 1848 of the Act, physicians' charges for medical or surgical services to individual Medicare patients generally are covered under Part B on a fee-for-service basis under the Medicare physician fee schedule. The compensation that physicians receive from or through a provider for services that benefit patients generally (for example, administrative services, committee work, teaching, and supervision) can be covered under Part A or Part B, depending on the provider's setting. As required by section 1887(a)(2)(B) of the Act, allowable compensation for services furnished by physicians to providers that are paid by Medicare on a reasonable cost basis is subject to reasonable compensation equivalent
(RCE)limits. Under these limits, payment is determined based on the lower of the actual cost of the services to the provider (that is, any form of compensation to the physician) or a reasonable compensation equivalent. For purposes of applying the RCE limits, physician compensation costs means monetary payments, fringe benefits, deferred compensation and any other items of value (excluding office space or billing and collection services) that a provider or other organization furnishes a physician in return for the physician's services. The RCE limits do not apply to the costs of physician compensation that are attributable to furnishing inpatient hospital services paid for under the IPPS or GME costs. In addition, RCE limits do not apply to the costs CAHs incur in compensating physicians for services. Furthermore, compensation that a physician receives for activities that may not be paid for under either Part A or Part B are not considered in applying the RCE limits. The limits apply equally to all physician services to providers that are payable on a reasonable cost basis under Medicare. If a physician receives any compensation from a provider for his or her physician services to the provider (that is, those services that benefit patients generally), payment to those affected providers for the costs of such compensation is subject to the RCE limits. The RCE limits are not applied to payment for services that are identifiable medical or surgical services to individual patients and paid for under the physician fee schedule, even if the physician agrees to accept compensation (for example, from a hospital) for those services. (However, payments to teaching hospitals that have elected to be paid for these services on a reasonable cost basis in accordance with section 1861(b)(7) of the Act are subject to the limits.) Section 415.70(b) of the regulations specifies the methodology for determining annual RCE limits, considering average physician incomes by specialty and type of location, to the extent possible using the best available data. On October 31, 1997, the revised RCE limits update methodology was published in the **Federal Register** (62 FR 59075). For cost reporting periods beginning on or after January 1, 1998, updates to the RCE limits are calculated using the Medicare Economic Index (MEI). The inflation factor used to develop the initial RCE limits and, subsequently, to update those limits to reflect increases in net physician compensation was the Consumer Price Index for All Urban Consumers (CPI-U). In 1998, we revised the RCE limits update methodology by replacing the CPI-U with the physician fee schedule's inflation factor (the MEI), to achieve a measure of consistency in the methodologies employed to determine reasonable payments to physicians for direct medical and surgical services furnished to individual patients and reasonable compensation levels for physicians' services that benefit provider patients generally. 2. Publication of the Updated RCE Limits We intend to publish updated payment limits on the amount of allowable compensation for services furnished by physicians to providers in the FY 2004 IPPS final rule. These revised limits will be mere updates that will be calculated by applying the most recent economic index data. We are not proposing any change in the methodology. Therefore, in accordance with § 415.70(f), we are allowed to publish the revised RCE limits in a final rule without prior publication of a proposed rule for public comment. Furthermore, we believe that publication of the revised RCE limits in a proposed rule with opportunity for public comment is unnecessary, and we find good cause to waive the procedure. V. PPS for Capital-Related Costs In this proposed rule, we are not proposing any changes in the policies governing the determination of the payment rates for capital-related costs for short-term acute care hospitals under the IPPS. However, for the readers' benefit, in this section of this proposed rule, we are providing a summary of the statutory basis for the PPS for hospital capital-related costs, the methodology used to determine capital-related payments to hospitals, and a brief description of the payment policies under the PPS for capital-related costs for new hospitals, extraordinary circumstances, and exception (regular and special) payments. (Refer to the August 1, 2001 IPPS final rule (66 FR 39910) for a more detailed discussion of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals both during and after the transition period, and the policy for providing regular and special exceptions payments.) Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services “in accordance with a PPS established by the Secretary.” Under the statute, the Secretary has broad authority in establishing and implementing the PPS for capital related costs. We initially implemented the capital PPS in the August 30, 1991 IPPS final rule (56 FR 43358), in which we established a 10-year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). Federal fiscal year
(FY)2001 was the last year of the 10-year transition period established to phase in the PPS for hospital inpatient capital-related costs. Beginning in FY 2002, capital PPS payments are 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, if applicable) 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. During the 10-year transition period, a new hospital (as defined at 412.300(b)) was exempt from the capital PPS for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Originally, this provision was effective only through the transition period and, therefore, ended with cost reporting periods beginning in FY 2002. As we discussed in the August 1, 2002 final rule (67 FR 50101), 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. Therefore, we believe that the rationale for this policy applies to new hospitals after the transition period as well, and in that same final rule, we established regulations under § 412.304(c)(2) that provide the same special payment to new hospitals for cost reporting periods beginning on or after October 1, 2002. Therefore, a new hospital, defined under § 412.300(b), is paid 85 percent of its allowable Medicare inpatient hospital capital-related costs through its first 2 years of operation unless the new hospital elects to receive fully prospective payment based on 100 percent of the Federal rate. (For more detailed information regarding this policy, see the August 1, 2002 IPPS final rule (67 FR 50101).) Regulations at § 412.348(f) provide that a hospital may request an additional payment if the hospital incurs unanticipated capital expenditures in excess of $5 million due to extraordinary circumstances beyond the hospital's control. This policy was established for hospitals during the 10-year transition period, but we established regulations at § 412.312(e) to specify that payment for extraordinary circumstances is also made for cost reporting periods after the transition period (that is, cost reporting periods beginning on or after October 1, 2001). (For more detailed information regarding this policy, refer to the August 1, 2002 **Federal Register** (67 FR 50102).) During the transition period, under §§ 412.348(b) through (e), eligible hospitals could receive regular exception payments. These exception payments guaranteed a hospital a minimum payment of a percentage of its Medicare allowable capital-related costs depending on the class of hospital (§ 412.348(c)). However, after the end of the transition period, eligible hospitals can receive additional payments under the special exceptions provisions at § 412.348(g), which guarantees an eligible hospital a minimum payment of 70 percent of its Medicare allowable capital-related costs. Special exceptions payments may be made only for the 10 years after the cost reporting year in which the hospital completes its qualifying project, which can be no later than the hospital's cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital PPS transition period. Hospitals eligible for special exceptions payments were required to submit documentation to the intermediary indicating the completion date of their project. (For more detailed information regarding the special exceptions policy under § 412.348(g), refer to the August 1, 2001 IPPS final rule (66 FR 39911 through 39914) and the August 1, 2002 IPPS final rule (67 FR 50102).) VI. Proposed Changes for Hospitals and Hospital Units Excluded from the IPPS 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 Pub. L. 105-33) established caps on the target amounts for certain existing hospitals and hospital units excluded from the IPPS 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 LTCHs. 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), where applicable, 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 and then multiplying this figure by the number of Medicare discharges. Effective for cost reporting periods beginning on or after October 1, 2002, rehabilitation hospitals and units are paid 100 percent of the Federal rate. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs also are no longer paid on a reasonable cost basis but are paid under a DRG-based PPS. As part of this process for LTCHs, we established a 5-year transition period from reasonable cost-based reimbursement to a fully Federal PPS. However, a LTCH, subject to the blend methodology, may elect to be paid based on a 100 percent of the Federal prospective rate. (Sections VII.A.3. and 4. of this preamble contain for a more detailed discussion of the IRF PPS and the LTCH PPS.) 2. Updated Caps for New Excluded Hospitals and Units Section 1886(b)(7) of the Act establishes a payment limitation for new psychiatric hospitals and units, new rehabilitation hospitals and units, and new LTCHs. 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 statute, 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 IPPS on or after October 1, 1997. The amount of payment for a “new” psychiatric 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 of new excluded psychiatric hospitals and units for cost reporting periods beginning during FY 2004. These figures are updated with the most recent data available to reflect the projected market basket increase percentage of 3.5 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 Office of the Actuary of CMS based on its historical experience with the IPPS). For a new provider, the labor-related share of the target amount is multiplied by the appropriate geographic area wage index, without regard to IPPS 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 2004 proposed labor-related share FY 2004 proposed nonlabor-related share Psychiatric $7,301 $2,902 Effective for cost reporting periods beginning on or after October 1, 2002, this payment limitation is no longer applicable to new LTCHs because they are paid 100 percent of the Federal rate. Under the LTCH PPS, a new LTCH is defined as a provider of inpatient hospital services that meets the qualifying criteria for LTCHs specified under § 412.23(e)(1) and (e)(2) and whose first cost reporting period as a LTCH begins on or after October 1, 2002 (§ 412.23(e)(4)). (We note that this definition of new LTCHs should not be confused with those LTCHs first paid under the TEFRA payment system for discharges occurring on or after October 1, 1997, and before October 1, 2002.) New LTCHs are paid based on 100 percent of the fully Federal prospective rate (they may not participate in the 5-year transition from cost-based reimbursement to prospective payment). In contrast, those “new” LTCHs that meet the definition of “new” under § 413.40(f)(2)(ii) and that have their first cost reporting periods beginning on or after October 1, 1997, and before October 1, 2002, may be paid under the LTCH PPS transition methodology. Since those hospitals by definition would have been considered new before October 1, 2002, they would have been subject to the updated payment limitation on new hospitals that was published in the FY 2003 IPPS final rule (67 FR 50103). Under existing regulations at § 413.40(f)(2)(ii), the “new” hospital would be subject to the same cap in its second cost reporting period; this cap would not be updated for the new hospital's second cost reporting year. Thus, because the same cap is to be used for the new LTCH's first two cost reporting periods, it is no longer necessary to publish an updated cap for new LTCHs. 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 because they are paid 100 percent of the Federal prospective rate under the IRF PPS. Therefore, it is also no longer necessary to update the payment limitation for new rehabilitation hospitals or units. 3. Implementation of a PPS for IRFs 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 PPS 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 PPS 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 PPS 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, subject to the blend methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act. On August 7, 2001, we issued a final rule in the **Federal Register** (66 FR 41316) establishing the PPS for inpatient rehabilitation facilities, effective for cost reporting periods beginning on or after January 1, 2002. Under the IRF PPS, for cost reporting periods beginning on or after January 1, 2002, and before October 1, 2002, payment consisted 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, payments are based entirely on the Federal prospective payment rate determined under the IRF PPS. 4. Implementation of a PPS for LTCHs 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 established a per discharge, DRG-based PPS for LTCHs as described in section 1886(d)(1)(B)(iv) of the Act for cost reporting periods beginning on or after October 1, 2002, in a final rule issued on August 30, 2002 (67 FR 55954). The LTCH PPS uses information from LTCH hospital patient records to classify patients into distinct LTC-DRGs based on clinical characteristics and expected resource needs. Separate payments are calculated for each LTC-DRG with additional adjustments applied. As part of the implementation of the system, we established a 5-year transition period from reasonable cost-based reimbursement to the fully Federal prospective rate. A blend of the reasonable cost-based reimbursement percentage and the prospective payment Federal rate percentage would be used to determine a LTCH's total payment under the LTCH PPS during the transition period. Certain LTCHs may elect to be paid based on 100 percent of the Federal prospective rate. All LTCHs will be paid under the fully Federal prospective rate for cost reporting periods beginning on or after October 1, 2006. B. Payment for Services Furnished at Hospitals-Within-Hospitals and Satellite Facilities Existing regulations at § 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. Moreover, existing § 412.22(f) provides for the grandfathering of hospitals-within-hospitals that were in existence on or before September 30, 1995. Sections 412.22(h) and 412.25(e), relating to satellites of hospitals and hospital units, respectively, excluded from the IPPS, define a satellite facility as a part of a hospital or 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. Sections 412.22(h)(3) and 412.25(e)(3) provide for the grandfathering of excluded hospitals and units that were structured as satellite facilities on September 30, 1999, to the extent they operate under the same terms and conditions in effect on that date. In providing for the grandfathering of satellite facilities of hospitals and hospital units, we believed it was appropriate to require that the satellite facilities operate under the same terms and conditions that were in effect on September 30, 1999. There are similarities between the definition of the two types of satellite facilities and the definition of hospitals-within-hospitals (that is, hospitals-within-hospitals and satellite facilities are both physically located in acute care hospitals that are paid for their inpatient services on a prospective payment basis). Also, satellite facilities of both excluded hospitals and hospital units and hospitals-within-hospitals provide inpatient hospital services that are paid at a higher rate than would apply if the facilities were treated by Medicare as part of an acute care hospital. We are proposing to revise § 412.22(f) to specify that, effective with cost reporting periods beginning on or after October 1, 2003, a hospital operating as a hospital-within-a-hospital on or before September 30, 1995, is exempt from the criteria in § 412.22(e)(1) through (e)(5) only if the hospital-within-a-hospital continues to operate under the same terms and conditions in effect as of September 30, 1995. The intent of the “grandfathering” provision was to ensure that hospitals that had been in existence prior to the effective date of our hospital-within-hospital requirements should not be adversely affected by those requirements. To the extent hospitals were already operating as hospitals-within-hospitals without meeting those requirements, we believe it is appropriate to limit the “grandfathering” provision to those hospitals that continue to operate in the same manner as they had operated prior to the effective date of those rules. However, if a hospital changes the way it operates (for example, adds more beds) subsequent to the effective date of the new rules, it should no longer receive the benefit of the “grandfathering” provision. Under § 412.22(e), we specify the criteria that a hospital-within-a-hospital is required to meet in order to be excluded from the IPPS. One of these criteria, under § 412.22(e)(5)(i), requires that a hospital-within-a-hospital is able to perform basic hospital functions (for example, medical record services and nursing services) that are presently included in the Medicare hospital conditions of participation under Part 482 of the Medicare regulations. These requirements were first included in Part 412 in response to hospitals organizing themselves as what is referred to as the hospital-within-a-hospital model. Thus, to avoid recognizing nominal hospitals, while allowing hospitals adequate flexibility and opportunity for legitimate networking and sharing of services, we included, by reference, certain hospital conditions of participation as additional criteria in part 412 for hospitals-within-hospitals that request exclusion from the IPPS. (Further discussion can be found in a final rule published in the **Federal Register** on September 1, 1994 (59 FR 45389).) Modifications to the conditions of participation have been made since the publication of that September 1, 1994 final rule. Thus, we need to update the references to the conditions of participation in § 412.22(e)(5)(i) to make them consistent with existing provisions under the basic hospital conditions of participation. Therefore, we are proposing to amend § 412.22(e)(5)(i) to add references to § 482.43 (discharge planning) and § 482.45 (organ, tissue, and eye procurement) as basic hospital functions that a hospital-within-a-hospital would also be required to meet. C. Clarification of Classification Requirements for LTCHs Under § 412.23(e)(2), to qualify to be excluded from the IPPS as a LTCH and to be paid under the LTCH PPS, a hospital must have an average Medicare length of stay of greater than 25 days (which includes all covered and noncovered days of stay for Medicare patients) as calculated under the criteria of § 412.23(e)(3). In calculating this average Medicare inpatient length of stay, data from the hospital's most recently filed cost report are used to make this determination. However, if the hospital has not yet filed a cost report or if there is an indication that the most recently filed cost report does not accurately reflect the hospital's current Medicare average length of stay, data from the most recent 6-month period are used. Our interpretation of § 412.23(e)(3)(ii) and (e)(3)(iii) was to allow hospitals that submit data for purposes of exclusion from the IPPS to use a period of at least 5 months of the most recent data from the preceding 6-month period. This longstanding policy interpretation was necessary in order to comply with the time requirement in § 412.22(d) that specifies that, for purposes of the IPPS, status is determined at the beginning of each cost reporting period and is effective for the entire cost reporting period. Therefore, we are proposing to revise §§ 412.23(e)(3)(ii) and
(iii)to reflect our longstanding interpretation of the regulations. D. Criteria for Payment on a Reasonable Cost Basis for Clinical Diagnostic Laboratory Services Performed by CAHs Section 1820 of the Act provides for the establishment of Medicare Rural Hospital Flexibility Programs, under which individual States may designate certain facilities as critical access hospitals (CAHs). Facilities that are so designated and meet the CAH conditions of participation in 42 CFR part 485, subpart F, will be certified as CAHs by CMS. Section 1834(g) of the Act states that the amount of payment for outpatient services furnished by a CAH will be the reasonable costs of the CAH in providing these services. Regulations implementing section 1834(g) of the Act are set forth at § 413.70. These regulations state, in paragraph (b)(2)(iii), that payment to a CAH for outpatient clinical diagnostic laboratory tests will be made on a reasonable cost basis only if the individuals for whom the tests are performed are outpatients of the CAH, as defined in 42 CFR 410.2, at the time the specimens are collected. The regulations also state that clinical diagnostic laboratory tests for persons who are not patients of the CAH at the time the specimens are collected will be paid for in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act. These provisions, which also are the basis for payment for clinical diagnostic laboratory tests performed by independent laboratories and by hospitals on specimens drawn at other locations, set payment at the least of:
(1)Charges determined under the fee schedule as set forth in section 1833(h)(1) or section 1834(d)(1) of the Act;
(2)the limitation amount for that test determined under section 1833(h)(4)(B) of the Act; or
(3)a negotiated rate established under section 1833(h)(6) of the Act. Payments determined under this methodology are typically referred to as “fee schedule payments,” and are so described here both for ease of reference and to differentiate them from payments determined on a reasonable cost basis. The definition of an “outpatient” in 42 CFR 410.2 states that an outpatient means a person who has not been admitted as an inpatient but who is registered on hospital or CAH records as an outpatient and receives services (rather than supplies alone) directly from the hospital or CAH. Recently, we have received numerous questions about how Medicare pays for laboratory services that a CAH may furnish to Medicare beneficiaries in various settings other than the CAH. Specifically, the questioners have asked whether a CAH may obtain reasonable cost payment for such services to individuals in other locations by sending a CAH employee into the setting and registering the individual as a CAH patient while the blood is drawn or other specimen collection is accomplished. The settings that have been referred to most frequently are:
(1)A rural health clinic (RHC), especially one that is provider-based with respect to the CAH;
(2)the individual's home; and
(3)a SNF. We have considered these suggestions and understand the position taken by those who believe that nominal compliance with the requirements for outpatient status should be enough to warrant reasonable cost payment for clinical diagnostic laboratory tests for individuals at locations outside the CAH. However, we do not agree that providing reasonable cost payment under these circumstances would be appropriate. On the contrary, we believe that extending reasonable cost payment for services furnished to individuals who are not at the CAH when the specimen is drawn would duplicate existing coverage, create confusion for beneficiaries and others by blurring the distinction between CAHs and other providers, such as SNFs and HHAs, and increase the costs of care to Medicare patients without enhancing either the quality or the availability of that care. To clarify our policies in this area and avoid possible misunderstandings about the scope of the CAH benefit, we are proposing to revise § 413.70(b)(2)(iii) to state that payment to a CAH for outpatient clinical diagnostic laboratory tests will be made on a reasonable cost basis only if the individuals for whom the tests are performed are outpatients of the CAH, as defined in 42 CFR 410.2, “and are physically present in the CAH” at the time the specimens are collected. (We note that, in some cases, the CAH outpatients from whom specimens are collected at the CAH may include individuals referred to the CAH from RHCs or other facilities to receive the tests.) We are proposing to further revise this paragraph to state that clinical diagnostic laboratory tests for individuals who do not meet these criteria but meet other applicable requirements will be paid for only in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act, that is, payment will be made only on a fee schedule basis. By making the second proposed change, we wish to emphasize that this proposal does not mean that no payment would be made for clinical diagnostic laboratory tests performed by CAHs that do not meet the revised criteria. On the contrary, such tests would be paid, but on a fee schedule basis. We believe these clarifications are appropriate, as the CAH is not providing CAH services but is acting as an independent laboratory in providing these clinical diagnostic laboratory tests. E. Technical Change On July 30, 1999, we published in the **Federal Register** a final rule (64 FR 41532) that set forth criteria for a satellite facility of a hospital or hospital unit to be excluded from the IPPS under § 412.25. Section 412.25(e)(3) of the regulations specifies that any unit structured as a satellite facility on September 30, 1999, and excluded from the IPPS on that date, is grandfathered as an excluded hospital to the extent that the unit continues operating under the same terms and conditions, including the number of beds and square footage considered to be part of the unit, in effect on September 30, 1999, except as we specified in § 412.25(e)(4). When we specified the exception for the number of beds and square footage requirement under § 412.25(e)(4), we inadvertently referred to paragraph (e)(4) as being an exception to paragraph (h)(3). We should have specified that it was an exception to paragraph (e)(3). We are proposing to correct this reference. VII. MedPAC Recommendations We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC's IPPS recommendations in our annual proposed rule. We have reviewed MedPAC's March 1, 2003 “Report to the Congress: Medicare Payment Policy” and have given it careful consideration in conjunction with the proposals set forth in this document. For further information relating specifically to the MedPAC report or to obtain a copy of the report, contact MedPAC at
(202)653-7220, or visit MedPAC's Web site at: *http://www.medpac.gov.* MedPAC's Recommendation 2A-6 concerning the update factor for inpatient hospital operating costs and for hospitals and distinct-part hospital units excluded from the IPPS is discussed in Appendix C to this proposed rule. MedPAC's other recommendations relating to payments for Medicare inpatient hospital services focused mainly on the expansion of DRGs subject to the postacute care transfer policy, a reevaluation of the labor-related share of the market basket used in determining the hospital wage index, an increase in the DSH adjustment, and payments to rural hospitals. These recommendations and our responses are set forth below: *Recommendation 2A-1:* The Secretary should add 13 DRGs to the postacute transfer policy in FY 2004 and then evaluate the effects on hospitals and beneficiaries before proposing further expansions. *Response:* We are proposing to expand the postacute care transfer policy to 19 additional DRGs for FY 2004. A thorough discussion of this proposal, including a summary of MedPAC's analysis, can be found at section IV.A.3. of this preamble. *Recommendation 2A-2:* The Congress should enact a low-volume adjustment to the rates used in the inpatient PPS. This adjustment should apply only to hospitals that are more than 15 miles from another facility offering acute inpatient care. *Response:* MedPAC's analysis “revealed that hospitals with a small volume of total discharges have higher costs per discharge than larger facilities, after controlling for the other cost-related factors recognized in the payment system.” Although there are special payment protections for some rural hospitals such as CAHs, SCHs, and MDHs, MedPAC believes these provisions do not sufficiently target hospitals with low discharge volume. This recommendation, which MedPAC estimates would increase Medicare payments to hospitals by less than $50 million in FY 2004, and others requiring Congressional action, should be considered in the context of larger discussions within Congress and between Congress and the Administration regarding Medicare reform and payment refinements. Therefore, we are not responding specifically to MedPAC's recommendation regarding a low-volume adjustment to the IPPS payments at this time. *Recommendation 2A-3:* The Secretary should reevaluate the labor share used in the wage index system that geographically adjusts rates in the inpatient PPS, with any resulting change phased in over 2 years. *Response:* CMS defines the labor-related share to include costs that are likely related to, influenced by, or vary with local labor markets, even if they could be purchased in a national market. Since the implementation of the IPPS, the labor-related share has been determined by adding together the cost weights from categories in the hospital market basket that are influenced by local labor markets. When the hospital market basket weights are updated or rebased, the labor-related share is updated. The estimate of the labor- related share using the most recently revised and rebased hospital market basket (1997-based) is 72.495 percent. This was the labor-related share proposed in the FY 2003 proposed rule. In the August 1, 2002 IPPS final rule, we elected to continue to use 71.066 percent as the labor-related share applicable to the standardized amounts (67 FR 50041). At that time, we indicated that we would conduct further analysis to determine the most appropriate methodology for the labor-related share. We are not proposing to use the updated labor-related share at this time because we have not yet completed our research into the appropriateness of this measure. Specifically, we are currently reviewing the labor-related share in two ways. First, we are updating the regression analysis that was done when the IPPS was originally developed, with the expectation that it would help give an alternative indication of the labor-related share. Second, we are reevaluating the methodology we currently use for determining the labor-related share using the hospital market basket. Our regression analysis attempts to explain the variation in operating cost per case for a given year using many different explanatory variables, such as case-mix, DSH status, and ownership type. We described this methodology and some of our initial results in the May 9, 2002 **Federal Register** (67 FR 31447-31479). When included in the regression, the area wage index produces a coefficient that can be interpreted as the proportion of operating costs that vary with the geographic location of the hospital. The latest results on 1997 data produced a coefficient for the area wage index of 0.621, which can be interpreted as a labor share of 62.1 percent and is very close to the results reached by other groups. However, using the same specification produced coefficients of 76.7 percent for rural hospitals and 47.6 percent for urban hospitals, a disparity that cannot be supported either by theory or existing cost data. For example, the proportion of costs accounted for by wages, benefits, and contract labor is 60.8 percent for urban hospitals and 62.3 percent for rural hospitals, a spread much smaller than the regressions indicate. In addition, when the regressions were run separately by case-mix quartile and with hospital-specific wage variation (as opposed to using the area wage index), the findings were both difficult to explain and inconsistent with the underlying cost data. Thus, we believe at this point that the regression results are not robust enough to support changing the current labor-related share measurement. A second approach was to reevaluate our methodology for determining the labor-related share using the hospital market basket. We have researched various alternative data sources for further breaking down the cost categories in the market basket and have begun to evaluate alternative methodologies. While each of these alternatives has strengths and weaknesses, it is not clear at this point that any one alternative is superior to the current methodology. We want to continue researching these alternatives, in part, because changing from the current methodology would impact the labor-related shares for SNFs, HHAs, and all of the excluded hospital payment systems, since they use a similar methodology. Our research plan includes consulting with experts on these issues, including MedPAC, to evaluate the various alternative approaches to determining the labor-related share. We plan to invite public comments on any proposed change to the labor-related share. In conclusion, we are proposing to continue using the 71.066 percent labor-related share that was calculated from the 1992-based market basket until we have completed our research. *Recommendation 2A-4:* The Congress should raise the inpatient base rate for hospitals in rural and other urban areas to the level of the rate for those in large urban areas, phased in over 2 years. *Response:* This recommendation, which MedPAC estimates would increase Medicare payments to hospitals by between $200 and $600 million in FY 2004, and others requiring Congressional action, should be considered in the context of larger discussions within Congress and between Congress and the Administration regarding Medicare reform and payment refinements. Therefore, we are not responding specifically to MedPAC's recommendation regarding raising the base rate for hospitals in rural and other urban areas at this time. *Recommendation 2A-5:* The Congress should raise the cap on the disproportionate share add-on a hospital can receive in the inpatient PPS from 5.25 percent to 10 percent, phased in over 2 years. *Response:* This recommendation, which MedPAC estimates would increase Medicare payments to hospitals by between $50 and $200 million in FY 2004, and others requiring Congressional action, should be considered in the context of larger discussions within Congress and between Congress and the Administration regarding Medicare reform and payment refinements. Therefore, we are not responding specifically to MedPAC's recommendation regarding raising the maximum DSH adjustments at this time. VIII. 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 file, if applicable, are listed below. Anyone wishing to purchase data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to CMS-PUF) to cover the cost to the following address: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, PO Box 7520, Baltimore, MD 21207-0520,
(410)786-3691. Files on the Internet may be downloaded without charge. 1. CMS Wage Data This file contains the hospital hours and salaries for FY 2000 used to create the proposed FY 2004 prospective payment system wage index. The file will be available by the beginning of February for the NPRM and the beginning of May for the final rule. Processing year Wage data year PPS fiscal year 2003 2000 2004 2002 1999 2003 2001 1998 2002 2000 1997 2001 1999 1996 2000 1998 1995 1999 1997 1994 1998 1996 1993 1997 1995 1992 1996 1994 1991 1995 1993 1990 1994 1992 1989 1993 1991 1988 1992 These files support the following: • 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 2004 PPS Update. 2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index Values Only) This file contains a history of all wage indices since October 1, 1983. *Media:* Diskette/most recent year on the Internet. *File Cost:* $165.00 per year. *Periods Available:* FY 2004 PPS Update. 3. 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 2004 PPS Update. 4. 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 2004 PPS Update. 5. 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 1010/01/87 10/01/88 PPS-VI 1010/01/88 10/01/89 PPS-VII 1010/01/89 10/01/90 PPS-VIII 1010/01/90 10/01/91 PPS-IX 1010/01/91 10/01/92 PPS-X 1010/01/92 10/01/93 PPS-XI 1010/01/93 10/01/94 PPS-XII 1010/01/94 10/01/95 ( **Note:** The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and PPS-XVIII Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and PPS-XVIII Hospital Data Set Files (refer to item 9 below).) 6. PPS-IX to PPS-XII Capital Data Set The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare certified hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. *Media:* Tape/Cartridge. *File Cost:* $770.00 per year. Periods beginning on or after and before PPS-IX 10/01/91 10/01/92 PPS-X 10/01/92 10/01/93 PPS-XI 10/01/93 10/01/94 PPS-XII 10/01/94 10/01/95 ( **Note:** The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and PPS-XVIII Capital Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and PPS-XVIII Hospital Data Set Files (refer to item 9 below).) 7. PPS-XIII to PPS-XVIII Hospital Data Set The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare-certified hospital by the Medicare fiscal intermediary to CMS. The data set is updated at the end of each calendar quarter and is available on the last day of the following month. *Media:* Diskette/Internet. *File Cost:* $2,500.00. Periods beginning on or after and before PPS-XIII 10/01/95 10/01/96 PPS-XIV 10/01/96 10/01/97 PPS-XV 10/01/97 10/01/98 PPS-XVI 10/01/98 10/01/99 PPS-XVII 10/01/99 10/01/00 PPS-XVIII 10/01/00 10/01/01 8. 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 2004 PPS Update. 9. 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 2004. 10. 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 2004 PPS Update. 11. 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 2004 PPS Update. 12. 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 2004 PPS Update. 13. 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 2004 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. Collection of Information Requirements This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995. List of Subjects 42 CFR Part 412 Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 413 Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements. For the reasons stated in the preamble of this proposed rule, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as follows: PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES 1. The authority citation for part 412 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 2. Section 412.4 is amended by— A. Revising paragraphs (b), (c), and (d). B. In paragraph (f)(1), revising the reference “paragraph (b)(1) or (c)” to read “paragraph
(b)or (c)”. The revisions read as follows: § 412.4 Discharges and transfers.
(b)*Acute care transfers.* A discharge of a hospital inpatient is considered to be a transfer for purposes of payment under this part if the patient is readmitted the same day (unless the readmission is unrelated to the initial discharge) to another hospital that is—
(1)Paid under the prospective payment system described in subparts A through M of this part; or
(2)Excluded from being paid under the prospective payment system described in subparts A through M of this part because of participation in an approved statewide cost control program as described in subpart C of part 403 of this chapter.
(c)*Postacute care transfers.* A discharge of a hospital inpatient is considered to be a transfer for purposes of this part when the patient's discharge is assigned, as described in § 412.60(c), to one of the qualifying diagnosis-related groups
(DRGs)listed in paragraph
(d)of this section and the discharge is made under any of the following circumstances:
(1)To a hospital or distinct part hospital unit excluded from the prospective payment system described in subparts A through M of this part under subpart B of this part.
(2)To a skilled nursing facility.
(3)To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge.
(d)*Qualifying DRGs.* For purposes of paragraph
(c)of this section, the qualifying DRGs are:
(1)For discharges occurring on or after October 1, 1998, DRGs 14, 113, 209, 210, 211, 236, 263, 264, 429, and 483.
(2)For discharges occurring on or after October 1, 2003, the DRGs listed in paragraph (d)(1) of this section and DRGs 12, 24, 25, 89, 90, 121, 122, 130, 131, 239, 243, 277, 278, 296, 297, 320, 321, 462, and 468. 3. Section 412.22 is amended by: A. Republishing the introductory text of paragraph (e)(5) and revising the first sentence of paragraph (e)(5)(i). B. Revising paragraph (f). The revisions read as follows: § 412.22 Excluded hospitals and hospital units: General rules.
(e)* * *
(5)*Performance of basic hospital functions.* The hospital meets one of the following criteria:
(i)The hospital performs the basic functions specified in §§ 482.21 through 482.27, 482.30, 482.42, 482.43, and 482.45 of this chapter through the use of employees or under contracts or other agreements with entities other than the hospital occupying space in the same building or on the same campus, or a third entity that controls both hospitals. * * *
(f)*Application for certain hospitals.* If a hospital was excluded from the prospective payment systems under the provisions of this section on or before September 30, 1995, and at that time occupied space in a building also used by another hospital, or in one or more buildings located on the same campus as buildings used by another hospital, the criteria in paragraph
(e)of this section do not apply to the hospital. However, effective for cost reporting periods beginning on or after October 1, 2003, those hospitals-within-hospitals must continue to operate under the same terms and conditions, including the number of beds and square footage considered, for purposes of Medicare participation and payment, in effect on September 30, 1995. 4. Section 412.23 is amended by revising paragraphs (e)(3)(ii) and (e)(3)(iii) to read as follows: § 412.23 Excluded hospitals: Classifications.
(e)*Long-term care hospitals.* * * *
(3)*Calculation of average length of stay.* * * *
(ii)If a change in the hospital's Medicare average length of stay is indicated, the calculation is made by the same method for the period of at least 5 months of the immediately preceding 6-month period.
(iii)If a hospital has undergone a change of ownership (as described in § 489.18 of this chapter) at the start of a cost reporting period or at any time within the period of at least 5 months of the preceding 6-month period, the hospital may be excluded from the prospective payment system as a long-term care hospital for a cost reporting period if, for the period of at least 5 months of the 6 months immediately preceding the start of the period (including time before the change of ownership), the hospital has the required Medicare average length of stay, continuously operated as a hospital, and continuously participated as a hospital in Medicare. § 412.25 [Amended] 5. In § 412.25(e)(4), introductory text, the reference “paragraph (h)(3) of this section” is revised to read “paragraph (e)(3) of this section”. 6. Section 412.87 is amended by revising paragraph (b)(3) to read as follows: § 412.87 Additional payment for new medical services and technologies: General provisions.
(b)*Eligibility criteria.* * * *
(3)The DRG prospective payment rate otherwise applicable to discharges involving the medical service or technology is determined to be inadequate, based on application of a threshold amount to estimated charges incurred with respect to such discharges. To determine whether the payment would be adequate, CMS will determine whether the charges of the cases involving a new medical service or technology will exceed a threshold amount set at 75 percent of one standard deviation beyond the geometric mean standardized charge for all cases in the DRG to which the new medical service or technology is assigned (or the case-weighted average of all relevant DRGs if the new medical service or technology occurs in many different DRGs). Standardized charges reflect the actual charges of a case adjusted by the prospective payment system payment factors applicable to an individual hospital, such as the wage index, the indirect medical education adjustment factor, and the disproportionate share adjustment factor. 7. Section 412.105 is amended by— A. In paragraph (a)(1), introductory text, revising the phrase “paragraph
(f)of this section” to read “paragraphs
(f)and
(h)of this section”. B. In paragraph (a)(1)(i), revising the phrase “affiliated groups” to read “Medicare GME affiliated groups”. C. Revising paragraph (b). D. Adding a sentence at the end of paragraph (f)(1)(v). E. In paragraph (f)(1)(vi), revising the phrase “affiliated group” to read “Medicare GME affiliated group”. F. Revising paragraph (f)(1)(x). The revisions and additions read as follows: § 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
(b)*Determination of number of beds.* For purposes 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 and dividing that number by the number of days in the cost reporting period. This count excludes bed days associated with—
(1)Beds in any other units or wards where the level of care provided would not be payable under the acute care hospital inpatient prospective payment system;
(2)Beds in units unoccupied for the previous 3 months;
(3)Beds that could not be made available for inpatient occupancy within 24 hours.
(4)Beds in excluded distinct part hospital units;
(5)Beds otherwise countable under this section used for outpatient observation services (unless the patient is subsequently admitted for acute inpatient care), skilled nursing swing-bed services, or ancillary labor/delivery services;
(6)Beds or bassinets in the healthy newborn nursery; and
(7)Custodial care beds;
(f)*Determining the total number of full-time equivalent residents for cost reporting periods beginning on or after July 1, 1991.*
(1)* * *
(v)* * * Subject to the provisions of paragraph (f)(1)(x) of this section, effective for cost reporting periods beginning on or after April 1, 2000, FTE residents in a rural track program are included in the urban hospital's rolling average calculation described in this paragraph (f)(1)(v).
(x)An urban hospital that establishes a new residency program (as defined in § 413.86(g)(13) of this subchapter), or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those rural tracks in accordance with the applicable provisions of § 413.86(g)(12) of this subchapter effective for discharges occurring on or after April 1, 2002 and before October 1, 2003, and the applicable provisions of § 413.86(g)(12) of this subchapter effective for discharges occurring on or after October 1, 2003. 7. Section 412.106 is amended by revising paragraphs (a)(1)(ii) and (b)(4)(i) to read as follows: § 412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.
(a)General considerations.
(1)* * *
(ii)For purposes of this section, the number of patient days in a hospital includes only those days attributable to units or wards of the hospital providing acute care services generally payable under the prospective payment system and excludes patient days associated with—
(A)Beds in excluded distinct part hospital units;
(B)Beds otherwise countable under this section used for outpatient observation services (unless the patient is subsequently admitted for acute inpatient care), skilled nursing swing-bed services, or ancillary labor/delivery services; and
(C)Beds in any other units or wards where the level of care provided would not be payable under the acute care hospital inpatient prospective payment system.
(b)*Determination of a hospital's disproportionate payment percentage.* * * *
(4)*Second computation.* * * *
(i)For purposes of this computation, a patient is deemed eligible for Medicaid on a given day only if the patient is eligible for inpatient hospital services under an approved State Medicaid plan or under a waiver authorized under section 1115(a)(2) of the Act on that day, regardless of whether particular items or services were covered or paid under the State plan or the authorized waiver. 8. In § 412.112, the introductory text is republished and a new paragraph
(d)is added to read as follows: § 412.112 Payments determined on a per case basis. A hospital is paid the following amounts on a per case basis.
(d)Additional payments for new medical services and technologies determined under subpart F of this part. 9. Section 412.116 is amended by revising paragraph
(e)to read as follows: § 412.116 Method of payment.
(e)*Outlier payment and additional payments for new medical services and technologies.* Payments for outlier cases and additional payments for new medical services and technologies (described in subpart F of this part) are not made on an interim basis. These payments are made based on submitted bills and represent final payment. PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES 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 413.70 is amended by revising paragraph (b)(2)(iii), introductory text, to read as follows: § 413.70 Payment for services of a CAH.
(b)*Payment for outpatient services furnished by CAH.* * * *
(2)*Reasonable costs for facility services.* * * *
(iii)Payment for outpatient clinical diagnostic laboratory tests is not subject to the Medicare Part B deductible and coinsurance amounts. Payment to a CAH for clinical diagnostic laboratory tests will be made on a reasonable cost basis under this section only if the individuals are outpatients of the CAH, as defined in § 410.2 of this chapter, and are physically present in the CAH, at the time the specimens are collected. Clinical diagnostic laboratory tests performed for persons who are not physically present in the CAH when the specimens are collected will be made in accordance with the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Social Security Act. 3. Section 413.85 is amended by— A. Adding under paragraph
(c)a definition of “Certification” in alphabetical order. B. Republishing the introductory text of paragraph (d)(1) and adding a new paragraph (d)(1)(iii). C. Adding a new paragraph (g)(3). D. Republishing the introductory text of paragraph
(h)and revising paragraph (h)(3). The addition and revision read as follows. § 413.85 Cost of approved nursing and allied health education activities.
(c)*Definitions.* * * * *Certification* means the ability to practice or begin employment in a specialty as a whole.
(d)*General payment rules.*
(1)Payment for a provider's net cost of nursing and allied health education activities is determined on a reasonable cost basis, subject to the following conditions and limitations:
(iii)The costs of certain nonprovider-operated programs at wholly owned subsidiary educational institutions are reimbursable on a reasonable cost basis if the provisions of paragraph (g)(3) of this section are met.
(g)*Payments for certain nonprovider-operated programs.* * * *
(3)*Special rule: Payment for certain nonprovider-operated programs at wholly owned subsidiary educational institutions.*
(i)Effective for portions of cost reporting periods occurring on or after October 1, 2003, a provider that incurs costs for a nursing or allied health education program(s) where those program(s) had originally been provider-operated according to the criteria at paragraph
(f)of this section, and then operation of the program(s) was transferred to a wholly owned subsidiary educational institution in order to meet accreditation standards prior to October 1, 2003, and where the provider has continuously incurred the costs of both the classroom and clinical training portions of the program(s) at the educational institution, may receive reasonable cost payment for such a program(s) according to the specifications under paragraphs (g)(3)(ii) and (g)(3)(iii) of this section.
(ii)Payment for the incurred costs of educational activities identified in paragraph (g)(3)(i) of this section will be made on a reasonable cost basis if a provider, as described in paragraph (g)(3)(i) of this section, received Medicare reasonable cost payment for those nursing and allied health education program(s) both prior and subsequent to the date the provider transferred operation of the program(s) to its wholly owned subsidiary educational institution (and ceased to be a provider-operated program(s) according to the criteria under paragraph
(f)of this section).
(iii)The provider that meets the requirements in paragraphs (g)(3)(i) and (g)(3)(ii) of this section will be eligible to receive payment under this paragraph for:
(A)the clinical training costs incurred for the program(s) as described in paragraph (g)(3)(i) of this section; and
(B)classroom costs, but only those costs incurred by the provider for the courses that were included in the programs described in paragraph (g)(3)(i) of this section.
(h)*Activities treated as normal operating costs.* The costs of the following educational activities incurred by a provider but not operated by that provider are recognized only as normal operating costs and paid in accordance with the reimbursement principles specified in part 412 of this subchapter. They include:
(3)Educational seminars, workshops, and continuing education programs in which the employees participate that enhance the quality of medical care or operating efficiency of the provider and, effective October 1, 2003, do not lead to certification required to practice or begin employment in a nursing or allied health specialty. 4. Section 413.86 is amended by— A. Under paragraph (b)—
(1)Removing the definitions of “Affiliated group” and “Affiliation agreement”.
(2)Adding definitions of “Community support”, “Medicare GME affiliated agreement”, “Medicare GME affiliated group”, and “Redistribution of costs” in alphabetical order.
(3)Under the definition of “Rural track FTE limitation”, revising the phrase “paragraph (g)(11)” to read “paragraph (g)(12)”. B. Revising the introductory text of paragraph (f). C. Adding a new paragraph (f)(4)(iv). D. In paragraph (g)(1)(i), revising the reference “paragraphs (g)(1)(ii) and (g)(1)(iii)” to read “paragraphs (g)(1)(ii) through (g)(1)(iv)”. E. Revising the introductory text of paragraph (g)(4). F. Revising paragraph (g)(4)(iv). G. Revising the introductory text of paragraph (g)(5). H. Adding a new paragraph (g)(5)(vii). I. Revising paragraphs (g)(6)(i)(D) and (g)(6)(i)(E). J. Revising paragraph (g)(7). K. Revising the introductory text of paragraph(g)(12). L. Revising paragraph (g)(12)(i). M. Revising paragraph (g)(12)(ii), introductory text. N. Revising paragraph (g)(12)(ii)(A). O. Revising paragraph (g)(12)(ii)(B)( *1* )( *i* ). P. Revising paragraph (g)(12)(iii). Q. Revising paragraph (g)(12)(iv), introductory text. R. Revising paragraph (g)(12)(iv)(A). S. Revising paragraph (g)(12)(iv)(B)( *1* ). T. Redesignating paragraphs
(i)and
(j)as paragraphs
(j)and (k), respectively, and adding a new paragraph (i). The additions and revisions read as follows: § 413.86 Direct graduate medical education payments.
(b)*Definitions* . * * * *Community support* means funding that is provided by the community and generally includes all non-Medicare sources of funding (other than payments made for furnishing services to individual patients), including State and local government appropriations. Community support does not include grants, gifts, and endowments of the kind that are not to be offset in accordance with section 1134 of the Act. *Medicare GME affiliated group* means—
(1)Two or more hospitals that are located in the same urban or rural area (as those terms are defined in § 412.62(f) of this subchapter) or in a contiguous area and meet the rotation requirements in paragraph (g)(7)(ii) of this section.
(2)Two or more hospitals that are not located in the same or in a contiguous urban or rural area, but meet the rotation requirement in paragraph (g)(7)(ii) of this section, and are jointly listed—
(i)As the sponsor, primary clinical site or major participating institution for one or more programs as these terms are used in the most current publication of the *Graduate Medical Education Directory;* or
(ii)As the sponsor or is listed under “affiliations and outside rotations” for one or more programs in operation in *Opportunities, Directory of Osteopathic Postdoctoral Education Programs* .
(3)Two or more hospitals that are under common ownership and, effective for all Medicare GME affiliation agreements beginning July 1, 2003, meet the rotation requirement in paragraph (g)(7)(ii) of this section. *Medicare GME affiliation agreement* means a written, signed, and dated agreement by responsible representatives of each respective hospital in a Medicare GME affiliated group, as defined in this section, that specifies—
(1)The term of the Medicare GME affiliation agreement (which, at a minimum is one year), beginning on July 1 of a year;
(2)Each participating hospital's direct and indirect GME FTE caps in effect prior to the Medicare GME affiliation;
(3)The total adjustment to each hospital's FTE caps in each year that the Medicare GME 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;
(4)The adjustment to each participating hospital's FTE counts resulting from the FTE resident's (or residents') participation in a shared rotational arrangement at each hospital participating in the Medicare GME affiliated group for each year the Medicare GME affiliation agreement is in effect. This adjustment to each participating hospital's FTE count is also reflected in the total adjustment to each hospital's FTE caps (in accordance with paragraph
(3)of this definition); and
(5)The names of the participating hospitals and their Medicare provider members. *Redistribution of costs* means an attempt by a hospital to increase the amount it is allowed to receive from Medicare under this section by counting FTE residents that were in medical residency programs where the costs of the programs had previously been incurred by the educational institution.
(f)*Determining the total number of FTE residents* . Subject to the weighting factors in paragraphs
(g)and
(h)of this section, and subject to the provisions of paragraph
(i)of this section, the count of FTE residents is determined as follows:
(4)* * *
(iv)The hospital is subject to the principles of community support and redistribution of costs as specified in the provisions of paragraph
(i)of this section.
(g)*Determining the weighted number of FTE residents* .
(4)Subject to the provisions of paragraph
(i)of this section, for purposes of determining direct graduate medical education payment—
(iv)Hospitals that are part of the same Medicare GME 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.
(5)Subject to the provisions of paragraph
(i)of this section, for purposes of determining direct graduate medical education payment—
(vii)Subject to the provisions under paragraph (g)(12) of this section, effective for cost reporting periods beginning on or after April 1, 2000, FTE residents in a rural track program at an urban hospital are included in the urban hospital's rolling average calculation described in paragraph (g)(5) of this section.
(6)* * *
(i)* * *
(D)An urban hospital that qualifies for an adjustment to its FTE cap under paragraph (g)(6)(i) of this section is not permitted to be part of a Medicare GME affiliated group for purposes of establishing an aggregate FTE cap.
(E)A rural hospital that qualifies for an adjustment to its FTE cap under paragraph (g)(6)(i) of this section is permitted to be part of a Medicare GME affiliated group for purposes of establishing an aggregate FTE cap.
(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 a Medicare GME affiliated group (as defined under paragraph
(b)of this section). Under this provision—
(i)Each hospital in the Medicare GME affiliated group must submit the Medicare GME 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 Medicare GME affiliation agreement will be in effect.
(ii)Each hospital in the Medicare GME affiliated group must have a shared rotational arrangement, as defined in paragraph
(b)of this section, with at least one other hospital within the Medicare GME affiliated group, and all of the hospitals within the Medicare GME affiliated group must be connected by a series of such shared rotational arrangements.
(iii)During the shared rotational arrangements under an Medicare GME affiliation agreement, as defined in paragraph
(b)of this section, more than one of the hospitals in the Medicare GME affiliated group must count the proportionate amount of the time spent by the resident(s) in its FTE resident counts. No resident may be counted in the aggregate as more than one FTE.
(iv)The net effect of the adjustments (positive or negative) on the Medicare GME affiliated hospitals' aggregate FTE cap for each Medicare GME affiliation agreement must not exceed zero.
(v)If the Medicare GME affiliation agreement terminates for any reason, the FTE cap of each hospital in the Medicare GME 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.
(12)Subject to the provisions of
(i)of this section, an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those rural tracks, in addition to the residents subject to its FTE cap specified under paragraph (g)(4) of this section. An urban hospital with a rural track residency program may count residents in those rural tracks up to a rural track FTE limitation if the hospital complies with the conditions specified in paragraphs (g)(12)(i) through (g)(12)(vi) of this section.
(i)If an urban hospital rotates residents to a separately accredited rural track program at a rural hospital(s) for two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for more than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count for the time the rural track residents spend at the urban hospital. The urban hospital may include in its FTE count those residents in the rural track training at the urban hospital, not to exceed its rural track FTE limitation, determined as follows:
(A)For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents, subject to the rolling average at paragraph (g)(5)(vii) of this section, training in the rural track at the urban hospital.
(B)Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of the highest number of residents, in any program year, who during the third year of the rural track's existence are training in the rural track at the urban hospital or the rural hospital(s) and are designated at the beginning of their training to be rotated to the rural hospital(s) for at least two-thirds of the duration of the program for cost reporting periods beginning on or after April l, 2000 and before October 1, 2002, or for more than one-half of the duration of the program effective for cost reporting periods beginning on or after October 1, 2003, and the number of years those residents are training at the urban hospital.
(ii)If an urban hospital rotates residents to a separately accredited rural track program at a rural nonhospital site(s) for two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for more than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count, subject to the requirements under paragraph (f)(4) of this section. The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
(A)For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents, subject to the rolling average specified in paragraph (g)(5)(vii) of this section, training in the rural track at the urban hospital and the rural nonhospital site(s).
(B)* * * ( *1* ) * * * ( *i* ) The urban hospital and are designated at the beginning of their training to be rotated to a rural nonhospital site(s) for at least two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for more than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003; and
(iii)If an urban hospital rotates residents in the rural track program to a rural hospital(s) for less than two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for one-half or less than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the rural hospital may not include those residents in its FTE count (if the rural track is not a new program under paragraph (g)(6)(iii) of this section, or if the rural hospital's FTE count exceeds that hospital's FTE cap), nor may the urban hospital include those residents when calculating its rural track FTE limitation.
(iv)If an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for period of time is less than two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2000 and before October 1, 2003, or for one-half or less than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003, the urban hospital may include those residents in its FTE count, subject to the requirements under paragraph (f)(4) of this section. The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track limitation, determined as follows:
(A)For the first 3 years of the rural track's existence, the rural track FTE limitation for the urban hospital will be the actual number of FTE residents, subject to the rolling average specified in paragraph (g)(5)(vii) of this section, training in the rural track at the rural nonhospital site(s).
(B)* * * ( *1* ) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the rural nonhospital site(s) or are designated at the beginning of their training to be rotated to the rural nonhospital site(s) for a period that is less than two-thirds of the duration of the program for cost reporting periods beginning on or after April 1, 2002, and before October 1, 2003, or for one-half or less than one-half of the duration of the program for cost reporting periods beginning on or after October 1, 2003; and
(i)*Application of community support and redistribution of costs in determining FTE resident counts* .
(1)For purposes of determining direct graduate medical education payments, the following principles apply:
(i)*Community support* . If the community has undertaken to bear the costs of medical education through community support, the costs are not considered graduate medical education costs to the hospital for purposes of Medicare payment.
(ii)*Redistribution of costs* . The costs of training residents that constitute a redistribution of costs from an educational institution to the hospital are not considered graduate medical education costs to the hospital for purposes of Medicare payment.
(2)*Application* . A hospital must continuously incur the costs of direct graduate medical education of residents training in a particular program at a training site since the date the residents first began training in that program in order for the hospital to count the FTE residents in accordance with the provisions of paragraphs
(f)and (g)(4) through (g)(6) and (g)(12) of this section. (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance) Dated: April 22, 2003. Thomas A. Scully, Administrator, Centers for Medicare & Medicaid Services Dated: May 8, 2003. 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, 2003 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2003 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 IPPS. For discharges occurring on or after October 1, 2003, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the IPPS will be based on 100 percent of the Federal national rate, which will be based on the national adjusted standardized amount. This amount reflects the national average hospital costs per case from a base year, updated for inflation. SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: The Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of the Act, MDHs 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. MDHs do not have the option to use their FY 1996 hospital-specific rate. For hospitals in Puerto Rico, the payment per discharge is based on the sum of 50 percent of a Puerto Rico rate reflecting base year average costs per case of Puerto Rico hospitals and 50 percent of a blended Federal national rate (a discharge-weighted average of the national large urban and other areas standardized amounts). ( *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 2004. The changes, to be applied prospectively effective with discharges occurring on or after October 1, 2003, 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 2004. Section IV. of this Addendum sets forth our proposed changes for determining the rate-of-increase limits for hospitals excluded from the IPPS for FY 2004. Section V. of this Addendum sets forth policies on payment for blood clotting factor administered to hemophilia patients. The tables to which we refer in the preamble to this proposed rule are presented in section VI. of this Addendum. II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2004 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 VI. of this Addendum reflect— • Updates of 3.5 percent for all areas (that is, the full market basket percentage increase of 3.5 percent); • An adjustment to ensure the proposed DRG recalibration and wage index update and changes, as well as the add-on payments for new technology, 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 2003 budget neutrality factor and applying a revised factor; • An adjustment to apply the new outlier offset by removing the FY 2003 outlier offsets and applying a new offset. A. Calculation of Adjusted Standardized Amounts 1. Standardization of Base-Year Costs or Target Amounts The national standardized amounts are based on per discharge averages of adjusted hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The preamble to the September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043, 33066) contains a detailed explanation of how the target amounts were determined and how they are used in computing the Puerto Rico rates. Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low-income patients. Under sections 1886(d)(2)(H) and (d)(3)(E) of the Act, in making payments under the IPPS, the Secretary estimates from time to time the proportion of costs that are wages and wage-related costs. Based on the estimated labor-related share, the standardized amounts are divided into labor-related and nonlabor-related amounts. As discussed in section IV. of the preamble to the August 1, 2002 IPPS final rule, when we revised the market basket in FY 2003, we did not revise the labor share of the standardized amount (the proportion adjusted by the wage index). We consider 71.1 percent of costs to be labor-related for purposes of the IPPS. The average labor share in Puerto Rico is 71.3 percent. 2. Computing Large Urban and Other Area Average Standardized Amounts 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. In accordance with section 1886(b)(3)(B)(i) of the Act, the large urban average standardized amount is 1.6 percent higher than the other area average standardized amount. Section 402(b) of Pub. L. 108-7 required that, effective for discharges occurring on or after April 1, 2003, and before October 1, 2003, the Federal rate for all IPPS hospitals would be based on the large urban standardized amount. However, for discharges occurring on or after October 1, 2003, the Federal rate will again be calculated based on separate average standardized amounts for hospitals in large urban areas and for hospitals in other areas. 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 Pub. L. 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 2004. These areas are identified in Table 4A of section VI. of this Addendum. 3. Updating the Average Standardized Amounts 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 2004 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XIX) of the Act. 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 2004 is 3.5 percent. Thus, for FY 2004, the update to the average standardized amounts equals 3.5 percent for hospitals in all areas. Although the update factors for FY 2004 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 2004 for both IPPS hospitals and hospitals excluded from the IPPS. 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 B of this proposed rule. 4. Other Adjustments to the Average Standardized Amounts As in the past, we are proposing to adjust the FY 2004 standardized amounts to remove the effects of the FY 2003 geographic reclassifications and outlier payments before applying the FY 2004 updates. We then apply the new offsets to the standardized amounts for outliers and geographic reclassifications for FY 2004. We do not remove the prior years' budget neutrality adjustment because, in accordance with section 1886(d)(4)(C)(iii) of the Act, estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition. Budget neutrality is determined by comparing aggregate IPPS payments before and after making the changes that are required to be budget neutral (for example, reclassifying and recalibrating the DRGs, updating the wage data, and geographic reclassifications). We include outlier payments in the payment simulations because outliers may be affected by changes in these payment parameters. Because the proposed changes to the postacute care transfer policy discussed in section IV.A. of this preamble are not budget neutral, we included the effects of expanding this policy to additional DRGs prior to estimating the payment effects of the DRG and wage data changes. 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. Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is 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 Pub. L. 105-33 to be budget neutral. Therefore, we include the effects of this provision in our calculation of the wage update budget neutrality factor. In addition, we are required to ensure that any add-on payments for new technology under section 1886(d)(5)(K) of the Act are budget neutral. As discussed in section II.E. of this proposed rule, we are proposing to approve one new technology for add-on payments in FY 2004. We estimate that the proposed total add-on payments for this new technology would be $50 million for FY 2004. To comply with the requirement that DRG reclassification and recalibration of the relative weights be budget neutral, and the requirement that the updated wage index be budget neutral, we used FY 2002 discharge data to simulate payments and compared aggregate payments using the FY 2003 relative weights, wage index, and new technology add-on payments to aggregate payments using the proposed FY 2004 relative weights and wage index, plus the proposed additional add-on payments for new technology. The same methodology was used for the FY 2003 budget neutrality adjustment. Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 1.003133. We also adjust the Puerto Rico-specific standardized amounts for the effect of DRG reclassification and recalibration. We computed a proposed budget neutrality adjustment factor for Puerto Rico-specific standardized amounts equal to 1.000627. These budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 2003 budget neutrality adjustments. 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, 2003. (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 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 IPPS after implementation of the provisions of sections 1886(d)(8)(B) and
(C)and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. To calculate this budget neutrality factor, we used FY 2002 discharge data to simulate payments, and compared total IPPS payments prior to any reclassifications to total IPPS payments after reclassifications. Based on these simulations, we are proposing to apply an adjustment factor of 0.991848 to ensure that the effects of reclassification are budget neutral. The proposed adjustment factor is applied to the standardized amounts after removing the effects of the FY 2003 budget neutrality adjustment factor. We note that the proposed FY 2004 adjustment reflects proposed FY 2004 wage index and standardized amount reclassifications approved by the MGCRB or the Administrator as of February 28, 2003, and the effects of section 1886(d)(10)(D)(v) of the Act 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 2004 or from a hospital's request for the withdrawal of a reclassification for FY 2004 will be reflected in the final budget neutrality adjustment required under section 1886(d)(8)(D) of the Act and published in the IPPS final rule for FY 2004. c. Outliers. Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments, for “outlier” cases, that is, cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for outlier payment). To determine whether the costs of a case exceed the fixed-loss 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 the average standardized amounts by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce the average standardized amounts applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. i. FY 2004 outlier fixed-loss cost threshold. In the August 1, 2002 IPPS final rule (67 FR 50124), we established a threshold for FY 2003 that was equal to the prospective payment rate for the DRG, plus any IME and DSH payments and any additional payments for new technology, plus $33,560. The marginal cost factor (the percent of costs paid after costs for the case exceed the threshold) was 80 percent. In the March 5, 2003 **Federal Register** (67 FR 10420), we published proposed changes to our outlier policy. We noted recent analyses indicate that some hospitals have taken advantage of our existing outlier payment methodology to maximize their outlier payments. Therefore, we proposed three central changes to our outlier policy in the March 5, 2003 proposed rule. The first of the proposed changes was that fiscal intermediaries would use more up-to-date data when determining the cost-to-charge ratio for each hospital. Currently, fiscal intermediaries use the hospital's most recent settled cost report. We proposed to revise our regulations to specify that fiscal intermediaries would use either the most recent settled or the most recent tentative settled cost report, whichever is from the latest reporting period. The second proposed change was to remove the current requirement in our regulations specifying that a fiscal intermediary will assign a hospital the statewide average cost-to-charge ratio when the hospital has a cost-to-charge ratio that falls below established thresholds (3 standard deviations below the national geometric mean cost-to-charge ratio). We proposed that hospitals would receive their actual cost-to-charge ratios no matter how low their ratios actually fall. The third proposal was to add a provision to our regulations to provide that the outlier payments for some hospitals may become subject to reconciliation when the hospitals' cost reports are settled. In addition, outlier payments would be subject to an adjustment to account for the time value of any outlier overpayments or underpayments that are ultimately reconciled. However, as of the time this FY 2004 proposed rule was prepared, these proposed changes to the outlier policy had not been finalized. Therefore, the proposed changes have not been factored into the calculation of the proposed FY 2004 fixed-loss threshold. If these changes are made final prior to (or as part of) the publication of the final FY 2004 fixed-loss threshold, they will be reflected in the analysis used to establish the final FY 2004 threshold. To calculate the proposed FY 2004 outlier thresholds, we simulated payments by applying proposed FY 2004 rates and policies using cases from the FY 2002 MedPAR file. Therefore, in order to determine the appropriate proposed FY 2003 threshold, it was necessary to inflate the charges on the MedPAR claims by 2 years, from FY 2002 to FY 2004. As discussed in the August 1, 2002 IPPS final rule (67 FR 50124), 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, as had been done in prior years, we used a 2-year average annual rate of change in charges per case to calculate the FY 2003 outlier threshold. We are proposing to continue to use a 2-year average annual rate of change in charges per case to establish the proposed FY 2004 threshold. The 2-year average annual rate of change in charges per case from FY 2000 to FY 2001, and from FY 2001 to FY 2002, was 12.8083 percent annually, or 27.3 percent over 2 years. Using the methodology above for setting the charge inflation factors for FY 2004, 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 $50,645. This single threshold would be applicable to qualify for both operating and capital outlier payments. We also are proposing to maintain the marginal cost factor for cost outliers at 80 percent. Again, any final rule subsequent to the March 5, 2003 proposed rule that implements changes to the outlier payment methodology is likely to affect how we will calculate the final FY 2004 outlier threshold. Therefore, the final FY 2004 threshold is likely to be different from this proposed threshold, as a result of any changes subsequent to the March 5, 2003 proposed rule. For example, if we were to implement the proposal to no longer apply the statewide average cost-to-charge ratio when hospitals' actual ratios fall below the established threshold (see below), this change would impact our calculation of the threshold. ii. Other changes concerning 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 2004 would result in outlier payments equal to 5.1 percent of operating DRG payments and 5.5 percent of capital payments based on the Federal rate. In accordance with section 1886(d)(3)(B), we reduced the proposed FY 2004 standardized amounts by the same percentage to account for the projected proportion of payments paid to outliers. The proposed outlier adjustment factors to be applied to the standardized amounts for FY 2004 are as follows: Operating standardized amounts Capital federal rate National 0.948981 0.945484 Puerto Rico 0.981549 0.984490 We apply the outlier adjustment factors after removing the effects of the FY 2003 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. These costs are then combined and compared with the fixed-loss outlier threshold. Once again, although a final rule subsequent to the March 5, 2003 proposed rule on outliers may be published before (or as part of) the FY 2004 IPPS final rule, we are proposing changes for FY 2004 without taking the proposals contained in the March 5, 2003 proposed rule into account at this time. For those hospitals for which the fiscal intermediary computes operating cost-to-charge ratios lower than 0.194 or greater than 1.223, or capital cost-to-charge ratios lower than 0.012 or greater than 0.163, we are proposing statewide average ratios would be used to calculate costs to determine whether a hospital qualifies for outlier payments. 7 Table 8A in section VI. 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 proposed statewide average ratios would replace the ratios published in the August 1, 2002 IPPS final rule (67 FR 50263). Table 8B in section VI. of this Addendum contains the proposed comparable statewide average capital cost-to-charge ratios. Again, the cost-to-charge ratios in Tables 8A and 8B would be used during FY 2004 when hospital-specific cost-to-charge ratios based on the latest settled cost report are either not available or are outside the range noted above. 7 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 2002 and FY 2003 outlier payments. In the August 1, 2002 IPPS final rule (67 FR 50125), we stated that, based on available data, we estimated that actual FY 2002 outlier payments would be approximately 6.9 percent of actual total DRG payments. This estimate was computed based on simulations using the FY 2001 MedPAR file (discharge data for FY 2001 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2002 bills but instead reflected the application of FY 2002 rates and policies to available FY 2001 bills. Our current estimate, using available FY 2002 bills, is that actual outlier payments for FY 2002 were approximately 7.9 percent of actual total DRG payments. Thus, the data indicate that, for FY 2002, the percentage of actual outlier payments relative to actual total payments is higher than we projected before FY 2002 (and thus exceeds the percentage by which we reduced the standardized amounts for FY 2002). Nevertheless, consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2002 are equal to 5.1 percent of total DRG payments. We currently estimate that actual outlier payments for FY 2003 will be approximately 5.5 percent of actual total DRG payments, 0.4 percentage points higher than the 5.1 percent we projected in setting outlier policies for FY 2003. This estimate is based on simulations using the FY 2002 MedPAR file (discharge data for FY 2002 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2003 by applying FY 2003 rates and policies including an outlier threshold of $33,560 to available FY 2002 bills. If changes to the outlier payment methodology are made effective during FY 2003, these may affect the actual percentage of FY 2003 outlier payments. 5. FY 2004 Standardized Amounts The adjusted standardized amounts are divided into labor and nonlabor portions. Table 1A in section VI. of this Addendum contains the two national standardized amounts that we are proposing will be applicable to all hospitals, except hospitals in Puerto Rico. As described in section II.A.1. of this Addendum, we are not proposing to revise the labor share of the national standardized amount from 71.1 percent. The following table illustrates the proposed changes from the FY 2003 national average standardized amounts. The first row in the table shows the updated (through FY 2003) average standardized amounts after restoring the FY 2003 offsets for outlier payments and geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2003 factor is not removed from the amounts in the table. Large urban Other Areas FY 2003 Base Rate (after removing reclassification budget neutrality and outlier offset) Labor $3,212.32 Nonlabor 1,276.01 Labor $3,161.41) Nonlabor 1,285.01 Proposed FY 2004 Update Factor 1.035 1.035 Proposed FY 2004 DRG Recalibrations and Wage Index Budget Neutrality Factor 1.003133 1.003133 Proposed FY 2004 Reclassification Budget Neutrality Factor 0.991848 0.991848 Proposed FY 2004 Outlier Factor 0.948997 0.948997 Proposed Rate for FY 2004 (after multiplying FY 2003 base rate by above factors) Labor $3,139.26 Nonlabor 1,276.01 Labor $3,089.56 Nonlabor 1,255.81 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 of section VI. of this Addendum. 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 section VI. of this Addendum, contain the labor-related and nonlabor-related shares that we are proposing to use to calculate the prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico. 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 2004 wage index. The proposed FY 2004 wage index is set forth in Tables 4A, 4B, 4C, and 4F of section VI. of this Addendum. 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 2004, 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, 2003, we will publish them in the final rule and use them in determining FY 2004 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 VI. of this Addendum contains the relative weights that we are proposing to use for discharges occurring in FY 2004. These factors have been recalibrated as explained in section II. of the preamble. D. Calculation of Proposed Prospective Payment Rates for FY 2004 General Formula for Calculation of Proposed Prospective Payment Rates for FY 2004 The proposed operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, equals the Federal rate based on the proposed amounts in Table 1A in section VI. of this Addendum. The proposed prospective payment rate for SCHs equals the higher of the proposed applicable Federal rate from Table 1A or the hospital-specific rate as described below. The proposed prospective payment rate for MDHs equals the higher of the Federal rate, or the Federal rate plus 50 percent of the difference between the Federal rate and the hospital-specific rate as described below. The proposed prospective payment rate for Puerto Rico equals 50 percent of the Puerto Rico rate plus 50 percent of the proposed national rate from Table 1C in section VI. of this Addendum. 1. Federal Rate For discharges occurring on or after October 1, 2003 and before October 1, 2004, except for SCHs, MDHs, and hospitals in Puerto Rico, payment under the IPPS is based exclusively on the Federal rate. The Federal rate is determined as follows: Step 1—Select the appropriate average standardized amount considering the location of the hospital (large urban or other) (see Table 1A in section VI. 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 VI. 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 VI. of this Addendum). The Federal rate as determined in Step 5 may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. 2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs) a. Calculation of Hospital-Specific Rate. Section 1886(b)(3)(C) of the Act provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. 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 rates based on either FY 1982 or FY 1987 costs per discharge. MDHs do not have the option to use their FY 1996 hospital-specific rate. Hospital-specific rates have been determined for each of these hospitals based on either the FY 1982 costs per discharge, the FY 1987 costs per discharge or, for SCHs, the FY 1996 costs 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 proposed budget neutrality adjustment factor (that is, by 1.003133) as discussed in section II.A.4.a. of this Addendum. The resulting rate would be used in determining the payment rate an SCH or MDH would receive for its discharges beginning on or after October 1, 2003. b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2004. We are proposing to increase the hospital-specific rates by 3.5 percent (the hospital market basket percentage) for SCHs and MDHs for FY 2004. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2004, is the market basket rate of increase. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs also equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2004, is the market basket rate. 3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2003 and Before October 1, 2004 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 VI. 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 VI. 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 VI. 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 VI. 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. This rate may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2004 The PPS for acute care hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period 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 PPS 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 2004, which would be effective for discharges occurring on or after October 1, 2003. The 10-year transition period ended with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002). Therefore, for cost reporting periods beginning in FY 2002, all hospitals (except “new” hospitals under §§ 412.304(c)(2) and 412.324(b)) are paid based on 100 percent of the capital Federal rate. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the standard Federal rate, as provided in § 412.308(c)(1), to account for capital input price increases and other factors. Section 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) exception under § 412.348. Section 412.308(c)(4)(ii) requires that the standard 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 FY 1998, 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 discussed in the August 1, 2002 IPPS final rule (67 FR 50102) and implemented in § 412.308(b)(6)), a small part of that reduction was restored effective October 1, 2002. To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs, that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors during the transition period. As we explained in the August 1, 2001 IPPS final rule (66 FR 39911), beginning in FY 2003, an adjustment for regular exception payments is no longer necessary because regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991, and before October 1, 2001 (see § 412.348(b)). Since payments are no longer being made under the regular exception policy in FY 2003 and after, we no longer use the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the August 1, 2001 IPPS final rule (66 FR 40099). In accordance with section 1886(d)(9)(A) of the Act, under the IPPS for acute care hospital operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended 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 PPS 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 Proposed Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update In the final IPPS rule published in the **Federal Register** on August 1, 2002 (67 FR 50127), we established a Federal rate of $407.01 for FY 2003. Section 402(b) of Public Law 108-7 requires that, effective for discharges occurring on or after April 1, 2003, and before October 1, 2003, the Federal rate for operating costs for all IPPS hospitals would be based on the large urban standardized amount. However, for discharges occurring on or after October 1, 2003, the Federal rate will again be calculated based on separate average standardized amounts for hospitals in large urban areas and for hospitals in other areas. In addition, a correction notice to the FY 2003 final IPPS rule issued in the **Federal Register** on April 25, 2003 (68 FR 22272) contains corrections and revisions to the wage index and geographic adjustment factor (GAF). In conjunction with the change to the operating PPS standardized amounts made by Public Law 108-7 and the wage index and GAF corrections, we have established a capital PPS standard Federal rate of $406.93 effective for discharges occurring on or after April 1, 2003 through September 30, 2003. The rates effective for discharges occurring on or after April 1, 2003 through September 30, 2003, were used in determining the proposed FY 2004 rates. As a result of the changes that we are proposing to the factors used to establish the Federal rate that are explained in this Addendum, the proposed FY 2004 capital standard Federal rate is $411.72. In the discussion that follows, we explain the factors that were used to determine the proposed FY 2004 capital Federal rate. In particular, we explain why the proposed FY 2004 Federal rate has increased 1.18 percent compared to the FY 2003 Federal rate (effective for discharges occurring on or after April 1, 2003 through September 30, 2003). We also estimate aggregate capital payments will increase by 2.5 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 less than last year (5.81 percent), mostly due to the restoration of the 2.1 percent reduction to the capital Federal rate in FY 2003 (§ 412.308(b)(6)). Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital PPS are estimated to increase in FY 2004 compared to FY 2003. 1. Proposed 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 several other policy adjustment factors. Specifically, we have adjusted the projected CIPI rate of increase as appropriate each year for case-mix index-related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 2004 under that framework is 0.7 percent, based on data available at this time. This proposed update factor is based on a projected 0.7 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a 0.0 percent adjustment for the FY 2002 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. We explain the basis for the FY 2004 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 IPPS. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments. The case-mix index can change for any of several reasons: • The average resource use of Medicare patients changes (“real” case-mix change); • Changes in hospital coding of patient records result in higher weight DRG assignments ( coding effects ); and • The annual DRG reclassification and recalibration changes may not be budget neutral (“reclassification effect”). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. In the update framework for the PPS 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 year 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 2002 DRG reclassification and recalibration as part of our update for FY 2004.) We have adopted this case-mix index adjustment in the capital update framework as well. For FY 2004, 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 2004. Therefore, the net adjustment for case-mix change in FY 2004 is 0.0 percentage points. We estimate that FY 2002 DRG reclassification and recalibration will result in a 0.0 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 0.0 percent adjustment for DRG reclassification and recalibration in the update for FY 2004 to maintain budget neutrality. 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 0.2 percentage points was calculated for the FY 2002 update. That is, current historical data indicate that the forecasted FY 2002 CIPI used in calculating the FY 2002 update factor (0.7 percent) overstated the actual realized price increases (0.5 percent) by 0.2 percentage points. This slight overprediction was mostly due to an underestimation of the interest rate cuts by the Federal Reserve Board in 2002, which impacted the interest component of the CIPI. However, since this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are making a 0.0 percent adjustment for forecast error in the update for FY 2004. Under the capital PPS system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that are used in the framework for the operating PPS. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, for changes in within-DRG severity, and for expected modification of practice patterns to remove noncost-effective services. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor, that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one-half of the estimated annual increase in intensity, to allow for within-DRG severity increases and the adoption of quality-enhancing technology. As we discussed in the May 9, 2002 proposed rule (67 FR 51514), we have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (“Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988” by G. M. Carter, J. P. Newhouse, and D. A. Relles, R-4098-HCFA/ProPAC (1991)) suggest that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.4 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. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with § 412.308(c)(1)(ii), we began updating the standard Federal capital rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2001 and 2002, we found that case-mix constant intensity was increasing and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. Using the methodology described above, for FY 2004 we examined 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 for FYs 1998 though 2002. We found that, over this period and in particular the last 3 years of this period (FYs 2000 through 2002), the charge data appear to be skewed. More specifically, we found a dramatic increase in hospital charges for FYs 2000 through 2002 without a corresponding increase in hospital case-mix index. If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals' case-mix to increase proportionally. The timing of this increase in charge growth is consistent with the dramatic increase in charges that we discussed in the March 5, 2003 high-cost outlier proposed rule (68 FR 10420 through 14029). As we discussed in that proposed rule, because hospitals have the ability to increase their outlier payments through dramatic charge increases, we proposed several changes in our high-cost outlier policy at §§ 412.84(i) and
(m)in order to prevent hospitals from taking advantage of our current outlier policy. As discussed above, because our intensity calculation relies heavily upon charge data and we believe that this charge data may be inappropriately skewed, we are proposing a 0.0 percent adjustment for intensity in FY 2004. In past FYs (1996 through 2000) when we found intensity to be declining, we believed a zero (rather then negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to propose a zero intensity adjustment for FY 2004 until we believe that any increase in charges can be tied to intensity rather then to attempts to maximize outlier payments. Above we described the basis of the components used to develop the proposed 0.7 percent capital update factor for FY 2004 as shown in the table below. CMS's Proposed FY 2004 Update Factor to the Capital Federal Rate Capital Input Price Index 0.7 Intensity 0.0 Case-Mix Adjustment Factors: Projected Case-Mix Change −1.0 Real Across DRG Change 1.0 Subtotal 0.0 Effect of FY 2002 Reclassification and Recalibration 0.0 Forecast Error Correction 0.0 Total Proposed Update 0.7 b. Comparison of CMS and MedPAC Update Recommendation. In the past, MedPAC has included update recommendations for capital PPS in a Report to Congress. In its March 2003 Report to Congress, MedPAC did not make an update recommendation for capital PPS payments. However, in that same report, MedPAC made an update recommendation for hospital inpatient and outpatient services (page 4). MedPAC stated that hospital inpatient and outpatient services should be considered together because they are so closely interrelated. Their recommendation is based on an assessment of whether payments are adequate to cover the costs of efficient providers, an estimate of input price inflation (measured by the market basket index), and an adjustment for technological charges, which is offset by reasonable expectations in productivity gains. 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 PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments. In the August 1, 2002 IPPS final rule (67 FR 50129), we estimated that outlier payments for capital in FY 2003 would equal 5.31 percent of inpatient capital-related payments based on the FY 2003 Federal rate. Accordingly, we applied an outlier adjustment factor of 0.9469 to the FY 2003 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 would equal 5.45 percent of inpatient capital-related payments based on the Federal rate in FY 2004. Therefore, we are proposing an outlier adjustment factor of 0.9455 to the Federal rate. Thus, the projected percentage of capital outlier payments to total capital standard payments for FY 2004 is higher than the percentage for FY 2003. 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 2004 is 0.9985 (0.9455/0.9469). The outlier adjustment decreases the proposed FY 2004 Federal rate by 0.15 percent compared with the FY 2003 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 IPPS 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 exception payment adjustment factor. As we explain in section III.A.4. of this Addendum, beginning in FY 2003 an adjustment for regular exception payments is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments. To determine the proposed factors for FY 2004, we compared (separately for the national rate and the Puerto Rico rate) estimated aggregate Federal rate payments based on the FY 2003 DRG relative weights and the FY 2003 GAF to estimated aggregate Federal rate payments based on the proposed FY 2004 relative weights and the proposed FY 2004 GAF. In the August 1, 2002 IPPS final rule (67 FR 50129) for FY 2003, the budget neutrality adjustment factors were 0.9885 for the national rate and 0.9963 for the Puerto Rico rate. As a result of the revisions to the GAF effective for discharges occurring on or after April 1, 2003 through September 30, 2003, the budget neutrality adjustment factor is 0.9983 for the national rate for discharges occurring on or before April 1, 2003 through September 30, 2003. The budget neutrality adjustment factor for the Puerto Rico rate remained unchanged (0.9963). As we noted above, the rates effective for discharges occurring on or after April 1, 2003 through September 30, 2003 were used in determining the proposed FY 2004 rates. 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, based on calculations using updated data, we are proposing to apply an incremental budget neutrality adjustment of 1.0034 for FY 2004 to the previous cumulative FY 2003 adjustment (0.9883), yielding a proposed cumulative adjustment of 0.9929 through FY 2004. For the Puerto Rico GAF, we are proposing to apply an incremental budget neutrality adjustment of 1.0002 for FY 2004 to the previous cumulative FY 2003 adjustment (0.9963), yielding a proposed cumulative adjustment of 0.9964 through FY 2004. (This is the rounded result of a calculation performed on unrounded numbers.) We then compared estimated aggregate Federal rate payments based on the FY 2003 DRG relative weights and the FY 2003 GAF to estimated aggregate Federal rate payments based on the proposed FY 2004 DRG relative weights and the proposed FY 2004 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 1.0004 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for changes in the GAF through FY 2004 are 0.9920 nationally and 0.9968 for Puerto Rico (this is the rounded result of a calculation performed with unrounded numbers). 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 0.99782 1.00009 0.99791 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 0.99915 0.99662 0.99577 0.98848 1.00809 0.99662 1.00468 0.99628 2003 6 7 0.99896 7 0.99662 7 0.99558 0.98830 7 1.00809 7 0.99662 7 1.00468 0.99628 2004 8 1.00341 8 1.00036 8 1.00376 0.99202 8 1.00015 8 1.00036 8 1.00051 0.99679 1 Factors effective for the first half of FY 2001 (October 2000 through March 2001). 2 Factors effective for the second half of FY 2001 (April 2001 through September 2001). 3 Incremental factors are applied to FY 2000 cumulative factors. 4 Incremental factors are applied to the cumulative factors for the first half of FY 2001. 5 Factors effective for the first half of FY 2003 (October 2002 through March 2003). 6 Factors effective for the second half of FY 2003 (April 2003 through September 2003). 7 Incremental factors are applied to FY 2002 cumulative factors. 8 Incremental factors are applied to the cumulative factors for the second half of FY 2003. The methodology used to determine the proposed recalibration and geographic (DRG/GAF) budget neutrality adjustment factor for FY 2004 is similar to that used in establishing budget neutrality adjustments under the PPS for operating costs. One difference is that, under the operating PPS, the budget neutrality adjustments for the effect of geographic reclassifications are determined separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital PPS, there is a single DRG/GAF budget neutrality adjustment factor (the national 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. In the August 1, 2002 IPPS final rule (67 FR 50129), we calculated a GAF/DRG budget neutrality factor of 0.9957 for FY 2003. As we noted above, as a result of the revisions to the GAF effective for discharges occurring on or after April 1, 2003 through September 30, 2003, we calculated a GAF/DRG budget neutrality factor of 0.9956 for discharges occurring on or after April 1, 2003 through September 30, 2003. Furthermore, the rates effective for discharges occurring on or after April 1, 2003 through September 30, 2003 were used in determining the proposed FY 2004 rates. For FY 2004, we are proposing a GAF/DRG budget neutrality factor of 1.00038. 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 2003 to FY 2004 is 1.00038. The proposed cumulative change in the rate due to this adjustment is 0.9920 (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, FY 2003, and the proposed incremental factor for FY 2004: 0.9980 × 1.0053 0.9998 × 0.9994 × 0.9987 × 0.9989 × 1.0028 × 0.9985 × 0.9979 × 0.9934 × 0.9956 × 1.00038 = 0.9920). 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 2004 geographic reclassification decisions made by the MGCRB compared to FY 2003 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 PPS payments. In estimating the proportion of regular exception payments to total capital PPS payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the August 1, 2001 IPPS final rule (66 FR 40099)) to determine the exceptions payment adjustment factor, which was applied to both the Federal and hospital-specific rates. An adjustment for regular exception payments is no longer necessary in determining the FY 2004 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 IPPS final rule (66 FR 39949), in FY 2003 and subsequent fiscal years, no payments will be made under the regular exceptions provision. However, in accordance with § 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under § 412.348(g). We describe our methodology for determining the special exceptions adjustment used in calculating the proposed FY 2004 capital Federal rate below. Under the special exceptions provision specified at § 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share percentage of at least 20.2 percent or qualify for DSH payments under § 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive special exceptions payments if it meets
(1)a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at § 412.348(g)(4);
(2)an age of assets test as described at § 412.348(g)(3); and
(3)a project size requirement as described at § 412.348(g)(5). As we explained in the August 1, 2001 IPPS 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 exceptions 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 subsequent fiscal years. 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 PPS. 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 2002. PPS year Cost reporting 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. XVII FY 2000. XVIII FY 2001. 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 2000). (Although some FY 2001 cost reports are available in HCRIS, only a few hospitals have submitted FY 2001 costs. Consequently, too few cost reports are available to reliably model FY 2001 special exceptions payments.) 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 exception provision 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 PPS payments and costs, and the cumulative operating margin offset (excluding 75 percent of operating DSH payments). Our modeling of special exception payments for FY 2004 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 1 PPS XII 4 PPS XIII 5 PPS XIV 11 PPS XV 15 PPS XVI 24 0.0002 PPS XVII 27 0.0005 PPS XVIII N/A N/A We note that hospitals still have one more cost reporting period (PPS XVIII) to complete their projects in order to be eligible for special exceptions payments, and, therefore, we estimate that about 30 hospitals could qualify for special exceptions payments. Thus, we project that special exception payments as a fraction of capital payments to all hospitals to be approximately 0.0005. Because special exceptions are budget neutral, we are proposing to offset the Federal capital rate by 0.05 percent for special exceptions payments for FY 2004. Therefore, the proposed exceptions adjustment factor would equal 0.9995 (1 − 0.0005) to account for special exceptions payments in FY 2004. Furthermore, we are proposing to estimate the exceptions payment adjustment factor for special exceptions payments in FY 2004 in the final rule based on updated data. In the August 1, 2002 IPPS final rule (67 FR 50131) for FY 2003, we estimated that total (special) exceptions payments would equal 0.30 percent of aggregate payments based on the Federal rate. Therefore, we applied an exceptions reduction factor of 0.9970 (1 − 0.0030) in determining the FY 2003 Federal rate. As we stated, we estimate that exceptions payments in FY 2004 would equal 0.05 percent of aggregate payments based on the proposed FY 2004 Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9995 (1 − 0.0005) to the proposed Federal rate for FY 2004. The proposed exceptions adjustment factor for FY 2004 is 0.25 percent higher than the factor for FY 2003 published in the August 1, 2002 IPPS final rule (67 FR 50131). This increase is primarily due to a refined analysis of more recent data. 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 factor used in determining the proposed FY 2004 Federal rate is 0.9995/0.9970, or 1.0025. 5. Proposed Standard Capital Federal Rate for FY 2004 In the August 1, 2002 IPPS final rule (67 FR 50131) we established a capital Federal rate of $407.01 for FY 2003. As we noted above, as a result of the revisions to the GAF effective for discharges occurring on or after April 1, 2003 through September 30, 2003, we have established a capital Federal rate of $406.93 for discharges occurring on or after April 1, 2003 through September 30, 2003. The rates effective for discharges occurring on or after April 1, 2003 through September 30, 2003, were used in determining the proposed FY 2004 rates. In this proposed rule, we are proposing a capital Federal rate of $411.72 for FY 2004. The proposed Federal rate for FY 2004 was calculated as follows: • The proposed FY 2004 update factor is 1.0070; that is, the update is 0.70 percent. • The proposed FY 2004 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 1.0038. • The proposed FY 2004 outlier adjustment factor is 0.9455. • The proposed FY 2004 (special) exceptions payment adjustment factor is 0.9995. Since the proposed 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 2004 affected the computation of the proposed FY 2004 Federal rate in comparison to the FY 2003 Federal rate. The proposed FY 2004 update factor has the effect of increasing the Federal rate by 0.70 percent compared to the FY 2003 Federal rate, while the proposed GAF/DRG budget neutrality factor has the effect of increasing the Federal rate by 0.38 percent. The proposed FY 2004 outlier adjustment factor has the effect of decreasing the Federal rate by 0.15 percent compared to the FY 2003 Federal rate. The proposed FY 2004 exceptions payment adjustment factor has the effect of increasing the Federal rate by 0.25 percent compared to the exceptions payment adjustment factor for FY 2003. The combined effect of all the proposed changes is to increase the Federal rate by 1.18 percent compared to the FY 2003 Federal rate. Comparison of Factors and Adjustments: FY 2003 Federal Rate and Proposed FY 2004 Federal Rate FY 2003 Proposed FY 2004 Change Percent change Update factor 1 1.0110 1.0070 1.0070 0.70 GAF/DRG Adjustment Factor 1 0.9957 1.0038 1.0038 0.38 Outlier Adjustment Factor 2 0.9469 0.9455 0.9985 −0.15 Exceptions Adjustment Factor 2 0.9970 0.9995 1.0025 0.25 Federal Rate $406.93 $411.72 1.0118 1.18 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 2003 to FY 2004 resulting from the application of the proposed 1.0038 GAF/DRG budget neutrality factor for FY 2004 is 1.0038. 2 The outlier reduction factor and the exceptions adjustment 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 proposed FY 2004 outlier adjustment factor is 0.9455/0.9469, or 0.9985. 6. 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 PPS (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 PPS 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 1.0002, while the proposed DRG adjustment is 1.0004, for a proposed combined cumulative adjustment of 0.9968. 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. In FY 2003, a small part of that reduction was restored. For FY 2003, before application of the GAF, the special rate for Puerto Rico hospitals was $198.29. With the changes we are proposing to the factors used to determine the rate, the proposed FY 2004 special rate for Puerto Rico is $201.26. B. Calculation of Inpatient Capital-Related Prospective Payments for FY 2004 With the end of the capital PPS transition period in FY 2001, all hospitals (except “new” hospitals under § 412.324(b) and under § 412.304(c)(2)) are paid based on 100 percent of the Federal rate in FY 2004. 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 2004, 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 proposed outlier thresholds for FY 2004 are in section II.A.4.c. of this Addendum. For FY 2004, 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 $50,645. An eligible hospital may also qualify for a special exceptions payment under § 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets:
(1)A project need requirement described at § 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at § 412.348(g)(4); and
(2)a project size requirement as described at § 412.348(g)(5). Eligible hospitals include 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 PPS to the cumulative minimum payment level. This amount is offset by:
(1)Any amount by which a hospital's cumulative capital payments exceed its cumulative minimum payment levels applicable under the regular exceptions process for cost reporting periods beginning during which the hospital has been subject to the capital PPS; and
(2)any amount by which a hospital's current year operating and capital payments (excluding 75 percent of operating DSH payments) exceed its operating and capital costs. Under § 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals. During the transition period, new hospitals (as defined under § 412.300) were exempt from the capital PPS 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, under § 412.304(c)(2), for cost reporting periods beginning on or after October 1, 2002, we pay a new hospital 85 percent of their reasonable costs during the first 2 years of operation unless it elects to receive payment based on 100 percent of the Federal rate. Effective with the third year of operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS). C. Capital Input Price Index 1. Background Like the operating input price index, the capital input price index
(CIPI)is a fixed-weight price index that measures the price changes associated with 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 1997 in the August 1, 2002 final rule (67 FR 50044). 2. Forecast of the CIPI for Federal Fiscal Year 2004 We are forecasting the proposed CIPI to increase 0.7 percent for FY 2004. This reflects a projected 1.2 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.4 percent increase in other capital expense prices in FY 2004, partially offset by a 2.0 percent decline in vintage-weighted interest rates in FY 2004. 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 As discussed in section VI. of the preamble of this proposed rule, 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 existing psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals excluded from the IPPS are no longer subject to limits on a hospital-specific target amount (expressed in terms of the inpatient operating cost per discharge) that are set for each hospital, based on the hospital's own historical cost experience trended forward by the applicable rate-of-increase percentages (update factors). Effective for cost reporting periods beginning on or after October 1, 2002, rehabilitation hospitals and units are no longer paid on a reasonable cost basis but are paid under the IRF PPS. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs also are no longer paid on a reasonable cost basis but are paid under a DRG-based PPS. As part of the payment process for LTCHs, we established a 5-year transition period from reasonable cost-based reimbursement to a fully Federal PPS. However, a LTCH, subject to the blend methodology, may elect to be paid based on a 100 percent of the Federal prospective rate. In accordance with existing § 413.40(c)(4)(ii) and (d)(1)(i) and (ii), where applicable, excluded hospitals and units that continue to be paid on a reasonable cost basis will have payments based on their Medicare inpatient operating costs, not to exceed the ceiling (as defined in § 413.40(a)(3)). Section 1886(b)(7) of the Act had established a payment limitation for new hospitals and units excluded from the IPPS. While both rehabilitation hospitals and units and LTCHs are now paid under a PPS, psychiatric hospitals and units continue to be subject to the payment limitation. 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). The amount of payment for a “new” psychiatric hospital or unit would be determined as follows: • Under existing § 413.40(f)(2)(ii), for cost reporting periods beginning on or after October 1, 1997, the amount of payment for a new hospital or unit that was not paid as an excluded hospital or unit before October 1, 1997, is the lower of:
(1)The hospital's net inpatient operating costs per case; or
(2)110 percent of the national median of the target amounts for the same class of excluded hospitals and units, adjusted for differences in wage levels and updated to the first cost reporting period in which the hospital receives payment. The second cost reporting period is subject to the same target amount applied to the first cost reporting period. • In the case of a hospital that received payments under § 413.40(f)(2)(ii) as a newly created hospital or unit, to determine the hospital's or unit's target amount for the hospital's or unit's third 12-month cost reporting period, the payment amount determined under § 413.40(f)(2)(ii)(A) for the preceding cost reporting period is updated to the third cost reporting period. The proposed amounts included in the following table reflect the updated 110 percent of the national median target amounts of new excluded psychiatric hospitals and units for cost reporting periods beginning during FY 2004. These figures are updated with the most recent data available to reflect the projected market basket increase percentage of 3.5 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 CMS's Office of the Actuary based on its historical experience with the IPPS). For a new provider, the labor-related share of the target amount is multiplied by the appropriate geographic area wage index, without regard to IPPS 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 2004 proposed labor-related share FY 2004 proposed nonlabor-related share Psychiatric $7,301 $2,902 Effective for cost reporting periods beginning on or after October 1, 2002, this payment limitation is no longer applicable to new LTCHs since they will be paid 100 percent of the Federal rate. A new LTCH is a provider of inpatient hospital services that meets the qualifying criteria for LTCHs specified under § 412.23(e)(1) and (e)(2) and whose first cost reporting period as a LTCH begins on or after October 1, 2002 (§ 412.23(e)(4)). Under the LTCH PPS, new LTCHs are paid based on 100 percent of the fully Federal prospective rate (they may not participate in the 5-year transition from cost-based reimbursement to prospective payment). In contrast, those “new” LTCHs that meet the definition of “new” under § 413.40(f)(2)(ii) and that have their first cost reporting periods beginning on or after October 1, 1997, and before October 1, 2002, may be paid under the LTCH PPS transition methodology. Since those hospitals by definition would have been considered new before October 1, 2002, they would have been subject to the updated payment limitation on new hospitals that was published in the FY 2003 IPPS final rule (67 FR 50103). Under existing regulations at § 413.40(f)(2)(ii), the “new” hospital would be subject to the same cap in its second cost reporting period; this cap would not be updated for the new hospital's second cost reporting year. Thus, since the same cap is to be used for the “new” LTCH's first two cost reporting periods, it is no longer necessary to publish an updated cap. V. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients In December 2002, the Department implemented a policy that established the Single Drug Pricer
(SDP)to correct identified discrepancies, further the legislative goal of establishing a uniform payment allowance as a reflection of the average wholesale price (AWP), and otherwise apply the existing stature and regulation more accurately and efficiently (CMS Program Memorandum AB-02-174, December 3, 2002, which can be accessed at: *http:/www.cms.hhs.gov/manuals* ). Under the SDP, CMS will establish prices centrally, thereby resulting in greater consistency in drug pricing nationally. The SDP instruction applies to blood clotting factors furnished to hospital inpatients. The payment allowance for the single national drug price for each Medicare covered drug is based on 95 percent of the AWP, except for drugs billed to durable medical equipment regional carriers (DMERCs) and hospital outpatient drugs billed to fiscal intermediaries. We are publishing this notice here because we previously have addressed the add-on payment for the costs of administering blood clotting factor in the IPPS annual rule (see the August 1, 2000 IPPS final rule (65 FR 47116). On a quarterly basis, CMS will furnish three SDP files to all fiscal intermediaries. Each fiscal intermediary must accept the SDP files and process claims for any drug identified on the files on the basis of the price shown on the applicable file. Previously, the fiscal intermediary performed annual update calculations based on the most recent AWP data available to the carrier. The fiscal intermediary should use the SDP to price the blood clotting factors. VI. 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, 10, and 11 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 2002 (1998 Wage Data), 2003 (1999 Wage Data), and 2004 (2000 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 from the CC Exclusions List Table 7A—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V20.0 Table 7B—Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V21.0 Table 8A—Statewide Average Operating Cost-to-Charge Ratios for Urban and Rural Hospitals (Case Weighted) March 2003 Table 8B—Statewide Average Capital Cost-to-Charge Ratios (Case Weighted) March 2003 Table 9—Hospital Reclassifications and Redesignations by Individual Hospital—FY 2004 Table 10—Mean and Standard Deviations by Diagnosis-Related Groups (DRGs)—FY 2004 Table 11—Proposed LTC-DRGs Relative Weights and Geometric and Five-Sixths of the Average Length of Stay-FY 2004 Table 1A.—National Adjusted Operating Standardized Amounts, Labor/nonlabor Large urban areas Labor-related Nonlabor-related Other areas Labor-related Nonlabor-related $3,139.26 $1,276.01 $3,089.56 $1,255.81 Table 1C.—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/nonlabor Large urban areas Labor Nonlabor Other areas Labor Nonlabor National $3,112.84 $1,265.27 $3,112.84 $1,267.03 Puerto Rico 1,516.86 610.57 1,492.84 600.90 Table 1D.—Capital Standard Federal Payment Rate Rate National $411.72 Puerto Rico $201.26 * Denotes wage data not available for the provider for that year. ** Based on the sum of the salaries and hours computed for Federal FYs 2002, 2003, and 2004. Table 2.—Hospital Average Hourly Wage for Federal Fiscal Years 2002 (1998 Wage Data), 2003 (Wage Data), and 2004 (2000 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages Provider No. Average hourly wage FY 2002 Average hourly wage FY 2003 Average hourly wage FY 2004 Average hourly** wage (3 yrs) 010001 17.4467 17.9841 19.3989 18.2929 010004 19.0010 20.1613 19.9457 19.7003 010005 18.6554 19.9733 18.3970 19.0198 010006 17.6115 18.3931 19.0976 18.4162 010007 15.6788 16.0781 17.5462 16.4299 010008 17.4728 19.0182 19.6573 18.7416 010009 18.4979 19.7272 20.3130 19.5087 010010 16.4664 17.7348 18.5730 17.5867 010011 22.4292 24.8922 25.6737 24.2683 010012 15.8686 20.3376 20.0896 18.5710 010015 19.1178 19.8205 18.8890 19.2826 010016 20.2198 20.3175 21.7918 20.8284 010018 18.9388 19.5519 19.2071 19.2353 010019 17.0856 17.6414 18.6539 17.7694 010021 15.1241 25.3335 17.7595 18.4456 010022 17.6435 22.1250 22.2266 20.3667 010023 16.3209 18.4567 20.0397 18.1965 010024 15.9034 17.3746 18.5108 17.2202 010025 15.1548 17.4702 18.9839 17.1956 010027 16.8595 16.5157 14.0974 15.7259 010029 18.3605 19.3393 20.9608 19.6182 010031 18.6402 19.2612 21.0176 19.6504 010032 15.3590 16.3967 16.4712 16.0937 010033 21.2986 21.9828 24.5088 22.5487 010034 15.3639 14.9379 14.5106 14.9494 010035 15.9439 20.7808 21.6182 19.2869 010036 17.7166 18.7158 17.7766 18.0775 010038 19.6098 19.6887 18.5873 19.2586 010039 20.3406 21.3550 22.9241 21.5758 010040 20.0983 20.4486 20.7536 20.4392 010043 18.6640 17.3567 19.9012 18.6528 010044 24.0265 23.4575 25.8561 24.4502 010045 17.0417 18.7569 21.1167 18.8731 010046 18.9737 18.8741 19.7870 19.2388 010047 15.4190 13.4130 16.1695 14.9341 010049 15.5246 16.3349 16.2841 16.0555 010050 17.9830 20.3028 20.7398 19.6262 010051 11.8108 12.3280 14.2767 12.7951 010052 18.0653 19.8289 11.9019 15.6329 010053 15.5649 15.4156 17.3238 16.1023 010054 19.4955 20.9656 20.6203 20.3735 010055 18.8590 19.5667 19.8170 19.4298 010056 19.6577 20.5645 21.1104 20.4208 010058 16.9715 16.1265 17.7800 16.9302 010059 18.8020 19.1270 20.5534 19.4928 010061 14.5003 18.5320 16.9028 16.6415 010062 12.3259 16.9721 17.1786 15.3820 010064 19.5256 20.5650 21.7162 20.5136 010065 16.8752 17.0557 17.2698 17.0733 010066 13.1559 14.8904 14.8696 14.3351 010068 18.6925 23.4322 18.2092 20.2305 010069 14.7211 15.4497 16.9839 15.7052 010072 16.2339 16.5652 18.8807 17.1920 010073 14.1273 13.5594 14.9826 14.2068 010078 18.1363 18.5127 20.1447 18.9315 010079 17.0648 17.1612 20.7401 18.2252 010081 17.2996 * * 17.2996 010083 18.0312 18.4282 19.8525 18.7454 010084 18.7769 19.8773 21.6522 20.1274 010085 19.9023 21.5860 22.5282 21.3942 010086 16.5711 16.8886 18.0122 17.1417 010087 18.0567 18.7915 18.7253 18.4944 010089 17.7800 19.5241 19.5783 18.9652 010090 18.9445 19.5635 20.0287 19.5086 010091 17.0799 17.1775 17.4672 17.2432 010092 17.8144 18.5478 19.9289 18.7707 010095 12.2597 12.3064 12.5243 12.3676 010097 12.7286 14.2675 15.1593 14.0568 010098 14.0300 15.5763 15.1629 14.9158 010099 15.5619 15.9232 16.3307 15.9423 010100 17.9430 18.3755 19.8146 18.7658 010101 14.4625 18.9525 19.0718 17.2612 010102 13.8136 15.7777 16.4636 15.3148 010103 17.7242 22.0802 22.5709 20.6405 010104 16.8457 21.9457 20.9391 19.7211 010108 19.4617 19.1596 20.6337 19.7473 010109 14.6752 15.9627 18.2235 16.2157 010110 15.8283 15.5817 16.0015 15.8256 010112 16.8271 15.6041 17.9243 16.7545 010113 16.8936 18.2774 19.1978 18.1229 010114 17.0760 19.3772 20.1763 18.8237 010115 14.2261 15.3510 15.7873 15.0923 010118 17.0834 17.4620 19.4280 17.9013 010119 19.3942 19.5163 20.1990 19.7084 010120 18.2567 18.9975 19.4369 18.8719 010121 14.5262 15.2345 17.1640 15.7079 010123 19.2140 * * 19.2141 010124 16.7465 * * 16.7465 010125 16.0136 16.5117 16.8622 16.4618 010126 19.1065 19.5933 19.9845 19.5804 010127 18.2786 * * 18.2786 010128 14.4322 16.6899 14.7646 15.2637 010129 16.1733 16.7609 16.4904 16.4644 010130 19.5573 17.4614 18.7190 18.5367 010131 20.1883 19.0492 22.3132 20.5855 010134 19.9856 18.5179 16.8181 18.4871 010137 20.5828 21.3573 28.7410 23.1563 010138 14.5254 14.1369 14.2024 14.2898 010139 20.4331 20.5708 22.8390 21.2553 010143 17.6212 18.9084 20.6578 19.0594 010144 18.2040 18.8272 19.1497 18.7345 010145 20.5895 20.8157 21.7700 21.0799 010146 19.1415 18.3666 21.3384 19.6056 010148 15.8349 18.4591 17.6830 17.3825 010149 18.0156 19.0199 20.8645 19.3169 010150 18.9359 19.4819 21.1878 19.8964 010152 18.7677 19.8990 21.1438 19.9058 010155 15.0689 13.6136 * 14.4394 010157 * 17.7372 19.6977 18.7304 010158 18.3957 18.6052 18.5464 18.5206 010159 * 19.3950 * 19.3950 020001 28.0394 28.6530 30.1452 28.9867 020002 25.1987 28.2759 30.4165 27.8092 020004 25.4679 29.2351 27.3516 27.2833 020005 29.2378 35.0860 32.7936 32.3866 020006 28.1417 33.0843 31.2673 30.7745 020007 32.3852 27.7269 27.5708 28.8969 020008 30.8691 31.8878 33.4543 32.1364 020009 18.4660 18.5594 24.9415 20.3403 020010 22.7559 23.7275 20.7928 22.3051 020011 28.0658 27.5062 29.6249 28.3773 020012 25.5320 26.7586 27.9955 26.7886 020013 28.1557 29.5646 30.6424 29.4993 020014 24.5875 27.7870 29.6806 27.4656 020017 28.0572 28.8752 30.3017 29.1234 020024 25.3205 25.5933 28.0930 26.3977 020025 20.2583 29.4375 32.8655 26.7102 030001 21.7869 22.8996 25.7513 23.3305 030002 21.8375 23.1450 25.6038 23.5516 030003 22.6804 23.9849 22.1436 22.9249 030004 15.5478 13.8452 15.7742 15.0275 030006 20.0273 20.5019 23.0216 21.0706 030007 21.5169 22.2473 26.1551 23.4298 030008 22.2190 * * 22.2190 030009 18.7557 19.1258 19.9131 19.2261 030010 19.5123 19.8496 20.7204 20.0003 030011 19.4310 19.8141 21.0028 20.0690 030012 20.6585 21.1099 24.2366 22.1509 030013 20.0535 19.9517 21.9766 20.7166 030014 19.7966 20.3017 21.5382 20.5679 030016 19.4785 22.2526 24.3380 22.1886 030017 21.7938 23.1702 21.8792 22.2509 030018 20.8980 21.8067 24.9216 22.5811 030019 21.2540 22.0341 23.2973 22.2278 030022 19.5794 22.3351 24.9941 22.3479 030023 24.1678 25.4626 28.6628 26.2700 030024 23.6009 23.7663 26.7641 24.7020 030025 11.9894 20.2690 18.7967 16.8149 030027 17.6555 18.5500 19.4583 18.5927 030030 21.6932 23.1280 25.2425 23.1970 030033 20.2820 20.3034 26.4812 22.3008 030034 20.8689 19.5578 17.7772 19.3850 030035 20.0226 20.5339 * 20.2741 030036 21.6371 22.2690 24.9432 23.0233 030037 23.7615 23.7325 23.0542 23.5162 030038 22.9822 23.4477 25.2632 23.9087 030040 19.7636 19.3706 21.2717 20.1331 030041 18.8717 18.4750 18.6985 18.6886 030043 20.5598 20.5653 20.8619 20.6748 030044 17.6575 18.6781 21.9503 19.2464 030047 21.4412 22.7385 23.8939 22.7605 030049 19.3580 19.7315 * 19.5288 030054 15.0657 15.7973 16.8863 15.9671 030055 20.2991 20.8373 22.8612 21.3919 030059 22.6279 27.3929 * 24.8227 030060 18.6313 19.5021 21.7685 19.9508 030061 19.9047 21.1013 22.9706 21.3676 030062 18.7172 19.2670 21.1639 19.7478 030064 20.3837 21.6435 22.8009 21.6120 030065 20.7838 22.2846 24.6064 22.6068 030067 17.2778 17.6414 18.4004 17.7581 030068 17.7208 18.9718 19.7097 18.8803 030069 21.0936 23.4902 24.5432 23.0752 030080 20.6581 21.2299 22.7867 21.6244 030083 23.5229 23.5049 24.3273 23.8162 030085 20.8690 21.6542 21.8196 21.4875 030087 21.9465 23.1339 25.6344 23.5331 030088 20.5340 21.4491 23.5761 21.9185 030089 20.9516 22.0850 24.5055 22.5911 030092 21.8308 19.6625 20.6577 20.5622 030093 20.4314 21.7195 23.2485 21.9062 030094 22.8123 21.8049 24.5992 23.0301 030095 13.7664 20.5222 * 16.1313 030099 18.2263 19.8092 20.3310 19.5882 030100 23.7609 23.5868 * 23.6643 030101 19.2547 21.1029 23.8414 21.3423 030102 18.2413 21.5405 * 19.8425 030103 * 28.9308 40.8755 33.8153 030104 * 32.8668 34.6026 33.8315 040001 16.9178 16.3882 16.2652 16.4883 040002 15.1107 16.1353 18.0776 16.4361 040003 15.5740 15.5186 16.3918 15.8349 040004 17.9034 19.0105 19.8567 18.9476 040005 11.1318 16.5465 * 13.6054 040007 18.6998 22.5319 23.3992 21.2518 040008 14.7985 20.2121 * 17.4031 040010 19.4913 19.8251 20.4612 19.9398 040011 16.0995 17.1337 18.8346 17.5256 040014 18.1434 19.3996 22.4970 19.9652 040015 15.5207 17.9602 18.8513 17.4824 040016 20.2321 19.8087 21.2198 20.4114 040017 15.4736 16.5648 17.7545 16.6023 040018 18.7463 18.8203 22.2459 19.8242 040019 23.4163 21.0465 21.1711 21.7572 040020 18.9844 17.6056 18.0130 18.1484 040021 19.6835 21.3321 23.3840 21.5035 040022 20.8281 19.2393 20.5951 20.1448 040024 17.6607 17.1507 17.5750 17.4623 040025 13.4705 14.8071 17.6791 15.1660 040026 19.7924 21.0143 22.6617 21.1612 040027 17.4431 17.7161 19.3388 18.1973 040028 13.9946 15.2850 13.9975 14.4367 040029 21.1370 22.5094 22.1882 21.9489 040030 11.2402 16.5488 * 13.2353 040032 13.2872 13.8013 16.2781 14.3506 040035 10.9569 11.0611 11.8237 11.2698 040036 20.2012 21.1066 21.6742 21.0202 040037 14.0941 15.4984 * 14.7246 040039 14.7177 15.2811 15.9673 15.3471 040040 19.1984 19.6704 * 19.4380 040041 16.4624 17.7783 20.4646 18.2091 040042 15.2057 16.6875 16.2285 16.0552 040044 13.3501 17.1869 18.4270 16.2509 040045 16.2469 16.6648 19.5573 17.3603 040047 17.5336 18.6295 20.4173 18.8431 040050 14.0036 14.2087 15.1428 14.4627 040051 16.6039 18.2152 17.6964 17.5006 040053 15.0219 14.1508 19.2586 15.8377 040054 14.2577 16.5217 16.5573 15.7676 040055 18.0414 17.4236 17.1669 17.5528 040058 16.4278 19.3124 * 17.6419 040060 17.9805 15.4220 19.0007 17.4501 040062 17.8902 19.4255 20.6917 19.3314 040064 11.5029 13.3479 18.6107 14.1151 040066 19.7144 19.5619 21.7766 20.3116 040067 14.4741 15.0081 16.0516 15.1736 040069 17.0026 18.9754 20.5968 18.8667 040070 16.9700 18.6066 20.5214 18.8036 040071 17.6144 18.4956 18.7641 18.2815 040072 17.4960 21.3320 18.4032 18.9950 040074 18.7542 20.8465 22.0800 20.5126 040075 14.0975 14.6681 15.7875 14.8313 040076 20.5840 21.8010 23.5948 21.9901 040077 13.9114 14.7230 16.7832 15.1038 040078 18.5821 19.6363 21.4854 19.9519 040080 19.3707 22.8153 18.3431 19.9751 040081 11.1332 12.4796 13.2797 12.2892 040082 15.1331 16.4840 18.1636 16.5196 040084 17.7295 18.3410 20.1163 18.7753 040085 16.5216 14.1782 15.5811 15.3778 040088 17.1624 18.3159 19.8286 18.3979 040090 19.0824 16.6619 * 17.8591 040091 20.1378 20.2904 20.6688 20.3813 040093 13.9741 14.7132 * 14.3380 040100 15.6833 17.0271 17.8889 16.9700 040105 14.3896 14.8936 15.4697 14.9508 040106 18.1341 19.0936 19.1726 18.8593 040107 17.8628 20.6852 17.6695 18.7676 040109 16.6278 16.2496 17.1706 16.6926 040114 21.1231 21.3826 21.3532 21.2885 040118 18.2123 19.6248 21.8065 19.9138 040119 16.9407 18.6028 19.9013 18.5380 040124 19.2889 * * 19.2889 040126 11.6517 16.3391 13.3832 13.6732 040132 10.3875 24.6941 29.2337 17.5163 040134 19.0185 22.1291 * 20.6229 040135 23.0084 * * 23.0082 040136 * 21.4139 * 21.4138 040137 * * 24.7813 24.7813 040138 * * 21.0859 21.0859 050002 36.9630 30.2629 30.9729 32.2632 050006 18.2061 22.4890 25.4618 22.0352 050007 30.8676 31.6270 34.1406 32.1656 050008 26.3682 28.2021 32.4067 28.7024 050009 28.4734 28.3021 30.2740 29.0378 050013 28.0569 27.2552 30.1682 28.4525 050014 23.6745 25.1664 27.7646 25.5586 050015 27.7731 28.2204 27.5652 27.8552 050016 21.2045 22.7014 25.1232 23.0550 050017 25.6178 25.7403 28.4165 26.5820 050018 15.2903 16.5909 17.9621 16.7254 050022 24.5254 26.2574 28.1312 26.3930 050024 22.4274 21.5230 25.1016 22.9531 050025 24.8245 26.0161 29.8262 26.8932 050026 23.1904 23.4651 23.8785 23.5278 050028 17.6138 17.9421 18.7866 18.1131 050029 24.6839 26.6783 30.2538 27.1782 050030 21.5621 21.8639 21.9251 21.7896 050032 24.3598 24.4176 24.6284 24.4685 050033 32.0179 31.1768 * 31.6954 050036 21.8239 24.8017 25.3885 24.0459 050038 29.9698 32.1757 36.1619 32.5954 050039 22.8288 23.8478 26.8993 24.5711 050040 30.2607 30.1153 30.7426 30.3810 050042 24.5260 25.4903 27.6765 25.9508 050043 33.8255 38.8988 37.3217 36.6008 050045 21.1474 21.0356 22.1691 21.4359 050046 25.2005 25.3067 25.5490 25.3505 050047 29.9580 31.6959 34.4427 32.0849 050051 18.7809 17.9266 * 18.3161 050054 22.0982 19.2395 21.3495 20.8463 050055 29.2730 32.0923 36.1182 32.3322 050056 23.8396 24.7994 27.1458 25.3250 050057 20.7420 22.2584 24.2758 22.4840 050058 23.3009 24.8366 23.2205 23.7636 050060 20.5450 21.9971 22.9491 22.0213 050061 24.5488 23.9906 25.3042 24.6040 050063 25.7593 25.5798 28.6093 26.6450 050065 24.6290 27.6677 28.8369 27.0472 050066 16.1649 26.3920 * 19.8363 050067 25.8857 22.1250 27.8867 24.8006 050068 19.3615 19.2325 21.9031 19.5920 050069 24.6153 25.8560 27.2744 25.8994 050070 34.0721 36.4136 39.5178 36.7625 050071 34.4367 36.4834 40.1344 37.0182 050072 39.7321 36.1146 39.2188 38.3181 050073 32.8555 36.1054 38.6763 35.9238 050075 33.7160 37.8104 40.2265 37.4233 050076 33.9752 37.0415 40.8075 37.1398 050077 24.1404 25.3481 27.1234 25.5664 050078 24.3150 23.0613 23.2913 23.5117 050079 30.0167 36.5455 39.6651 35.3854 050082 23.7617 23.7718 23.9154 23.8161 050084 25.4517 25.1155 25.9728 25.5331 050088 24.9641 25.2282 27.1103 25.7384 050089 22.8450 23.4120 24.7857 23.6599 050090 24.6070 25.4545 27.4193 25.8348 050091 23.7713 26.6463 29.2522 26.4442 050092 17.1211 17.1883 18.1132 17.4867 050093 25.6647 27.2048 29.2642 27.4393 050095 30.4847 29.2226 * 29.7245 050096 22.7394 22.5034 23.0526 22.7555 050097 22.5991 24.2548 24.4129 23.7724 050099 25.3722 26.2363 27.1308 26.2772 050100 25.2031 23.9877 25.3258 24.8411 050101 31.8957 33.1232 32.3802 32.4675 050102 24.0014 22.6741 25.5763 24.0204 050103 25.4133 23.5946 25.0854 24.6669 050104 26.9726 27.3260 26.1592 26.8000 050107 22.2019 22.2746 22.6900 22.4227 050108 25.1758 25.6983 28.5244 26.4357 050110 19.9589 21.3399 21.9296 21.1132 050111 20.7897 21.0813 23.7715 21.9292 050112 26.8182 29.1268 31.9797 29.3043 050113 28.5224 32.4493 32.6932 31.3678 050114 26.6757 27.6486 28.1909 27.5327 050115 23.0182 24.3748 24.1481 23.8529 050116 24.9196 27.0331 28.2924 26.6320 050117 22.2123 23.0697 24.7555 23.3917 050118 23.7129 24.9094 28.9358 25.8815 050121 18.7272 18.8430 24.6584 20.3903 050122 26.9546 26.9048 29.1534 27.6723 050124 24.5069 23.9379 23.0843 23.8087 050125 32.0230 33.3290 35.6572 33.6339 050126 24.6752 26.9718 27.7126 26.4996 050127 20.9027 20.5928 21.8559 21.1158 050128 26.6132 26.2519 28.7668 27.1805 050129 24.0108 23.7432 25.2780 24.3452 050131 32.5462 33.0980 37.7844 34.4656 050132 24.0173 24.1583 28.0265 25.4346 050133 23.2093 23.9479 25.1948 24.1576 050135 24.7157 23.2750 12.5413 18.0625 050136 24.7280 28.0754 31.1484 27.7833 050137 32.9192 33.7489 35.0503 33.8818 050138 38.1584 40.8912 43.0858 40.6538 050139 31.4984 35.1492 33.8749 33.3407 050140 32.7609 36.7096 36.1708 35.1295 050144 27.4069 29.8983 30.3678 29.2851 050145 34.5185 37.5003 37.5722 36.5610 050148 20.0971 21.1622 17.3908 19.5271 050149 26.8674 25.8880 28.0501 26.8823 050150 24.6596 25.9494 26.7728 25.8255 050152 33.3305 34.5096 34.5694 34.1486 050153 32.3389 33.3333 34.5870 33.4428 050155 25.3354 23.2118 21.2069 23.1002 050158 28.6071 28.9764 30.6598 29.4328 050159 22.5313 26.6139 21.3422 23.0637 050167 21.8796 21.9596 23.1879 22.3467 050168 25.1937 27.1971 26.4047 26.2183 050169 24.8407 24.7737 25.6896 25.1108 050170 24.3654 27.7693 29.4075 26.9505 050172 19.6120 22.0400 24.5849 22.0737 050173 24.8694 * 27.7070 26.3141 050174 30.2775 31.6888 33.5204 31.9008 050175 24.7548 26.0146 26.9627 25.9076 050177 21.1396 22.5039 23.1575 22.2317 050179 23.8868 22.8941 23.0583 23.2574 050180 33.3257 34.0900 36.9905 34.8613 050186 23.6288 25.0791 27.6638 25.5202 050188 28.2364 30.6007 34.1503 31.0517 050189 27.4071 28.3295 32.3514 29.2097 050191 25.3516 29.4162 28.1689 27.6587 050192 14.1996 19.0400 19.5157 17.3616 050193 24.9444 25.5294 24.6307 25.0325 050194 29.5678 28.5389 28.0291 28.6722 050195 36.9068 39.1617 42.1735 39.4471 050196 18.2411 19.4304 19.8203 19.1752 050197 32.4030 34.6878 25.9224 30.7008 050204 22.7099 23.0192 24.9458 23.5600 050205 24.1691 24.1275 25.2841 24.5169 050207 22.9941 23.7774 25.1863 23.9991 050211 31.7280 33.2481 34.3396 33.0898 050213 21.4951 * * 21.4951 050214 24.0276 21.1480 22.2431 22.4178 050215 35.0459 31.6895 34.4745 33.7035 050217 20.2042 21.3026 22.2055 21.2565 050219 21.2458 21.7637 21.8649 21.6598 050222 23.3563 23.0670 24.6959 23.7403 050224 23.5101 24.8431 25.1943 24.5595 050225 21.6820 22.0981 24.5601 22.7516 050226 24.4443 26.1959 26.0826 25.7144 050228 34.2596 36.0632 38.6751 36.2629 050230 26.6291 26.7963 30.0380 27.8217 050231 26.7321 27.4697 27.0320 27.0798 050232 24.5245 25.8640 25.3439 25.2423 050234 24.6126 25.0104 23.2830 24.1727 050235 27.0922 26.0323 27.2838 26.7962 050236 25.9458 27.7406 26.9290 26.8640 050238 24.5823 25.1796 26.0312 25.2541 050239 23.2711 24.9469 27.0911 25.1055 050240 26.7620 28.8910 32.8542 29.7204 050241 29.8345 * * 29.8345 050242 32.0829 33.5646 34.4412 33.3749 050243 26.4627 26.0256 28.5626 27.0708 050245 23.2716 24.6092 25.7585 24.5579 050248 27.6457 28.4413 29.1192 28.4523 050251 23.6360 27.9531 24.4552 25.2214 050253 16.7540 21.0399 23.9247 20.2377 050254 20.1176 22.3414 23.3358 21.9420 050256 23.4835 25.1104 26.8618 25.3035 050257 17.2596 15.6379 17.4909 16.8191 050260 27.4234 30.1623 24.9073 27.2549 050261 20.1040 19.4649 21.4693 20.3613 050262 29.5550 30.8866 33.0425 31.0973 050264 36.0331 33.2270 37.5425 35.5478 050267 26.0401 27.8393 26.6558 26.7955 050270 25.3757 26.4092 27.9871 26.6878 050272 23.0587 23.3443 24.0921 23.5076 050276 33.3302 34.0633 34.4832 33.9454 050277 26.0822 23.6065 35.6323 28.8604 050278 23.9289 24.9699 26.0331 24.9976 050279 21.8949 22.2776 23.5145 22.5756 050280 25.6651 26.3392 28.4969 26.8343 050281 24.2251 25.2699 25.7832 25.1246 050282 25.4428 26.4698 * 25.9126 050283 31.7669 32.3270 35.1831 33.1816 050286 19.4241 20.6191 19.7351 19.9268 050289 30.4750 32.2125 34.9651 32.5458 050290 29.6796 31.5000 31.9510 31.0288 050291 29.4029 30.9334 28.3451 29.5051 050292 20.8410 21.4357 27.6114 23.1188 050293 24.1875 17.1935 * 20.0134 050295 21.7883 25.4405 25.4332 24.2106 050296 28.3906 30.0984 33.5948 30.6658 050298 23.2006 22.4000 26.1833 23.8635 050299 25.5035 24.6751 26.9870 25.7710 050300 25.9228 26.0298 26.6700 26.2233 050301 21.1403 24.7987 22.7711 22.8646 050305 36.7908 36.6981 38.7597 37.4248 050308 28.9284 30.3887 31.6790 30.3648 050309 25.3515 25.5221 25.5367 25.4704 050312 26.0015 26.0172 28.2557 26.8194 050313 25.6827 28.9126 25.0948 26.4529 050315 22.7359 22.5906 23.6638 23.0139 050320 32.4809 31.6571 31.9686 32.0209 050324 25.3694 26.8313 28.4931 27.0063 050325 23.6327 22.6353 26.6326 24.1679 050327 25.6450 31.1527 33.0549 29.6283 050329 21.6984 24.2134 26.6341 24.1720 050331 25.0230 25.2110 21.5193 23.7909 050333 19.1449 14.1808 15.6929 16.0637 050334 34.2557 34.3956 37.2336 35.3386 050335 22.9926 22.9335 23.9713 23.3018 050336 21.3402 22.0203 * 21.6868 050342 20.8255 22.4510 23.0282 22.0864 050348 25.1085 29.3364 28.9864 27.7954 050349 15.0667 15.4536 15.6042 15.3828 050350 26.4161 27.2368 27.2573 26.9829 050351 24.8121 25.2436 27.4042 25.8956 050352 26.4262 27.7489 32.6772 28.8662 050353 23.2699 24.1009 24.8223 24.0722 050355 21.0969 41.4710 * 27.5904 050357 24.5345 24.3540 25.2126 24.7119 050359 21.7548 19.7653 22.9175 21.4664 050360 31.7583 33.3592 35.9032 33.7039 050366 19.6823 22.0442 23.4696 21.8093 050367 30.7328 31.7487 32.6760 31.7233 050369 26.2234 26.6627 28.0909 27.0127 050373 27.8275 29.9749 30.4697 29.3692 050376 28.0990 28.4026 30.3530 28.9347 050377 17.0012 11.6463 14.3889 14.7469 050378 26.9101 27.8389 30.4937 28.3969 050379 18.4278 24.2408 27.5150 22.7721 050380 31.9578 31.5962 35.1536 32.9076 050382 25.9244 26.3968 26.8949 26.4027 050385 * 27.1692 * 27.1692 050388 22.0122 17.6762 15.6834 18.4348 050390 24.2700 25.8556 25.7881 25.2656 050391 20.0615 19.0832 20.2887 19.7798 050392 22.9430 24.9003 21.8139 23.1475 050393 24.1981 25.4028 26.4918 25.4171 050394 23.1526 23.1641 25.1869 23.8865 050396 25.3729 25.7580 28.4161 26.5200 050397 20.6397 23.3212 24.7280 22.8187 050401 18.4593 * * 18.4593 050404 15.9839 16.4845 20.0233 17.3758 050406 17.8596 21.5282 23.0438 20.5476 050407 30.8346 32.0753 33.2894 32.0587 050410 19.8508 17.1718 19.8436 18.9151 050411 33.1943 33.1718 * 33.1828 050414 25.9723 24.5471 26.8815 25.7060 050417 23.3005 23.3862 24.4608 23.7300 050419 23.4936 25.1449 26.4357 25.0021 050420 23.5438 26.4201 26.7537 25.5652 050423 21.3552 24.8113 26.5188 24.3189 050424 24.0727 25.9378 27.5273 25.9000 050425 35.3712 33.7276 37.7347 35.6925 050426 29.0120 26.7941 30.9610 28.8680 050427 16.4330 31.4154 25.8360 23.8810 050430 21.2275 25.2322 31.5171 24.6961 050432 24.5630 26.0686 28.2074 26.3472 050433 18.9021 17.7980 14.3846 17.2267 050434 * 24.0017 * 24.0017 050435 23.3426 22.5428 22.6561 22.8168 050438 23.2583 25.3763 26.5535 25.0490 050440 22.5400 25.4767 28.2209 25.3120 050441 31.8774 33.4696 36.6680 33.8900 050443 17.2875 16.8897 18.0063 17.3814 050444 22.4530 22.6469 23.5299 22.8500 050446 22.3422 20.3611 20.0104 20.8646 050447 18.9851 24.4339 25.7274 23.3050 050448 21.7718 22.6612 26.6967 23.5469 050449 23.4614 * * 23.4614 050454 30.0792 30.3063 34.4813 31.6390 050455 19.8577 20.5575 23.8527 21.3319 050456 18.1585 17.5846 23.7594 19.3948 050457 32.1910 34.2116 37.4570 34.4455 050464 25.7710 25.8092 31.4768 27.7900 050468 22.2926 22.9771 17.8128 20.5312 050469 24.5205 * 25.7995 25.2381 050470 16.0805 15.7765 21.2996 17.4624 050471 27.1597 29.4705 32.3570 29.6121 050476 24.0253 25.9458 25.9711 25.3460 050477 27.5819 30.8781 32.1676 30.2255 050478 26.3306 28.1829 28.3893 27.6685 050481 27.7973 28.5320 29.4912 28.6205 050482 16.0114 21.6091 23.0016 19.2164 050485 24.6906 25.2723 23.8237 24.5767 050488 31.7481 33.8291 37.2438 34.4285 050491 27.4600 27.7412 29.2987 28.1988 050492 20.5030 23.4977 23.7383 22.6518 050494 29.1296 30.2875 30.7725 30.1010 050496 34.9704 32.7474 35.7115 34.4409 050497 15.4115 * 14.4481 14.9306 050498 26.1716 27.6099 28.2196 27.3481 050502 25.3701 27.2724 27.9506 26.8641 050503 23.3745 25.7668 26.7924 25.3905 050506 25.0333 27.1555 30.4731 27.5747 050510 33.7481 36.2548 39.6005 36.5514 050512 34.4368 36.0785 39.0767 36.6044 050515 33.7321 37.3440 36.3131 35.7452 050516 26.1969 25.3450 30.0359 27.0104 050517 22.0985 23.6067 23.4131 22.9981 050522 36.2127 37.0295 38.9158 36.9675 050523 31.2522 32.1272 33.8053 32.4311 050526 26.4014 26.8814 29.0004 27.4593 050528 18.9155 21.1741 23.9177 21.3604 050531 21.3948 * 22.7311 22.0660 050534 24.0001 24.4038 26.7941 25.0949 050535 26.8511 27.7626 29.7904 28.1965 050537 24.0354 26.2342 25.1292 25.1574 050539 23.3846 23.7778 24.1196 23.7754 050541 36.6149 37.0551 41.1980 38.3379 050542 17.7737 21.8129 21.2846 19.9901 050543 21.6795 22.4134 24.0333 22.7542 050545 31.7280 33.6302 33.4322 32.9305 050546 38.8087 39.4266 42.8053 40.3552 050547 37.7681 37.7633 40.6483 38.6518 050548 29.8516 30.3336 32.3944 30.8485 050549 28.9615 30.0948 31.6709 30.2918 050550 25.6588 26.5515 29.0938 27.1362 050551 24.8084 26.1042 28.6834 26.5676 050552 20.3239 20.6068 24.9755 21.7907 050557 22.2562 23.8340 25.8401 24.0476 050559 24.7866 26.3799 25.3299 25.4887 050561 33.4423 34.2065 * 33.8236 050564 24.2091 * * 24.2090 050565 20.8349 * * 20.8349 050566 22.3448 21.7712 24.0648 22.6946 050567 25.0787 26.2588 27.8475 26.4308 050568 20.5376 21.9313 20.8324 21.0880 050569 27.3429 27.3294 27.7955 27.4880 050570 25.8619 26.8965 29.9470 27.6972 050571 24.0154 26.2226 29.1716 26.5115 050573 25.6589 25.9380 27.2328 26.2959 050575 20.7090 27.8579 23.1358 23.6994 050577 23.5487 25.2861 26.4806 25.0050 050578 28.9009 32.0554 31.1695 30.6550 050579 29.9348 32.0245 34.9794 32.4397 050580 24.6962 22.7522 27.2431 24.7685 050581 24.9807 26.0580 28.9696 26.6705 050583 25.8800 26.2664 30.0427 27.5806 050584 19.5805 24.5294 24.5544 22.7601 050585 24.2824 26.4446 26.0595 25.5822 050586 23.1850 * * 23.1850 050588 24.5472 27.0506 30.5453 27.6351 050589 23.8880 23.7918 27.9845 25.1893 050590 24.4797 25.1100 27.0535 25.5262 050591 25.0209 26.7662 28.6151 26.8393 050592 22.1174 23.8267 25.9545 23.8223 050594 27.7002 28.7415 30.8029 29.1185 050597 23.3280 23.1209 24.5542 23.6763 050598 23.9202 25.1622 31.1703 26.7495 050599 26.0892 26.3782 27.7684 26.7559 050601 29.7417 29.7734 32.3033 30.6813 050603 21.7031 24.9032 25.0996 23.8892 050604 35.4034 36.4669 42.0018 37.9795 050608 18.1664 20.9171 20.7954 19.9529 050609 33.5028 34.8949 * 34.1686 050613 30.2413 34.9768 * 32.5464 050615 27.5682 25.8698 29.4322 27.6985 050616 24.9843 25.0016 * 24.9928 050618 21.4895 22.3548 * 21.9734 050623 27.5832 28.6475 29.9553 28.6716 050624 26.4659 22.4030 23.4665 23.9161 050625 27.5816 29.3665 29.6612 28.9346 050630 24.2120 25.2915 27.7052 25.7731 050633 25.4283 27.8165 30.2883 27.9289 050636 23.5257 25.0214 23.2573 23.9123 050638 18.2159 15.6375 21.0088 18.1465 050641 17.1258 17.9379 21.5030 19.2373 050644 22.1489 * 28.4054 25.2877 050662 35.0989 38.9592 40.9243 38.2885 050663 24.9110 22.7770 22.9161 23.2174 050667 27.5045 26.9236 31.4906 28.5908 050668 61.7751 57.8627 * 59.6272 050670 24.6101 24.1626 * 24.3757 050674 32.4807 33.7845 36.8871 34.4747 050676 20.2087 16.3948 24.3105 19.1193 050677 33.6070 34.0936 * 33.8463 050678 22.7756 25.2143 27.1337 25.0885 050680 31.4839 31.9166 32.2371 31.8875 050682 17.3566 19.8107 23.0983 19.8665 050684 23.3697 24.2792 23.7443 23.7986 050685 35.1307 30.4194 * 32.6498 050686 33.4420 34.8278 * 34.1349 050688 31.0648 34.9936 36.5555 34.8315 050689 30.9399 34.0571 37.5449 34.4378 050690 34.8112 36.7516 41.1385 37.6299 050693 25.5662 29.1213 32.6638 29.3244 050694 23.5572 25.1964 25.8299 24.8850 050695 24.4301 26.2838 27.8742 26.2576 050696 28.3291 29.6685 29.9410 29.3284 050697 18.2338 24.1116 18.5357 19.9903 050698 * 24.9559 * 24.9559 050699 17.5296 23.4611 26.3932 21.9529 050701 24.3055 26.4901 28.4650 26.3518 050704 22.7618 25.6565 24.6072 24.3668 050707 27.8958 28.2637 27.7366 27.9699 050708 24.8647 24.5606 22.1605 23.8703 050709 19.4977 21.8770 22.7897 21.4220 050710 27.5828 30.5918 33.7204 30.7878 050713 16.8538 18.2822 19.0071 18.0075 050714 30.1925 30.3290 30.3262 30.2901 050717 28.7973 31.5021 33.0719 31.0905 050718 18.0940 22.5989 21.7835 21.3483 050719 23.0833 * 22.0997 22.4754 050720 25.8677 * 26.1941 26.0295 050723 * 32.0291 33.0797 32.5951 050725 * * 20.6592 20.6592 050726 * * 25.8742 25.8742 060001 21.1819 21.4562 23.1548 21.9595 060003 20.4682 21.9043 23.0807 21.8505 060004 21.4496 22.9265 25.0037 23.2681 060006 20.0213 21.0003 21.8609 21.0085 060007 18.2977 19.3071 22.2747 19.9022 060008 18.4590 18.7097 19.8803 19.0217 060009 22.7164 23.9272 24.1285 23.6009 060010 23.6827 24.2735 25.9341 24.6424 060011 22.3458 22.2058 25.4458 23.3434 060012 19.4932 21.2980 22.6374 21.1159 060013 19.1256 23.5248 23.3954 21.9829 060014 24.3210 25.7701 25.9159 25.3595 060015 23.2469 23.6015 27.6338 24.8106 060016 20.2408 20.2361 22.9300 21.1421 060018 21.5083 21.8478 21.0581 21.4599 060020 18.8985 19.7348 20.9025 19.8893 060022 21.0830 22.8059 19.8819 21.2558 060023 21.5475 22.4731 24.3749 22.8346 060024 22.9185 24.3658 25.2409 24.2358 060027 22.0713 22.1717 25.1480 23.2185 060028 23.1792 24.2985 27.3340 24.9108 060029 18.2938 19.8498 * 19.0675 060030 20.3452 21.2612 22.8309 21.5553 060031 22.5067 23.3995 23.8781 23.2637 060032 22.8123 24.7678 25.5628 24.4445 060033 16.0760 17.8514 16.7266 16.8791 060034 23.2816 24.3652 26.2141 24.6650 060036 18.5988 18.6521 18.1954 18.4720 060037 15.4513 15.7495 17.1258 16.1605 060038 14.3249 16.6525 15.3718 15.5616 060041 19.1263 19.5872 20.8745 19.8909 060042 20.8597 19.3967 22.5613 20.7473 060043 13.4443 15.4073 19.1085 15.9780 060044 20.8673 21.3102 25.6112 22.7216 060046 22.2699 22.6819 24.0645 23.0457 060047 17.1534 17.9173 18.1662 17.7570 060049 23.0613 25.9592 25.3425 24.9252 060050 19.0832 * 20.4386 19.8467 060052 14.8729 16.0543 18.2354 16.3844 060053 18.0232 19.4746 22.2894 19.8382 060054 20.4160 19.7753 20.9346 20.3624 060056 18.1263 21.9586 21.9389 20.8180 060057 25.4185 24.6599 24.4012 24.8132 060058 13.8539 16.4504 20.3154 16.7670 060060 15.6018 19.4418 21.0586 18.5977 060062 16.8640 17.1032 19.0995 17.6743 060064 22.7797 28.8746 29.1806 26.8320 060065 24.5572 24.4554 29.2179 26.0872 060066 17.2537 17.5556 14.6820 16.5806 060070 18.8960 19.2220 22.6894 20.3042 060071 17.4068 17.6452 20.1385 18.3916 060073 17.0846 18.4971 16.5027 17.3443 060075 23.8724 25.0552 27.2654 25.3696 060076 20.3265 22.9426 23.6266 22.3373 060085 14.3409 10.9724 15.6918 13.4494 060088 13.7174 20.7211 22.9170 18.6644 060090 16.3760 16.5321 * 16.4540 060096 20.8937 21.9951 20.0869 21.0065 060100 23.9305 24.8116 27.4972 25.4548 060103 23.5083 24.4962 26.7150 24.9461 060104 21.1820 24.4248 26.8237 23.9979 060107 21.9221 * * 21.9222 060108 * 19.1327 19.0011 19.0448 060109 * 27.3180 * 27.3180 060110 * * 31.3494 31.3494 070001 26.3596 27.7441 29.9592 27.9941 070002 26.1768 26.6881 28.1101 26.9593 070003 27.5200 28.1721 29.7864 28.5044 070004 24.2567 25.4310 25.7207 25.1218 070005 26.9151 27.6733 29.8173 28.0976 070006 28.6413 33.6291 32.6824 31.8244 070007 26.3313 28.0875 29.0734 27.8655 070008 24.2971 25.1362 24.3907 24.6106 070009 24.1871 24.9408 25.4576 24.8664 070010 29.2194 28.3168 30.4192 29.3329 070011 23.0883 24.8206 24.9457 24.2870 070012 28.8067 37.5917 34.9099 33.4527 070015 28.1204 29.2693 30.0614 29.1548 070016 24.4633 28.4833 31.2173 27.8518 070017 26.0424 27.5515 29.2978 27.4590 070018 30.6864 32.6301 33.8654 32.4296 070019 24.9249 26.2348 27.9838 26.4038 070020 25.9964 26.6203 28.4084 27.0418 070021 26.3043 29.4596 30.0915 28.7001 070022 26.9111 27.2423 29.2864 27.8032 070024 24.8948 26.3544 28.3460 26.5801 070025 25.4345 27.3592 28.3017 27.0096 070027 26.8450 25.9279 26.8236 26.5341 070028 25.7492 26.7286 28.2078 26.9036 070029 23.9682 23.8427 25.8107 24.5347 070030 22.1578 * * 22.1578 070031 24.1198 25.6347 25.5880 25.0884 070033 31.4736 34.1591 35.8504 33.8348 070034 29.4916 30.0744 32.4220 30.6177 070035 24.1423 24.5996 25.9776 24.8552 070036 29.9470 31.2961 32.4920 31.2720 070038 * 26.3126 * 26.3126 070039 22.3356 * 32.6059 29.3416 080001 24.8833 26.8887 28.0859 26.6310 080002 20.1965 20.9385 23.7309 21.6786 080003 23.1275 24.8200 24.8199 24.2173 080004 22.9706 21.7344 24.2251 22.9785 080006 22.6671 20.9399 20.9757 21.4333 080007 21.3746 21.5415 23.4933 22.1686 090001 21.5751 23.0365 7.5651 17.9081 090002 21.5726 20.6550 23.5159 21.8418 090003 23.1268 27.1087 22.7014 24.0752 090004 25.5054 25.9717 28.7417 26.8011 090005 26.3074 26.8690 28.6142 27.2997 090006 22.0957 22.9658 23.7111 22.9438 090007 29.2840 24.6668 25.8430 26.6042 090008 25.2708 * 19.3212 22.1162 090010 23.6616 25.9373 * 24.7397 090011 26.6349 27.6038 31.7710 28.7553 100001 20.2157 22.0101 21.7561 21.3158 100002 21.0222 21.5772 21.6362 21.4258 100004 15.4149 16.1638 15.6306 15.7493 100006 21.2293 21.6922 23.3307 22.1620 100007 22.1590 22.5317 23.9004 22.9055 100008 20.8381 21.6416 22.7706 21.7804 100009 22.1741 22.6370 23.7460 22.8738 100010 23.0637 23.9582 25.5614 24.1330 100012 20.4659 22.0244 24.2602 22.3053 100014 19.5770 21.9875 21.7566 21.0988 100015 18.0654 18.9383 22.1272 19.7135 100017 19.8655 20.1417 21.1905 20.4341 100018 21.6388 22.6587 24.2154 22.8672 100019 23.5462 25.8297 24.2201 24.5270 100020 20.7816 21.7421 23.1885 21.9438 100022 26.5695 27.4235 27.9072 27.2953 100023 19.1787 20.2034 21.8111 20.3897 100024 22.1332 22.9872 24.4070 23.2018 100025 19.4529 20.1360 21.2568 20.2991 100026 20.9461 21.3742 21.7970 21.3789 100027 14.7916 20.5889 21.9900 18.2354 100028 19.3371 20.3751 21.5305 20.4329 100029 20.8950 22.2553 24.6814 22.4835 100030 20.5952 19.5604 21.5303 20.5938 100032 19.7451 20.6543 21.6415 20.6364 100034 19.5282 20.0099 22.2146 20.5533 100035 23.8117 21.3519 22.6349 22.5792 100038 24.5864 24.9548 25.6018 25.0869 100039 21.7861 23.3111 23.8060 22.9806 100040 18.6321 19.5154 21.3865 19.8692 100043 18.8206 20.7688 21.7738 20.4584 100044 22.7236 22.9474 23.9952 23.2248 100045 21.0228 22.8096 30.3359 24.4856 100046 21.3028 23.2027 24.2746 22.8753 100047 20.6068 21.4971 24.3522 22.2329 100048 15.7790 17.3663 17.5533 16.9309 100049 19.1025 20.9490 21.8676 20.6412 100050 17.9039 17.8960 20.0405 18.6106 100051 17.9453 19.3258 19.9713 19.1475 100052 18.1780 19.6620 18.6363 18.8133 100053 19.6800 21.6634 23.7837 21.6611 100054 21.1518 20.9612 21.8613 21.3455 100055 18.8760 19.1324 19.6350 19.2002 100056 21.8506 23.1737 25.9245 23.6383 100057 19.5319 22.3406 24.4271 21.9677 100060 23.5997 * * 23.5997 100061 22.9176 24.5277 25.7559 24.3953 100062 21.4424 21.9054 24.9807 22.7317 100063 18.4642 19.2510 21.5620 19.9030 100067 18.4851 19.2168 23.6270 20.3382 100068 19.8308 19.9648 23.7197 21.3073 100069 17.3666 18.5789 19.6037 18.6041 100070 20.0381 20.9592 20.4770 20.4616 100071 17.7234 20.7461 21.7675 20.3419 100072 20.5968 22.0317 21.9184 21.5398 100073 22.2812 22.2425 23.5843 22.7262 100075 19.4480 20.4604 21.8589 20.5692 100076 17.8612 18.4815 19.6444 18.6617 100077 19.0640 20.9482 22.2470 20.8144 100078 19.2891 16.6003 17.4683 17.7417 100080 22.7153 22.9720 22.7056 22.7946 100081 15.4253 16.5149 16.4804 16.1357 100084 22.7009 24.5682 23.5435 23.6450 100086 23.3718 24.3067 25.2375 24.3294 100087 23.6562 22.1764 26.2514 24.0027 100088 20.5566 20.6667 23.6270 21.6062 100090 19.7695 21.0431 22.5894 21.1520 100092 20.1760 21.4601 25.4630 22.1148 100093 16.8422 18.7153 20.2949 18.6499 100098 20.8315 21.1723 20.0639 20.7185 100099 15.7591 16.5271 16.1165 16.1278 100102 19.7673 19.0193 21.6772 20.1082 100103 18.7844 19.1222 20.3633 19.4145 100105 21.8268 22.7793 24.5464 23.0784 100106 17.4958 21.4342 18.5389 19.1251 100107 20.0719 21.7553 23.3789 21.7356 100108 20.1125 18.4127 15.1791 17.6124 100109 20.8370 20.6007 22.3671 21.2613 100110 20.1853 22.8127 24.2271 22.5089 100112 15.2128 16.2109 16.9325 16.1723 100113 21.3489 23.3380 20.6110 21.7279 100114 22.8178 22.5326 25.3699 23.4863 100117 20.6962 21.3085 23.2994 21.7923 100118 20.7323 21.7067 24.1105 22.1068 100121 18.5842 19.9033 23.1100 20.5301 100122 19.2643 24.9765 23.6638 22.5106 100124 20.4022 20.0867 14.8231 17.8809 100125 19.6097 20.3232 22.4185 20.8356 100126 19.3103 21.4349 21.7977 20.8062 100127 19.2122 20.5153 21.0153 20.2670 100128 22.8826 23.5835 24.4104 23.6230 100130 20.0947 21.0023 20.2478 20.4482 100131 23.1622 24.6184 25.4186 24.4498 100132 18.7863 19.5259 21.1446 19.8043 100134 15.9733 16.9302 18.3392 17.1001 100135 19.1865 19.7675 20.3831 19.7887 100137 19.5562 20.9015 * 20.2591 100138 14.9539 14.9760 16.4384 15.4793 100139 15.2532 15.7378 18.2187 16.3579 100140 19.0584 20.2288 22.6326 20.6848 100142 18.4113 17.7250 20.0689 18.7079 100146 21.3359 20.8381 * 21.0641 100147 15.2348 17.1566 17.2835 16.5550 100150 21.5057 25.4269 22.9193 23.1341 100151 23.8489 26.6143 26.8564 25.9003 100154 20.4068 21.6715 23.0820 21.7335 100156 18.4779 20.0348 20.7649 19.8064 100157 22.6195 24.2188 23.1045 23.3126 100159 10.7818 15.0633 19.3145 15.1520 100160 23.3121 22.6942 23.4877 23.1680 100161 22.3053 23.3612 24.4326 23.3822 100162 20.3110 24.2950 23.8001 22.8069 100165 22.6622 * * 22.6623 100166 21.2309 22.2419 23.7327 22.3765 100167 23.2969 25.7676 26.8139 25.3034 100168 20.3167 23.0121 24.6276 22.6616 100169 20.3017 21.6397 22.5755 21.5513 100170 19.3005 21.2469 * 20.1922 100172 14.8826 15.7827 17.6051 16.0261 100173 17.1337 18.3828 19.7190 18.4365 100174 21.9807 * * 21.9807 100175 20.5442 21.2532 21.0474 20.9357 100176 24.3089 24.6595 26.8740 25.2920 100177 24.4284 25.1037 24.4295 24.6550 100179 23.0849 23.9633 22.8536 23.2786 100180 21.5388 22.7781 24.7990 23.1132 100181 18.9510 17.9048 18.1320 18.3165 100183 23.0654 22.2063 24.4575 23.2115 100187 20.8535 21.4988 23.4760 21.9203 100189 26.5962 27.1295 26.6653 26.7935 100191 21.0647 22.0526 24.2299 22.5063 100200 23.8729 24.8878 24.8120 24.5400 100204 20.2193 21.1922 22.2613 21.2482 100206 20.1171 20.3436 * 20.2327 100208 20.7029 20.4678 24.1482 21.8277 100209 23.3903 22.8236 23.5479 23.2587 100210 21.8545 23.0431 26.0933 23.6634 100211 20.7516 21.6367 * 21.1977 100212 21.1263 21.7239 22.6259 21.8401 100213 21.1818 22.0176 24.4995 22.6205 100217 22.7335 22.7116 24.0291 23.1695 100220 21.8246 24.6233 24.9733 23.7248 100221 21.2321 23.2263 * 22.1854 100223 20.2233 21.8962 21.1051 21.1071 100224 21.8628 22.3567 22.7403 22.3391 100225 21.5059 22.4619 23.9971 22.6579 100226 21.8808 22.7301 23.8070 22.8491 100228 20.8810 24.9691 * 22.9269 100229 18.2350 19.7259 21.0039 19.5689 100230 22.5650 23.4169 25.0408 23.8884 100231 18.7526 21.5712 22.8325 20.8200 100232 19.8002 20.1459 21.8906 20.6484 100234 21.6360 24.3355 24.0421 23.3485 100236 20.6942 21.7886 23.7286 22.0173 100237 23.2408 23.2712 26.7664 24.3476 100238 20.8252 23.3747 24.6513 22.9237 100239 19.4481 23.2242 24.9409 22.4134 100240 21.0606 21.3495 23.0650 21.8213 100241 17.1063 14.1059 14.6992 15.3546 100242 18.6938 19.1097 20.4142 19.4632 100243 20.8041 22.4495 23.2812 22.2413 100244 20.5352 21.4386 23.4876 21.8968 100246 21.9247 23.5614 26.6552 23.9760 100248 21.2988 22.1553 23.7614 22.4427 100249 18.1397 18.4932 21.3942 19.2694 100252 19.8079 22.0976 22.6481 21.5857 100253 22.4778 22.6517 23.4448 22.8823 100254 19.5523 20.4410 23.2068 21.2034 100255 21.0284 20.7228 22.9793 21.5458 100256 21.2786 22.4844 23.7315 22.4906 100258 20.0300 22.0790 24.5699 22.2126 100259 21.1160 21.4991 24.0960 22.2834 100260 24.9183 21.2413 23.4255 23.0969 100262 21.0927 22.7137 23.8006 22.3809 100264 19.9491 21.7410 22.4616 21.4161 100265 18.2291 20.2664 21.0688 19.9095 100266 19.3623 20.2821 21.5258 20.4415 100267 21.7430 22.8054 23.3558 22.6691 100268 24.0538 23.5414 26.0297 24.5763 100269 22.5114 26.0271 25.0014 24.5239 100270 16.7148 20.8217 16.8468 18.0052 100271 20.8695 21.9823 * 21.4488 100275 21.4904 23.2920 23.1316 22.6853 100276 24.1022 24.8251 25.4557 24.8136 100277 19.7241 14.9157 25.2985 18.4223 100279 22.5879 23.1776 24.6625 23.4267 100280 18.1972 19.0157 * 18.6075 100281 23.0142 23.4729 25.3382 24.0569 100282 18.4884 20.9256 21.8279 20.4704 100284 18.9448 18.5716 22.3046 19.9187 110001 20.1150 22.4535 24.0561 22.2069 110002 19.5158 20.2149 20.0125 19.9219 110003 17.1450 18.2792 19.7061 18.4215 110004 19.7733 20.6096 21.8791 20.7777 110005 22.4568 21.8105 23.6147 22.7129 110006 21.0601 22.0325 23.8762 22.3201 110007 25.2523 25.9135 27.8969 26.3641 110008 18.5265 20.4972 22.6308 20.7088 110009 17.4306 16.6452 16.2944 16.8215 110010 23.9104 25.1930 26.6265 25.2350 110011 18.9823 20.4028 23.2149 20.8820 110013 18.9160 16.7833 19.7781 18.4998 110014 18.1787 18.4463 18.7642 18.4629 110015 20.9926 21.2600 23.2279 21.9187 110016 14.2398 14.7571 18.8371 15.7745 110017 22.2537 21.2970 21.8808 21.8184 110018 22.1480 23.0577 24.7007 23.3525 110020 19.4617 20.9687 22.5988 20.9702 110023 22.0546 21.6512 23.6182 22.4827 110024 20.7345 21.3945 22.1471 21.4330 110025 20.4232 20.2493 29.0965 22.6398 110026 16.2484 16.9161 19.3200 17.4907 110027 14.7081 19.8976 19.8351 18.0251 110028 29.1670 28.1695 25.9474 27.6479 110029 21.2150 21.3694 23.0779 21.9337 110030 19.6412 20.4656 21.6618 20.6037 110031 20.0553 20.9219 22.8695 21.3219 110032 18.2014 19.2685 18.0744 18.4929 110033 25.6335 23.1939 24.1447 24.2752 110034 19.5554 23.0724 22.8541 21.6751 110035 22.7950 21.8646 23.4610 22.7096 110036 24.9234 22.5481 24.5675 23.9890 110038 17.7396 18.4508 20.1710 18.7818 110039 20.4998 18.9817 17.0608 18.7776 110040 16.8083 17.7798 17.3095 17.2984 110041 20.2755 20.1398 20.8080 20.4113 110042 25.2331 25.0535 25.5588 25.2869 110043 20.6150 21.2714 22.7589 21.5611 110044 17.2087 17.5905 19.2562 17.9982 110045 21.3049 22.2424 19.7747 21.0415 110046 21.4905 22.8820 21.6201 22.0167 110048 15.6113 18.8751 21.9621 18.7056 110049 16.8639 17.1396 18.9096 17.6498 110050 19.2291 18.9048 22.1089 20.1584 110051 17.2292 17.2050 17.6816 17.3795 110054 20.0549 20.7825 20.5387 20.4734 110056 17.7959 17.9037 21.7607 19.3353 110059 16.7990 17.8076 19.9802 18.2059 110061 16.3557 17.4601 18.6696 17.5523 110062 17.0053 17.9421 18.2038 17.7308 110063 18.5071 18.0256 19.4401 18.6913 110064 19.1203 18.8742 21.7636 19.8777 110065 16.3546 16.9829 19.9032 17.6656 110066 22.4189 23.4554 * 22.9140 110069 20.9575 21.1513 21.0518 21.0559 110070 17.3438 19.6361 20.8793 19.1178 110071 18.8321 21.5042 15.2336 18.3234 110072 12.7625 13.6626 * 13.1941 110073 16.4658 17.9372 15.2711 16.4347 110074 22.3769 24.4924 23.6564 23.5407 110075 20.1757 20.1604 19.6937 20.0081 110076 21.9798 23.6127 24.9264 23.5306 110078 24.0893 25.7416 27.7261 25.8462 110079 22.1070 22.3641 22.2908 22.2542 110080 19.1839 19.4635 * 19.3217 110082 24.3140 22.7015 24.0664 23.6678 110083 23.1463 22.2609 24.5253 23.3268 110086 16.6374 19.0164 18.8751 18.1588 110087 22.7069 24.0994 25.7908 24.2653 110089 19.3855 19.0453 20.6840 19.7079 110091 21.5328 23.7110 25.1996 23.4730 110092 16.9725 15.9178 16.9116 16.5923 110093 16.9827 * * 16.9827 110094 16.9503 16.8890 * 16.9211 110095 17.1195 18.9904 20.1024 18.8017 110096 17.4157 18.0418 18.5513 18.0235 110097 17.4558 17.8454 18.9464 18.0488 110098 16.0597 16.7800 17.5567 16.8549 110100 19.0764 18.6822 15.1316 17.6555 110101 18.8491 13.8787 13.3943 14.8763 110103 21.1837 21.5683 * 21.4221 110104 15.9431 16.6322 17.9805 16.8523 110105 16.7775 18.1306 19.2156 18.0663 110107 19.3897 21.2267 21.9213 20.8424 110108 25.2161 20.1140 18.4912 20.6647 110109 16.4031 16.5977 18.7397 17.2348 110111 18.3951 18.4274 22.5840 19.8648 110112 19.8986 18.9574 20.5171 19.8164 110113 15.9532 16.0942 18.0770 16.7135 110114 16.4812 16.8297 17.7019 17.0138 110115 22.5049 26.5759 26.3274 24.9969 110118 19.7509 17.5714 17.7344 18.2780 110120 17.7452 18.4738 20.3099 18.8660 110121 19.3643 18.8744 19.5230 19.2555 110122 21.1469 20.6070 21.1510 20.9707 110124 18.3366 19.4093 19.7005 19.1562 110125 18.0090 19.5666 19.8695 19.1558 110127 20.3765 16.1107 * 18.2840 110128 18.0835 20.3046 28.4942 21.9309 110129 19.0001 20.9442 21.5571 20.5238 110130 14.6011 16.6915 17.5272 16.2937 110132 16.3943 17.1820 17.2924 16.9658 110134 19.8639 19.0305 19.1891 19.3419 110135 17.3504 15.6668 18.5125 17.0191 110136 16.9629 20.7827 21.1235 19.3927 110140 17.7915 * * 17.7915 110141 14.4935 13.2710 14.3027 14.0327 110142 13.9525 14.1203 16.3359 14.8326 110143 22.5926 22.4254 23.5876 22.8713 110144 17.5112 17.5678 18.9425 17.9918 110146 17.1835 17.8499 17.2250 17.4052 110149 32.1975 25.2525 25.3618 27.1829 110150 21.2909 22.8322 22.7366 22.3193 110152 15.1324 16.3837 16.3352 15.9536 110153 20.5068 20.6972 21.5300 20.9068 110154 17.3761 16.5286 * 16.9482 110155 16.5146 16.4756 16.1785 16.4073 110156 16.3876 16.0759 * 16.2355 110161 22.2861 24.5776 26.1275 24.4282 110163 18.6637 20.1183 21.9411 20.2136 110164 21.2160 22.6605 23.7801 22.5540 110165 20.8030 22.5604 23.1047 22.2007 110166 20.5049 22.3822 23.6665 22.0307 110168 21.8058 22.3181 23.3426 22.5338 110169 22.6648 23.3750 24.7083 23.5314 110171 25.5296 24.5313 32.6386 27.7697 110172 23.6803 24.7005 25.2396 24.5635 110174 14.6199 * * 14.6199 110177 21.2796 22.7831 24.4715 22.8933 110179 22.0767 24.3673 26.1423 24.1256 110181 12.9798 13.9591 34.9028 19.4061 110183 22.5148 24.2899 26.4248 24.4133 110184 22.1920 22.2761 24.3379 22.9563 110185 17.7925 17.3330 19.1991 18.0592 110186 18.3178 19.7172 21.1176 19.7561 110187 19.8419 22.8248 23.2571 21.8964 110188 23.7032 22.0258 * 22.7714 110189 20.8786 19.8454 21.4255 20.7155 110190 18.3649 20.7292 20.5708 19.8383 110191 21.4033 21.3404 23.8471 22.2253 110192 21.0486 22.9684 24.3823 22.8864 110193 20.7867 22.1477 25.1779 22.7067 110194 14.8115 15.8129 16.8075 15.8165 110195 12.7261 10.9444 13.7718 12.4602 110198 24.8646 24.8275 28.0634 25.9885 110200 17.7744 17.9631 19.4363 18.4074 110201 20.9497 21.9313 23.7261 22.1742 110203 22.7453 24.2062 23.3838 23.4874 110204 30.7342 35.3699 * 32.7584 110205 21.3617 20.1405 23.1969 21.5575 110207 14.7154 14.6045 14.7077 14.6752 110208 15.6161 15.0350 * 15.3251 110209 18.6404 20.0629 14.4751 17.7558 110211 26.9151 20.1024 * 22.9486 110212 14.3790 15.8420 18.7651 16.2466 110215 18.1539 21.0263 .5679 20.7523 110216 27.1878 * * 27.1877 120001 29.0427 29.4126 30.0871 29.5170 120002 25.2021 23.5667 24.2715 24.3269 120003 23.9115 24.6238 24.4013 24.3140 120004 24.8632 26.1398 26.8010 25.9297 120005 24.1662 22.3213 23.0113 23.1311 120006 25.8943 26.6302 28.1562 26.8635 120007 22.8772 22.7179 27.8497 24.2388 120009 16.4485 16.7630 13.9812 15.7613 120010 24.1923 24.9089 25.4050 24.8421 120011 37.2759 35.2051 30.9308 34.0921 120012 21.8507 22.0371 21.8997 21.9292 120014 24.1208 25.3557 25.3682 24.9359 120015 42.6465 * 24.6284 30.4099 120016 45.1899 43.5083 39.1160 42.7373 120018 31.1879 * * 31.1877 120019 25.5659 23.8535 24.4036 24.5914 120021 23.1839 36.8286 23.2759 26.4621 120022 19.2614 22.2781 22.4951 21.2033 120024 32.2514 21.9657 * 26.7529 120025 50.6376 40.1332 40.2485 43.1574 120026 25.1314 25.7023 26.3653 25.7684 120027 24.4535 23.1434 24.9464 24.1547 120028 27.0897 27.5365 29.5070 28.0817 130001 17.6306 19.6328 18.4733 18.5954 130002 16.9867 18.5746 20.1143 18.6076 130003 22.3430 23.0994 23.9403 23.1432 130005 21.2386 22.6364 24.4844 22.7104 130006 20.4614 21.4640 22.8567 21.6494 130007 21.8107 22.0894 22.8475 22.2657 130008 13.6018 19.3392 25.7798 18.7207 130009 15.9701 20.8748 18.3511 18.2768 130010 17.5119 17.7826 * 17.6552 130011 20.1147 22.1125 23.1120 21.7785 130012 24.9976 24.2451 22.5761 23.9471 130013 15.1129 22.6624 23.5316 20.2820 130014 19.2107 19.8240 21.6770 20.2852 130015 18.5913 16.4136 * 17.4135 130016 19.0516 20.1220 20.5728 19.9684 130017 19.6875 19.9511 20.3656 20.0262 130018 19.8425 20.0563 22.1899 20.7223 130019 19.1711 19.5147 20.3983 19.7057 130021 15.6155 14.4430 16.8582 15.5456 130022 18.9127 19.7814 21.5602 20.1253 130024 19.0703 19.9934 22.1611 20.4440 130025 16.4627 17.5989 18.7814 17.6827 130026 21.8106 23.2093 24.4976 23.1615 130027 20.5344 20.6641 22.0107 21.0236 130028 20.9674 21.2217 21.1492 21.1146 130029 18.7694 22.9243 * 20.4335 130030 17.5759 18.5827 * 18.0583 130031 16.7766 20.4146 23.5135 19.8631 130034 18.9483 20.5802 20.2401 19.9098 130035 20.7770 17.2864 * 19.1660 130036 13.6362 15.1590 18.5921 15.7605 130037 18.6856 19.2108 19.3979 19.1230 130043 16.7904 17.6920 18.4636 17.6040 130044 13.4513 18.7067 20.5584 17.5508 130045 19.0208 17.5152 19.0271 18.5109 130048 16.7900 * * 16.7900 130049 22.4440 22.0520 23.7212 22.7595 130054 17.7085 16.4675 16.8484 16.9601 130056 20.9476 28.8008 17.3947 21.1836 130060 22.7399 23.2512 24.6773 23.5532 130061 14.7394 * * 14.7393 130062 19.8157 19.8264 24.0494 21.3157 130063 18.8024 18.4797 18.8782 18.7287 140001 17.7990 18.1511 20.0247 18.6600 140002 19.9284 20.9959 22.5567 21.1478 140003 17.8595 18.0163 * 17.9385 140004 17.4574 18.9713 19.3237 18.5860 140005 12.3002 12.4144 13.2365 12.6493 140007 23.8585 24.9847 25.1836 24.6934 140008 22.1111 24.2634 26.3152 24.1972 140010 28.5635 28.0863 39.3621 32.1479 140011 18.6164 18.4052 19.0903 18.7086 140012 21.4374 22.5885 24.4070 22.8406 140013 19.6722 20.3147 19.9800 19.9935 140014 21.4042 22.2944 25.0616 22.9171 140015 17.6805 20.3540 21.4328 19.8233 140016 14.4938 15.4454 16.3417 15.3940 140018 22.4132 23.4062 24.3285 23.3864 140019 16.4254 16.1180 17.4206 16.6387 140024 15.3782 16.1032 * 15.7337 140025 18.5135 21.7775 18.0748 19.4744 140026 18.3220 19.7839 20.4084 19.5156 140027 19.2149 20.5980 20.9855 20.2413 140029 26.0833 28.5670 25.5253 26.6612 140030 23.1760 25.3715 26.5229 25.0851 140031 17.6067 16.9650 17.7449 17.4509 140032 19.0383 19.8033 20.6273 19.8411 140033 25.1639 22.8705 23.4279 23.7474 140034 19.8792 19.7711 20.9635 20.1903 140035 15.5040 17.4514 17.9641 16.9828 140036 19.1076 21.2366 18.5788 19.7025 140037 14.1083 14.3082 15.5578 14.6732 140038 18.4948 19.8197 * 19.1560 140040 16.7450 18.0342 19.2160 18.0347 140041 18.5952 18.8042 19.2893 18.8908 140042 15.8892 16.1157 17.1757 16.3886 140043 20.1176 21.7356 23.3751 21.8035 140045 17.7799 17.4261 18.9587 18.0683 140046 18.6371 20.0859 21.7969 20.2134 140047 13.3610 16.6672 17.7090 15.6942 140048 23.9545 23.8652 25.9122 24.5813 140049 26.9483 26.7160 20.7688 24.9027 140051 24.0796 24.7180 24.2472 24.3525 140052 17.9571 21.0450 21.6607 20.0955 140053 19.9620 20.9768 22.6099 21.1760 140054 23.1576 23.9459 35.5659 27.3968 140055 14.3603 15.8756 16.4409 15.4892 140058 18.6861 19.1199 20.5089 19.4559 140059 * 18.2593 21.9969 19.9435 140061 18.2039 18.4264 22.7791 19.6252 140062 28.5304 28.6390 30.7005 29.3149 140063 29.1453 29.6998 30.5430 29.8595 140064 18.9379 19.6954 20.6505 19.7669 140065 25.3336 25.5939 25.8676 25.6079 140066 13.6491 15.4818 18.0915 15.5544 140067 19.5292 20.7511 21.9579 20.7435 140068 21.6188 22.3622 24.1316 22.6861 140069 17.3879 17.7785 19.0441 18.0826 140070 22.7153 25.2646 25.2960 24.2944 140074 21.6052 22.2563 22.8249 22.2227 140075 21.6434 21.8472 26.5350 22.9476 140077 17.3647 17.3236 18.0487 17.5877 140079 23.6928 22.7046 25.7058 24.0319 140080 22.1968 22.0682 24.4056 22.8890 140081 16.9808 18.1746 * 17.5725 140082 29.7262 26.5960 25.0474 26.9608 140083 21.0330 20.7704 23.2822 21.6156 140084 22.3467 23.0263 25.4818 23.6135 140086 19.1613 19.1815 * 19.1714 140087 17.1147 21.4593 * 19.1145 140088 25.4176 26.5258 27.7274 26.5193 140089 18.3157 19.3230 20.7632 19.4616 140090 26.9364 28.0530 35.0300 29.4280 140091 21.9322 23.5559 23.7560 23.1453 140093 20.1528 20.7564 21.5376 20.7969 140094 21.9383 22.8892 23.7841 22.8588 140095 24.2859 25.5716 25.4815 25.1248 140097 21.1719 21.8418 23.8291 22.4038 140100 23.1399 23.8226 27.1868 24.8138 140101 21.4211 23.1418 24.6106 23.0966 140102 17.5729 18.6328 19.8678 18.6663 140103 18.1303 19.1834 21.3727 19.5392 140105 22.8944 23.8258 27.3323 24.5505 140107 11.8383 11.5827 * 11.7127 140108 26.9971 27.9140 * 27.4761 140109 14.5498 15.9178 16.4262 15.6166 140110 19.2888 20.9631 21.9129 20.7530 140112 17.6974 18.1119 19.8563 18.5020 140113 19.5584 26.2393 25.2205 23.4083 140114 21.0976 23.0383 24.1926 22.8235 140115 21.0433 20.4587 25.3410 22.2094 140116 23.8993 25.5980 26.8366 25.5062 140117 21.4876 22.0889 23.3536 22.3483 140118 24.3260 25.3249 26.1627 25.2644 140119 27.9145 30.6468 31.3486 29.9292 140120 17.9716 17.7667 20.3237 18.6579 140121 16.6993 16.2607 17.6019 16.8238 140122 26.1270 26.7882 26.7457 26.5545 140124 27.9813 30.6820 30.7744 29.7761 140125 16.9516 17.8190 19.5359 18.0996 140127 20.0489 20.8397 21.3102 20.7463 140128 23.1327 23.5481 * 23.3351 140129 20.2868 21.6252 21.6495 21.1744 140130 23.4298 26.0464 25.7324 25.1138 140132 23.3054 23.7046 23.0595 23.3426 140133 21.4166 20.1740 21.0993 20.9011 140135 17.3985 18.2479 19.3222 18.3661 140137 18.6330 20.4807 21.6017 20.2583 140138 17.1968 14.5771 14.2313 15.2378 140139 11.0397 * 20.2063 14.6320 140140 17.6845 18.8185 19.1636 18.5459 140141 19.1097 20.2606 20.3707 19.9234 140143 19.0810 19.9885 22.0009 20.2373 140144 22.2864 24.8854 26.9259 24.6726 140145 18.1788 19.4509 20.6142 19.4469 140146 19.9704 19.4272 * 19.6862 140147 18.8049 17.1013 18.2691 18.0420 140148 18.7730 19.7630 21.5777 20.0626 140150 24.7976 28.9853 33.5463 28.8474 140151 20.0310 20.8820 21.5167 20.8051 140152 25.6011 28.3946 28.6284 27.5483 140155 20.2778 24.2907 24.4956 22.9401 140158 22.7988 23.7428 23.6949 23.4182 140160 17.7921 19.8825 20.9016 19.5649 140161 20.3799 21.2045 22.2191 21.3060 140162 20.3452 21.6901 22.6426 21.5722 140164 18.6589 19.8246 19.7774 19.4344 140165 14.7223 16.3700 17.0665 16.0112 140166 18.3833 19.3672 20.4085 19.3581 140167 17.6525 18.8532 19.5959 18.7351 140168 17.7453 18.2896 19.6114 18.5329 140170 16.4107 17.6901 17.0666 17.0536 140171 15.0237 15.2617 17.3214 15.8617 140172 23.6262 24.8587 24.2924 24.2266 140173 16.3924 16.0030 32.8692 19.8554 140174 35.9320 22.0418 21.7356 24.5213 140176 24.5338 26.3468 25.6824 25.5437 140177 15.0827 20.3142 20.8526 18.2773 140179 21.9859 22.7345 23.9872 22.8894 140180 22.7996 22.7508 25.4497 23.6328 140181 21.9864 22.6643 23.2767 22.6706 140182 28.9515 25.1302 32.1969 28.8546 140184 17.2401 17.9169 20.6843 18.6331 140185 18.2867 18.8573 20.0931 19.0822 140186 23.5034 25.6807 29.0998 26.0890 140187 18.3331 19.4049 20.7319 19.4734 140188 16.1907 * * 16.1907 140189 20.6627 21.1515 22.5875 21.4411 140190 17.5263 16.6673 17.9194 17.3611 140191 25.2628 27.4166 24.5446 25.6579 140193 17.4057 18.5651 20.5958 18.8417 140197 19.3774 19.9406 19.2979 19.5430 140199 18.0450 18.5409 19.7888 18.7992 140200 21.7680 22.4626 24.1358 22.8115 140202 23.7955 25.2777 26.2460 25.1620 140203 21.0848 24.8870 26.6624 24.2960 140205 20.0784 * 25.1010 22.9703 140206 22.5109 22.8223 24.8824 23.3989 140207 22.3905 25.4539 23.3197 23.6919 140208 26.2527 28.3112 27.2009 27.2556 140209 20.1557 20.2433 22.0813 20.8567 140210 14.8248 15.5345 * 15.2105 140211 22.6265 22.8852 25.8603 23.8157 140213 24.9892 25.6839 27.4607 26.0827 140215 15.2893 18.5502 18.6962 17.4895 140217 25.7329 25.9030 24.7146 25.4260 140218 14.9851 17.4171 * 16.1590 140220 17.8450 19.3915 20.2803 19.2049 140223 24.9017 26.2168 27.4355 26.1911 140224 32.8292 25.6766 31.4716 29.8171 140228 20.1688 21.8627 22.9899 21.6593 140230 18.2983 12.3494 * 14.8541 140231 24.5019 26.0208 25.5536 25.3988 140233 21.2333 24.4419 24.7103 23.5150 140234 * 19.7266 20.8676 20.3084 140236 12.9253 * * 12.9252 140239 20.3745 21.6074 23.9213 21.9721 140240 24.6949 25.1418 25.0325 24.9609 140242 25.2317 26.1850 26.7947 26.1303 140245 14.2481 15.1320 15.2537 14.8687 140246 11.6267 15.0650 16.1305 14.1116 140250 23.6449 25.3410 24.7737 24.5985 140251 21.9435 23.5128 24.8256 23.4339 140252 25.0220 26.4715 27.4640 26.3370 140253 19.5858 18.4567 * 19.0172 140258 25.3622 25.0743 27.8202 26.1250 140271 12.0079 16.0350 17.5175 14.8913 140275 23.8171 22.9656 20.1784 22.2596 140276 25.3134 26.1713 25.1140 25.5042 140280 18.8300 20.0763 21.7004 20.2210 140281 25.2719 26.5197 27.9115 26.6261 140285 18.5916 15.7435 * 17.0403 140286 26.1290 24.0368 25.9931 25.3447 140288 24.4331 25.8717 26.2186 25.5431 140289 18.1747 17.7886 21.3632 19.1491 140290 22.8590 26.5055 30.7221 26.7335 140291 24.9537 26.8628 26.7900 26.2319 140292 21.9950 26.8610 26.0858 25.0061 140294 17.7301 19.4218 20.5969 19.2265 140300 27.8436 28.9830 30.2598 29.0524 150001 24.0620 22.6875 25.4897 24.1367 150002 20.7651 20.7353 22.3327 21.2734 150003 20.8636 21.4649 21.0944 21.1408 150004 21.2449 22.8060 23.5250 22.4800 150005 21.6806 22.8149 23.8818 22.8498 150006 20.6523 21.8435 23.1779 21.9153 150007 20.6635 21.2811 22.1098 21.3541 150008 21.8457 23.0208 23.8916 22.9022 150009 19.0030 19.5869 19.1857 19.2602 150010 20.5570 21.2466 22.5445 21.4807 150011 18.3275 19.9096 22.1760 20.1162 150012 22.1402 21.7903 23.1644 22.3790 150013 16.9327 17.5531 19.8564 18.1751 150014 21.5168 22.8402 24.3754 22.8817 150015 21.9037 24.2370 21.1839 22.3970 150017 19.5339 20.6758 22.7670 21.0275 150018 21.0496 22.8922 24.6138 22.9251 150019 17.8585 19.8341 17.7411 18.4067 150020 16.6600 15.9405 18.4688 17.0524 150021 21.5944 23.3800 24.3658 23.1607 150022 17.9222 18.7751 22.2973 19.8109 150023 19.3412 20.3015 20.7199 20.0985 150024 19.2295 19.8368 21.5661 20.1308 150025 20.2750 * * 20.2750 150026 22.4978 21.9448 23.2169 22.5611 150027 18.0335 19.4238 21.5325 19.7090 150029 23.2454 24.8939 25.2067 24.4325 150030 19.2406 20.7256 22.2537 20.7871 150031 18.3463 21.3494 18.3291 19.2245 150033 22.6741 23.0756 24.1718 23.2965 150034 23.1533 23.3718 22.8812 23.1378 150035 21.2374 22.3779 23.5468 22.3841 150036 21.4567 22.1464 22.4098 21.9941 150037 24.4611 22.3699 26.4359 24.3457 150038 22.0572 20.3454 21.6608 21.3217 150039 19.6215 16.0227 19.2708 18.1689 150042 20.2221 18.0185 23.6783 20.4220 150043 20.1741 20.6301 20.8562 20.5460 150044 19.1309 19.8951 20.7412 19.9259 150045 18.1670 20.6406 22.9339 20.5458 150046 18.2543 19.4146 20.3453 19.3721 150047 22.0145 21.9824 24.8712 22.8866 150048 19.1648 21.1441 22.5181 20.9965 150049 18.6451 21.6309 18.4989 19.5784 150050 17.7354 18.0411 18.0624 17.9423 150051 19.7257 20.6895 22.0106 20.8739 150052 17.3750 18.8345 19.1070 18.4211 150053 18.8632 18.3493 19.4966 18.9082 150054 18.3916 19.3424 * 18.8632 150056 21.5774 23.0603 24.5540 23.0525 150057 16.9736 17.4044 28.0884 20.1891 150058 22.1409 23.0273 24.9479 23.3727 150059 22.7360 23.1398 24.5716 23.4998 150060 18.6159 19.5011 19.8990 19.3356 150061 19.7968 19.4014 17.5585 18.7895 150062 20.8274 21.2608 22.9214 21.6432 150063 22.6525 24.8587 28.5326 25.3429 150064 20.3865 20.6232 21.2512 20.7527 150065 21.2153 21.4572 23.0636 21.9337 150066 19.5313 19.6845 20.7240 20.0045 150067 18.8862 20.5000 21.4374 20.3431 150069 23.3969 23.5510 23.8869 23.5811 150070 18.0827 18.9332 20.7413 19.2893 150071 13.5111 16.4179 19.4530 16.5251 150072 15.0765 18.5813 18.5447 17.3134 150073 * 19.8034 14.8287 16.6860 150074 20.2305 21.3500 22.9598 21.5274 150075 16.7532 17.2267 20.0897 17.8847 150076 22.6424 23.3724 25.4519 23.8726 150078 19.9668 20.2068 20.1260 20.1068 150079 18.2051 18.3668 19.3860 18.6860 150082 17.8381 19.6881 20.7334 19.4332 150084 24.3107 24.9529 27.8354 25.7663 150086 18.3838 19.7763 21.5815 19.9584 150088 20.3366 22.3055 22.2627 21.6628 150089 22.1725 21.5664 21.4993 21.7481 150090 21.0945 21.9803 24.7940 22.5227 150091 22.4640 26.5235 26.4248 25.0867 150092 16.9179 18.2592 16.7372 17.2915 150094 17.5244 16.8351 19.5004 18.0298 150095 19.2749 22.3214 23.5231 21.7410 150096 20.8204 * 19.7975 20.2623 150097 19.7751 21.1462 22.3593 21.2002 150098 15.2829 16.4763 17.8106 16.4972 150100 19.8066 18.7289 21.2980 19.8754 150101 20.6209 21.2025 26.1272 22.4675 150102 23.7180 20.8818 21.3313 21.8627 150103 18.7036 19.3653 17.9684 18.6804 150104 20.0765 21.3141 21.0799 20.8409 150105 22.4412 21.6975 23.9540 22.7002 150106 16.8714 18.7088 19.1976 18.3084 150109 19.9066 21.7870 23.4642 21.7343 150110 21.9336 * * 21.9336 150111 19.2355 24.1559 * 21.5147 150112 20.5253 22.1939 23.5151 22.0747 150113 19.6603 20.5871 21.2412 20.5276 150114 17.9877 18.3097 * 18.1462 150115 18.4844 18.1308 21.5042 19.3163 150122 17.7867 20.7540 22.2752 20.2587 150123 14.0508 16.2898 15.5997 15.3438 150124 15.9487 16.2104 17.9062 16.6729 150125 21.3311 22.0299 23.1015 22.1704 150126 20.6857 24.0000 24.1917 22.8979 150127 17.0052 18.0532 * 17.5279 150128 19.5576 20.4742 20.9869 20.3528 150129 28.6211 29.9888 34.3166 30.8814 150130 18.4846 18.3852 18.5578 18.4750 150132 20.9443 21.2747 22.2707 21.4967 150133 18.4250 20.0320 21.8167 20.0930 150134 19.3632 20.2764 20.7680 20.1127 150136 21.8097 22.9091 25.8467 23.5584 150146 19.0204 * 25.1827 22.2199 150148 * * 26.2190 26.2188 160001 19.0085 20.1699 22.8425 20.6574 160002 16.6003 17.6600 19.9607 18.0502 160003 16.2208 17.5429 17.5050 17.1062 160005 17.9405 19.3348 20.3313 19.1990 160007 15.1738 14.9137 * 15.0384 160008 16.6193 16.7863 17.9463 17.1044 160009 17.9886 19.0664 20.5800 19.2128 160012 16.7112 17.9236 17.2718 17.2909 160013 18.6304 20.3023 21.0541 20.0165 160014 16.7146 18.7253 18.3097 17.9036 160016 19.9747 21.6050 21.8400 21.1711 160018 15.6141 16.0793 16.8377 16.1872 160020 15.5384 15.7960 16.6092 15.9961 160021 16.7617 16.7920 17.2152 16.9236 160023 15.0099 15.3854 16.9777 15.7718 160024 19.4764 20.5622 22.1034 20.6927 160026 19.5260 20.4567 22.8967 20.9474 160027 16.9417 18.2081 18.9985 18.0413 160028 21.0000 22.9000 25.4337 23.0923 160029 21.3457 22.2106 23.6148 22.4178 160030 19.6182 21.6899 23.3687 21.5386 160031 16.1267 16.8957 17.8994 16.9687 160032 18.3168 19.2464 20.5024 19.3173 160033 18.8859 20.1916 21.8778 20.2846 160034 16.5957 17.3644 19.0684 17.6441 160035 16.3991 17.0165 * 16.6797 160036 17.4558 20.2598 * 18.9565 160037 19.5045 19.5067 20.6425 19.8844 160039 17.8647 19.1998 19.8851 19.0101 160040 18.0667 19.6339 20.0567 19.2064 160041 17.4435 18.7943 * 18.1971 160043 14.8564 16.7841 15.5765 15.7233 160044 17.8323 19.5552 19.0956 18.8738 160045 20.0611 21.4757 22.1285 21.2575 160046 16.2737 16.8665 * 16.5694 160047 19.0787 20.4259 22.0610 20.5906 160048 15.6856 17.2709 17.7273 16.8247 160049 15.5673 15.3233 20.5531 16.9039 160050 17.7878 21.1184 21.6247 20.1164 160051 16.4261 15.8213 14.0556 15.4076 160052 21.7647 22.1933 22.2409 22.0595 160054 16.1981 16.5258 15.9074 16.2107 160055 15.1674 17.6177 14.5971 15.6313 160056 17.0172 17.9534 19.6493 18.1612 160057 19.1378 19.6802 20.8345 19.9113 160058 22.1061 22.2812 23.5663 22.6513 160060 17.2825 17.7489 18.1102 17.6991 160061 17.0938 17.2064 18.0413 17.4625 160062 17.4388 18.8163 22.6687 19.5483 160063 16.3583 17.3771 17.9229 17.2470 160064 22.2131 25.2962 23.8367 23.7172 160065 17.1043 17.0609 * 17.0808 160066 17.9971 19.3202 20.4609 19.2300 160067 16.7833 17.6602 19.9422 17.9572 160068 19.0572 20.5995 23.4967 21.0271 160069 19.1640 20.5989 21.7197 20.4818 160070 18.4588 17.7855 20.3683 18.7886 160072 14.4141 15.3384 15.6894 15.1633 160073 11.4997 15.5946 16.2186 14.2046 160074 17.9513 18.4624 22.2989 19.4707 160075 18.4613 20.7842 21.9161 20.2495 160076 17.8824 19.1590 20.1603 19.0456 160077 13.6658 15.0468 16.8030 15.1869 160079 18.6333 20.5010 21.6562 20.2670 160080 19.4925 19.6680 21.1713 20.1081 160081 17.4466 19.1442 20.4415 18.9934 160082 19.5322 20.7306 21.3139 20.5262 160083 19.7542 21.3221 23.1417 21.3360 160085 21.2557 19.1929 * 20.1491 160086 17.5308 19.0477 19.8991 18.7925 160088 22.3655 23.8098 25.3429 23.8526 160089 17.3449 18.3526 19.9688 18.5909 160090 17.9614 18.4210 19.6767 18.6779 160091 14.2573 14.8904 16.1660 15.1176 160092 17.0633 17.9251 20.4731 18.4608 160093 18.5675 19.5732 22.8552 20.0542 160094 17.6094 18.7835 20.3433 18.9270 160095 15.2722 16.4927 * 15.8700 160097 16.6790 17.7860 17.7992 17.4211 160098 16.8670 16.8997 17.9906 17.2476 160099 15.0880 16.0710 17.5828 16.2056 160101 18.9788 19.6314 22.1741 20.2613 160102 20.1161 14.4837 * 17.0012 160103 18.2741 19.6168 22.4647 20.1210 160104 17.4829 21.0060 23.2738 20.6777 160106 17.3474 19.4385 19.8906 18.8668 160107 18.0097 18.8936 19.5110 18.7905 160108 16.7779 17.7577 19.6390 18.0443 160109 17.9873 18.2938 18.5126 18.2742 160110 20.6215 20.9959 21.9299 21.2145 160111 14.9965 15.1104 16.7625 15.6341 160112 17.2450 19.6950 20.4038 19.1223 160113 15.4834 14.9449 16.7574 15.7259 160114 16.5006 18.0532 19.1743 17.9155 160115 16.5654 16.9991 17.6815 17.0701 160116 16.6993 18.4261 19.6923 18.2708 160117 18.7615 20.1682 22.3228 20.3906 160118 19.4472 17.1480 16.9466 17.7185 160120 15.6789 15.0577 15.9432 15.5897 160122 18.1469 18.8469 21.2843 19.4799 160124 19.1600 19.9144 21.2279 20.1448 160126 19.4903 17.8643 20.0149 19.0751 160129 17.2112 18.0113 18.1304 17.7899 160130 15.6666 16.2628 17.4584 16.4856 160131 16.0424 16.5397 18.0499 16.8700 160134 15.3012 14.6396 17.0092 15.5453 160135 18.7711 18.3973 18.7512 18.6539 160138 17.1491 18.3957 17.8475 17.7631 160140 18.5630 19.6155 22.1666 20.1522 160142 18.1467 17.2792 * 17.6980 160143 17.4497 18.1287 19.0623 18.2106 160145 16.9092 17.8887 18.4032 17.7185 160146 17.7010 19.0576 20.6638 19.0955 160147 19.4041 21.6062 22.7993 21.2446 160151 17.2177 18.3398 * 17.7679 160152 15.9500 17.0750 17.9285 16.9659 160153 21.2085 22.7004 23.5212 22.4610 170001 17.9218 18.5120 19.8150 18.7852 170004 16.1442 17.2262 18.6048 17.3314 170006 17.5982 19.1982 19.4488 18.7531 170008 16.8412 17.7061 18.2351 17.6303 170009 23.1349 25.0508 25.8246 24.6993 170010 19.4584 19.5990 20.6294 19.9051 170012 18.4432 20.2412 21.6824 20.1902 170013 19.4667 20.1852 21.4954 20.4080 170014 18.4931 19.6044 21.3084 19.7344 170015 17.1302 17.2443 18.0485 17.4844 170016 20.0675 22.1023 22.5856 21.5884 170017 19.5994 19.7908 21.8586 20.4248 170018 15.3237 14.8794 16.9170 15.7229 170019 16.9362 17.4699 18.7916 17.7083 170020 18.1325 19.1418 20.6658 19.3514 170022 19.1888 20.3269 21.1947 20.2097 170023 19.2441 19.6533 21.6273 20.2090 170024 14.3604 15.0081 16.1196 15.1666 170025 18.7182 19.1720 19.2124 19.0231 170026 14.8974 16.9094 17.0837 16.3226 170027 17.8690 18.4466 20.7776 19.0432 170030 15.9282 12.9413 14.4544 14.3349 170031 14.2151 16.4660 16.5916 15.7181 170032 16.3449 15.2207 16.1164 15.8915 170033 19.1952 20.4533 20.0065 19.9072 170034 16.9586 17.8239 18.1073 17.6353 170035 17.0945 19.8334 * 18.4676 170038 13.8582 15.2505 17.0172 15.4188 170039 17.0774 18.5780 18.4473 18.0348 170040 21.0617 23.1014 24.5234 22.7728 170041 12.4488 9.9263 13.9710 11.9108 170044 17.3254 * * 17.3256 170045 25.8331 20.5454 18.4142 21.3297 170049 20.7921 21.2917 22.9404 21.7361 170051 16.4851 16.9003 16.8455 16.7442 170052 15.2283 16.0948 15.8809 15.7508 170053 14.6133 14.3628 14.5886 14.5203 170054 14.6354 15.2814 18.5239 16.1318 170055 18.2607 18.1783 * 18.2208 170056 18.3550 19.7369 17.1872 18.5237 170058 19.5415 20.1090 23.0649 20.9522 170060 18.9853 17.5290 17.9830 18.1586 170061 15.0258 15.6412 16.6852 15.7398 170063 14.1185 13.7611 17.2821 14.6657 170066 16.2891 16.8009 18.3113 17.1768 170067 14.9921 20.7945 * 17.6559 170068 17.0022 19.2629 20.5512 18.8725 170070 14.0627 14.8348 15.0540 14.6220 170072 12.7709 * * 12.7710 170073 17.7056 17.7586 17.4493 17.6284 170074 17.3699 17.6543 18.5169 17.8689 170075 13.6816 14.4939 15.6809 14.6514 170076 14.6109 14.9392 16.0998 15.2083 170077 13.9104 14.1376 14.6378 14.2439 170079 11.5902 16.7227 * 13.7740 170080 14.8293 13.6794 15.0079 14.4977 170081 14.6823 15.0840 15.7141 15.0936 170082 13.7462 14.8154 15.9973 14.8264 170084 13.0519 13.6517 14.5770 13.7521 170085 17.5422 21.8907 17.2585 18.9901 170086 19.7182 20.7298 21.7451 20.7316 170088 13.4860 * * 13.4860 170089 15.4860 20.2263 16.2599 17.5460 170090 10.9444 23.6837 16.3550 15.3916 170093 14.0276 14.7803 14.9660 14.5908 170094 21.2035 21.2484 20.1253 20.9151 170095 15.3532 16.1078 16.8686 16.1165 170097 17.7540 18.6023 18.9865 18.4524 170098 16.6210 17.3480 18.5181 17.4543 170099 14.3370 16.5247 15.8118 15.5495 170101 18.0143 17.3381 17.9291 17.7556 170102 14.2447 14.4499 14.6874 14.4627 170103 17.9530 18.6172 20.1264 18.9371 170104 21.0049 22.0671 22.6619 21.9115 170105 16.7403 18.2788 18.3824 17.8166 170106 17.7467 * * 17.7468 170109 16.9782 18.3483 20.4661 18.7139 170110 18.5731 21.0637 16.5883 18.8196 170112 15.4049 15.8097 17.8740 16.3357 170113 14.6486 16.4938 19.9957 16.7158 170114 16.2645 13.9726 17.4687 15.7793 170115 12.9216 13.0253 13.6173 13.1746 170116 18.1830 19.4278 20.8800 19.4962 170117 16.8237 16.8301 17.5794 17.0795 170119 15.2708 15.1982 13.9828 14.8083 170120 17.4917 18.2832 18.7576 18.1504 170122 21.1769 21.4588 22.2681 21.6171 170123 23.6534 25.2122 25.0073 24.6043 170124 15.0596 16.3925 14.2191 15.2518 170126 13.5736 14.5527 15.4213 14.4901 170128 14.1676 17.6259 13.9704 14.9984 170133 18.8119 19.9778 20.0593 19.6138 170134 14.6799 15.1932 15.4176 15.0931 170137 19.3118 19.3344 21.4394 20.0379 170139 14.3001 14.8157 16.9180 15.1918 170142 17.7134 19.0547 19.6251 18.8022 170143 16.0415 16.3258 18.0308 16.8248 170144 20.4392 20.8488 23.9179 21.2803 170145 19.0142 20.1494 20.5099 19.8990 170146 21.7919 25.2520 27.0312 24.7198 170147 17.6717 18.4634 18.2480 18.1292 170148 19.1942 24.4828 26.3491 22.6386 170150 15.9072 14.9718 16.3723 15.7462 170151 14.3668 14.5002 15.7242 14.8570 170152 15.6423 16.0930 17.6328 16.4532 170160 14.4732 17.0629 * 15.6980 170164 17.4072 17.0791 18.4142 17.6451 170166 12.7507 16.5113 17.8131 15.5313 170171 13.1792 14.7051 14.7251 14.2074 170175 20.1907 20.8671 22.2203 21.0292 170176 23.5043 23.5743 25.5404 24.2059 170180 8.6352 * 25.0933 14.1579 170182 21.3454 21.9797 23.2115 22.1999 170183 19.5182 16.6577 19.6919 18.5350 170185 * 26.8136 26.5542 26.6930 170186 * 33.2457 28.4462 30.5174 170187 * * 20.8289 20.8289 170188 * * 25.2504 25.2504 170189 * * 28.1999 28.1996 180001 20.4885 20.8169 22.2674 21.1866 180002 17.5798 19.8195 20.0075 19.1094 180004 17.7149 18.0494 19.8552 18.5287 180005 22.4634 23.4941 22.6704 22.8061 180006 10.3400 11.2872 14.4066 11.8905 180007 17.9491 18.6823 21.3545 19.3281 180009 21.0608 21.7746 22.4450 21.7873 180010 19.6311 19.4210 21.8916 20.3621 180011 19.0526 22.6798 19.2490 20.3535 180012 19.0646 19.6614 19.9227 19.5547 180013 19.7418 20.0950 21.0512 20.3043 180014 21.3361 23.0067 * 22.1047 180016 21.1458 19.7242 20.5203 20.4674 180017 15.6583 16.7649 18.0329 16.8060 180018 15.4892 18.1529 17.5670 17.0578 180019 17.8285 19.5953 20.8416 19.3979 180020 18.0111 19.4391 20.5659 19.3119 180021 17.0618 16.5376 17.6330 17.0802 180023 17.4717 19.0574 20.8869 19.1283 180024 16.5040 19.6313 22.3922 19.4653 180025 15.4180 17.1875 18.3306 16.9977 180026 15.0118 13.9959 15.5354 14.8403 180027 17.5286 19.6928 20.5017 19.2757 180028 15.7005 26.2220 19.7853 19.6547 180029 17.7248 20.0841 19.9084 19.2475 180030 17.9543 17.5043 19.5826 18.3704 180031 13.1848 17.1003 11.7847 13.7078 180032 17.2784 17.2362 17.6939 17.3857 180033 15.4131 17.0498 14.8047 15.7339 180034 16.3991 17.0349 16.4944 16.6481 180035 21.3666 22.4651 23.3685 22.4188 180036 20.1860 20.6951 22.2389 21.0630 180037 21.2184 21.0177 22.7893 21.7251 180038 18.5923 19.3837 20.6888 19.5760 180040 21.2229 22.2270 23.1648 22.2239 180041 16.3699 17.5950 19.1325 17.6429 180042 17.1519 15.5660 17.5774 16.7135 180043 14.6526 17.2414 20.7367 17.3094 180044 19.4984 21.1057 21.8163 20.8254 180045 20.8455 20.7498 22.1027 21.2441 180046 21.2080 21.6955 23.1139 22.0204 180047 18.6938 17.8625 17.8574 18.1198 180048 17.7816 18.3151 18.8537 18.3242 180049 16.5459 17.8418 18.5188 17.6210 180050 17.1493 19.4992 18.9891 18.5564 180051 17.5441 18.3028 18.6730 18.1921 180053 15.8994 17.3167 17.6239 16.9255 180054 20.0946 17.4354 19.1340 18.8876 180055 15.8422 16.6072 17.8704 16.7352 180056 17.5881 18.7038 19.4072 18.5962 180058 14.5355 14.8840 17.6126 15.5719 180059 14.7032 17.2542 17.7683 16.4865 180063 12.4448 14.7338 15.5077 14.2770 180064 15.5066 16.3894 21.1067 17.5598 180065 11.1934 11.0966 9.9166 10.8002 180066 19.8956 20.7907 21.1883 20.6121 180067 20.1712 20.2762 21.5671 20.6602 180069 16.2916 19.0836 19.5693 18.2811 180070 15.9362 15.4643 16.9892 16.1274 180072 17.2347 17.0576 17.5411 17.2563 180078 21.7116 23.7765 23.4616 23.0019 180079 15.9048 18.1683 18.0472 17.3416 180080 16.6428 17.6735 18.8793 17.7518 180087 15.6089 16.2378 16.4726 16.1124 180088 22.1774 22.8908 22.9130 22.7063 180092 18.3597 18.8964 19.6790 18.9885 180093 17.8492 17.7592 18.8469 18.1473 180094 13.6233 14.3306 15.7641 14.5357 180095 13.9050 15.4478 15.9881 15.0485 180099 13.2991 14.0464 14.0115 13.7738 180101 * 21.0704 21.7454 21.4083 180102 18.5240 18.8169 20.1259 19.1237 180103 20.3490 20.9598 21.3867 20.8948 180104 19.3922 20.2731 21.3866 20.3724 180105 16.6997 18.2976 18.3521 17.7554 180106 15.2895 15.5278 15.4937 15.4371 180108 14.4740 14.8720 16.7327 15.3846 180115 16.9096 18.0951 19.2396 18.0795 180116 18.6077 19.2389 20.5453 19.4231 180117 23.0192 20.7961 17.8273 20.4194 180118 16.9250 17.9017 18.3618 17.7402 180120 15.3115 16.4226 20.4507 17.0636 180121 20.0494 16.9570 16.9881 17.9386 180122 18.1930 18.7549 26.1085 21.0314 180123 21.1067 21.5962 * 21.3452 180124 18.8487 19.7138 20.5265 19.6910 180125 14.9314 22.6609 18.2048 17.7710 180126 14.3551 14.8501 14.5644 14.5905 180127 17.6365 18.0498 19.9846 18.6169 180128 18.2817 18.7194 19.8756 18.9809 180129 22.3536 15.6637 14.1861 16.9914 180130 20.6450 21.9413 23.4841 22.0517 180132 19.5884 19.8393 19.9358 19.7903 180133 21.7800 23.2679 * 22.4729 180134 14.5387 16.5901 * 15.5000 180138 20.2102 19.8524 22.8363 20.9918 180139 20.5350 20.3816 20.6987 20.5422 180140 15.2719 14.6466 16.9631 15.5822 180141 23.8930 20.3404 22.5552 22.1339 180142 20.7510 * * 20.7510 180143 * 21.3197 19.7662 20.5610 190001 18.1514 18.8583 20.4946 19.2128 190002 19.8834 20.6057 21.0138 20.5155 190003 19.9121 19.5115 20.7504 20.0615 190004 18.3620 19.6755 20.5272 19.5326 190005 17.5161 19.0994 19.8177 18.7716 190006 17.5911 17.7333 18.7928 18.0215 190007 14.4720 16.3633 17.9392 16.3508 190008 19.2456 22.4797 20.3099 20.6400 190009 15.9731 16.0395 17.5144 16.4753 190010 16.5020 17.7616 18.1797 17.4941 190011 15.6351 15.7319 15.4699 15.6120 190013 15.5019 16.7770 * 16.1202 190014 17.8015 18.6929 * 18.2302 190015 18.9896 19.7673 20.5905 19.7878 190017 17.5381 19.8449 18.3528 18.5693 190018 11.1898 13.1355 18.6199 13.8655 190019 18.3788 18.7344 20.8052 19.3372 190020 17.6840 18.7252 18.5659 18.3279 190025 16.8686 18.1892 19.9177 18.2844 190026 18.5015 19.0130 19.9178 19.1653 190027 17.4761 18.4070 19.5358 18.4507 190029 19.1967 18.7344 18.1118 18.6759 190034 18.0754 19.2007 * 18.6247 190036 20.0300 21.2960 23.3903 21.5497 190037 19.9878 14.1323 15.6062 16.9453 190039 19.0376 18.7625 20.4160 19.3991 190040 21.7376 23.1819 22.9262 22.6065 190041 17.9535 19.5511 21.9983 19.8665 190043 15.5618 15.5645 15.7333 15.6215 190044 17.4471 17.6788 17.7460 17.6341 190045 21.2853 22.0065 22.8709 22.1191 190046 20.4458 20.2414 21.1659 20.6024 190048 16.8136 16.6848 18.1698 17.2383 190049 17.7417 18.5902 19.3768 18.5593 190050 16.2854 16.9053 18.6663 17.3158 190053 13.0080 13.4768 13.8037 13.4554 190054 18.9059 17.7269 19.9370 18.8703 190059 15.8373 17.8651 18.3334 17.3742 190060 17.8443 19.9121 20.2207 19.3688 190064 18.2466 19.7215 21.0488 19.7211 190065 18.3091 18.3280 20.3583 19.0184 190071 16.4138 16.3822 17.8444 16.8680 190077 16.5536 16.8829 17.0480 16.8252 190078 16.9383 19.5879 19.8607 18.8295 190079 17.9403 18.8187 * 18.3869 190081 14.9707 14.7919 11.4756 13.7796 190083 18.4951 16.2970 18.4954 17.7997 190086 16.5074 17.6237 18.2005 17.4309 190088 19.9362 20.4725 18.6738 19.7186 190089 15.0395 15.2055 15.5151 15.2626 190090 16.2351 19.8201 19.0519 18.4143 190095 17.3258 17.3637 16.9519 17.2138 190098 21.0847 21.4328 20.7537 21.0874 190099 19.0635 19.0545 23.1606 20.4338 190102 20.7870 21.1614 22.0190 21.3440 190103 14.4158 15.6415 * 15.0851 190106 18.5908 19.9117 20.3114 19.6058 190109 15.8187 16.3641 16.6515 16.2945 190110 15.7313 15.2652 16.5007 15.8208 190111 20.6508 21.3622 24.4380 22.2154 190112 22.0741 24.2806 * 23.0835 190113 * 19.0411 * 19.0411 190114 13.9209 13.5044 13.6101 13.6758 190115 22.7583 24.0098 25.4983 24.0285 190116 17.3757 18.3223 * 17.8596 190118 16.3776 17.8543 17.5060 17.2223 190120 17.2309 17.6708 18.5094 17.7933 190122 15.3742 16.7189 17.7811 16.6133 190124 20.1206 22.8245 21.9308 21.6225 190125 19.8298 20.1401 21.5692 20.4994 190128 20.8770 21.5869 23.8786 22.1716 190130 14.0379 14.5586 15.2678 14.6311 190131 18.8958 19.7483 21.3154 20.0242 190133 15.1393 15.7834 13.4062 14.7514 190134 12.4507 * * 12.4507 190135 21.3454 23.0213 24.5472 22.9404 190136 15.1662 15.6286 16.7852 15.8135 190140 14.6829 14.8738 15.4029 14.9883 190142 16.2280 19.0464 22.5765 19.3164 190144 18.4405 18.3513 21.3838 19.3822 190145 16.2505 16.4402 17.4407 16.7345 190146 21.9607 20.9312 22.1502 21.6747 190147 14.7202 15.2732 16.3596 15.4387 190148 15.5338 19.4518 19.3245 17.9652 190149 16.4722 16.5153 18.4197 17.1004 190151 15.5210 16.2783 17.3402 16.3739 190152 22.0319 22.7142 25.1136 23.3179 190156 16.0442 17.6573 18.0528 17.2654 190158 20.4078 21.6307 23.2361 21.7367 190160 18.4662 19.3139 19.8734 19.2722 190161 15.9280 15.7807 27.3615 18.5292 190162 20.1962 20.9645 20.7350 20.6423 190164 18.2379 19.0473 * 18.6694 190167 17.7611 15.5795 * 16.5290 190170 14.5222 16.2045 * 15.4153 190173 23.0934 * * 23.0934 190175 20.4580 23.0144 22.7574 22.0818 190176 22.2316 21.7051 24.3432 22.8033 190177 19.7794 20.3679 22.3318 20.8422 190178 12.0372 * * 12.0373 190182 20.7102 23.1997 23.6016 22.4491 190183 16.0752 16.7402 17.1805 16.6637 190184 19.8436 18.6583 20.6096 19.6762 190185 20.5852 20.7351 29.7870 23.2575 190186 17.4078 16.7272 18.4556 17.5015 190190 15.8985 13.7951 16.2819 15.2413 190191 19.6911 19.7218 21.9141 20.4097 190196 18.6138 19.1961 20.7601 19.5709 190197 20.2082 20.9871 21.6908 21.0235 190199 15.3522 17.8288 11.3015 14.1164 190200 21.6852 22.3510 24.2525 22.7566 190201 19.7421 21.7185 21.1903 20.9110 190202 * 22.4701 22.4062 22.4391 190203 21.7931 23.0636 24.9518 23.3496 190204 20.5784 22.9134 26.1231 23.1780 190205 19.3737 18.8750 20.2374 19.4986 190206 21.3307 21.7867 24.2892 22.5212 190207 19.0216 20.7024 19.7316 19.8068 190208 16.9641 17.6834 23.0838 18.5667 190218 19.2992 20.7290 21.6207 20.5593 190231 17.7247 * * 17.7247 190236 21.1982 22.5796 24.4661 22.8193 190238 20.6799 * * 20.6799 190239 19.7601 * * 19.7601 190240 14.3579 16.0658 15.4026 15.3226 190242 * * 12.2209 12.2209 200001 18.2513 19.7903 21.3664 19.8121 200002 22.3035 22.3145 24.7102 23.1322 200003 18.4141 18.5779 20.1431 19.0655 200006 21.0922 18.9818 * 20.0361 200007 18.1681 19.0387 21.3451 19.4241 200008 21.5556 23.2883 25.6369 23.5650 200009 21.4763 23.3090 24.6974 23.1816 200012 19.1047 20.5141 21.7931 20.4820 200013 17.9378 20.3793 22.9359 20.4733 200016 17.1187 16.2939 20.9892 18.0074 200018 17.8675 19.8848 21.2548 19.6846 200019 19.9245 21.1893 22.7794 21.2976 200020 22.3355 24.7433 27.0790 24.8621 200021 20.7361 22.0144 24.9384 22.6378 200023 20.2063 * * 20.2063 200024 20.8336 21.0633 22.7515 21.5341 200025 20.4165 21.4247 22.8869 21.5952 200026 17.9021 18.1459 19.7172 18.5708 200027 19.4220 20.2100 20.8262 20.1773 200028 18.8763 19.8886 22.2117 20.3329 200031 16.1641 17.7875 18.5637 17.4852 200032 19.4613 20.9148 22.1885 20.9008 200033 22.4685 23.6298 25.1723 23.7287 200034 20.4941 21.8266 23.5414 22.0096 200037 20.3015 19.5004 22.5582 20.7085 200038 21.2632 22.9220 23.7816 22.6253 200039 20.1508 21.5695 22.1873 21.3042 200040 18.9580 20.7744 21.8525 20.5333 200041 18.8131 20.2986 21.3816 20.1961 200043 19.4295 20.0280 * 19.7244 200050 20.2014 23.0314 23.6076 22.2752 200051 22.0712 * * 22.0712 200052 17.6271 18.9290 19.5066 18.7096 200055 18.5983 19.4998 19.8009 19.2948 200062 18.4279 18.0949 18.3225 18.2799 200063 21.2121 22.5265 26.3887 23.2533 200066 17.0570 18.4281 19.4759 18.3382 210001 18.6617 21.5280 22.6614 20.9120 210002 23.5132 26.5907 25.6975 24.9889 210003 26.0447 22.3090 23.0790 23.7255 210004 24.9760 27.2278 28.8679 27.0643 210005 21.3829 22.5304 24.7185 22.9229 210006 19.3682 20.8607 24.1987 21.4594 210007 23.8840 23.4582 27.5104 24.9372 210008 21.2895 21.0767 24.6569 22.4641 210009 20.7479 20.8476 23.4889 21.7419 210010 19.5908 20.4097 23.0440 21.0277 210011 21.4043 20.4017 22.1443 21.2906 210012 21.3977 24.8430 25.2892 23.7249 210013 19.4505 23.1649 23.0151 21.9197 210015 18.7448 23.9651 23.8419 22.0261 210016 26.5193 24.7441 27.2302 26.1373 210017 18.5079 18.2963 19.5294 18.7753 210018 22.8553 23.6442 25.3112 23.9214 210019 20.6025 21.5429 23.5259 21.9407 210022 24.5744 25.6728 27.6680 25.9838 210023 22.9989 24.4815 26.7837 24.7914 210024 24.4280 24.7858 24.8939 24.7076 210025 21.2769 21.4910 22.8882 21.8653 210026 13.8668 20.7986 * 16.5220 210027 17.1060 16.2219 19.1886 17.4744 210028 19.4157 20.4027 22.4054 20.7783 210029 25.4939 24.7605 26.2082 25.5405 210030 20.9574 21.9547 20.7801 21.2193 210032 20.1955 20.0825 20.3407 20.2132 210033 23.7588 22.8303 25.0300 23.8986 210034 19.4144 22.6812 22.8827 21.5075 210035 20.8317 21.6662 21.6973 21.4040 210037 20.5528 21.1659 23.5536 21.8146 210038 24.9762 25.9701 26.5696 25.8902 210039 21.3559 23.3583 23.5618 22.7399 210040 23.4252 23.7067 25.4729 24.1964 210043 22.4000 22.9504 20.9824 22.0358 210044 23.0917 22.9540 23.8101 23.2851 210045 12.1467 13.5654 11.8350 12.5334 210048 24.6921 24.9381 24.4328 24.6715 210049 19.3022 21.1056 23.4786 21.4119 210051 23.6476 24.8949 25.7103 24.7772 210054 23.2730 25.1694 27.3551 25.2404 210055 26.5272 23.8025 27.4218 25.8633 210056 22.9593 22.6958 23.5291 23.0845 210057 26.0076 25.6142 27.4175 26.3518 210058 16.3191 17.4250 22.0351 18.6822 210059 25.6052 * * 25.6053 210060 26.5846 26.4566 25.8377 26.3021 210061 16.1931 20.8975 22.5454 20.0819 220001 22.9064 23.4091 25.8030 24.0472 220002 24.5840 25.4158 26.3348 25.4205 220003 17.9319 17.6069 18.8150 18.0852 220006 22.6337 23.8920 25.9967 24.1779 220008 22.0796 24.2393 25.6647 24.0447 220010 22.0067 23.4009 24.5021 23.3133 220011 29.5290 20.6390 29.7597 26.1454 220012 31.2303 31.1041 31.8043 31.3960 220015 23.1893 24.1348 25.0272 24.1474 220016 23.0951 24.6149 25.5598 24.3980 220017 25.1568 25.9000 26.0635 25.6650 220019 19.8551 19.9268 21.6620 20.5000 220020 22.4295 22.5375 23.2840 22.7668 220024 21.9316 23.8620 24.1071 23.3004 220025 22.8593 22.0003 23.2374 22.6994 220028 21.0630 24.1251 31.4858 25.0402 220029 25.6560 25.7660 27.4792 26.3128 220030 18.7429 18.9012 20.0816 19.2486 220031 29.3091 28.3832 30.8324 29.5603 220033 20.3609 21.8156 25.2942 22.4280 220035 23.1892 25.7456 26.7656 25.1903 220036 24.4091 25.5771 26.1128 25.3339 220038 22.3162 22.9821 24.2072 23.1581 220041 27.5034 28.6790 29.4322 28.5477 220042 26.0473 28.4675 * 27.2387 220046 23.3149 24.1931 26.1955 24.5514 220049 27.2689 25.4358 26.7406 26.4572 220050 22.5265 23.3330 23.8005 23.2263 220051 21.7357 22.4826 22.2965 22.1608 220052 23.5225 25.4091 26.3043 25.1274 220057 25.8064 26.2945 * 26.0375 220058 26.8345 21.6814 22.4816 23.6744 220060 28.0794 28.3950 29.6290 28.7209 220062 20.2254 22.5567 22.6598 21.8448 220063 20.8079 21.8365 23.3704 22.0573 220064 22.7497 24.0982 * 23.3816 220065 20.1424 21.5657 22.4143 21.3853 220066 23.4477 24.5463 23.4622 23.8055 220067 27.5405 28.2685 26.9915 27.5793 220070 20.9128 23.9850 26.2697 24.8446 220071 27.4151 27.7679 27.7773 27.6608 220073 26.1328 27.4778 29.7863 27.7808 220074 24.3057 25.3331 26.4210 25.3967 220075 22.5329 24.6982 25.7813 24.3463 220076 23.2795 24.1224 24.8040 24.0785 220077 26.1545 27.1503 26.7165 26.6753 220079 22.0769 25.7305 * 23.1834 220080 22.1971 22.9911 24.6008 23.2916 220081 29.6682 31.1326 33.3649 31.4663 220082 22.1453 23.2818 23.9542 23.1292 220083 22.5815 27.2605 28.3533 25.8389 220084 25.3761 26.0395 26.8596 26.1410 220086 26.7778 28.7324 31.9999 29.0552 220088 23.4258 25.0671 25.0645 24.5354 220089 25.4106 25.3521 28.9252 26.5987 220090 23.3049 26.0265 26.0654 25.2015 220092 24.7905 29.4173 * 26.0747 220095 21.7851 22.6828 23.7629 22.7845 220098 23.1547 24.7180 26.2287 24.7066 220100 27.5841 26.8001 25.8127 26.6900 220101 27.0711 28.0856 26.9992 27.3742 220104 28.7258 * * 28.7258 220105 21.9185 25.5692 24.4095 24.0741 220106 25.9277 27.6812 * 26.8476 220108 23.4975 24.5939 26.0166 24.7052 220110 29.1648 30.6173 33.9228 31.2432 220111 24.7510 26.7573 26.9565 26.1374 220116 32.0049 28.5716 30.9871 30.4812 220119 23.8785 24.6344 25.5111 24.6718 220123 32.4678 29.6084 32.1805 31.3951 220126 23.6045 23.8123 36.1591 27.2823 220133 29.3911 29.8366 27.4183 28.8616 220135 28.3648 29.6837 31.2687 29.8642 220154 21.1563 23.3590 25.5654 23.5365 220163 29.2299 29.3552 27.8718 28.5798 220171 24.9261 27.3487 25.9496 26.1526 230001 20.0438 23.3051 22.0875 21.7854 230002 23.0439 24.3115 23.7972 23.6903 230003 21.2215 21.6493 22.6120 21.8276 230004 20.5005 22.4538 22.3271 21.7397 230005 17.0943 20.5596 20.2186 19.1829 230006 20.4978 20.6985 21.9442 21.0676 230013 22.2211 20.0954 20.4633 20.9362 230015 20.6464 21.9499 21.6344 21.3826 230017 22.9755 25.7900 26.1609 24.9780 230019 23.6674 23.8779 24.7356 24.1224 230020 21.8526 28.8869 25.8265 25.0793 230021 19.8256 20.9145 21.9537 20.8777 230022 21.9129 21.8808 22.2179 22.0038 230024 24.9664 26.2155 24.1272 25.0227 230027 19.6393 22.5114 22.1018 21.3775 230029 22.1782 24.9754 24.9385 23.9465 230030 18.6406 19.2441 19.2145 19.0453 230031 19.9465 19.4676 22.1874 20.5558 230032 24.8930 22.8436 23.5011 23.7370 230034 19.4366 17.9276 19.0026 18.7604 230035 17.7490 20.5906 18.0735 18.7098 230036 23.8398 25.1507 25.9801 25.0254 230037 23.2751 22.7382 24.7183 23.5739 230038 21.9692 20.9389 23.2065 22.0318 230040 20.7841 20.2451 21.8062 20.9418 230041 21.7364 23.2870 24.2297 23.0470 230042 21.3870 20.7745 22.5003 21.5609 230046 25.3206 26.1787 27.7076 26.3640 230047 22.3595 23.7178 24.3622 23.4689 230053 26.8917 23.5702 25.3705 25.3321 230054 20.8014 22.2105 18.9493 20.6840 230055 20.8492 20.8930 20.9350 20.8938 230056 17.8091 17.3516 19.4126 18.2031 230058 21.0303 21.6619 22.4579 21.7287 230059 20.7092 20.6540 20.6854 20.6835 230060 19.8987 20.5120 22.7605 21.0950 230062 18.8039 18.2283 * 18.4950 230065 22.7416 23.3414 26.3217 24.0577 230066 23.0475 23.2790 23.4679 23.2643 230069 24.2470 25.0212 26.4859 25.2413 230070 21.5666 21.2476 22.8588 21.8801 230071 23.1337 23.6398 23.6674 23.4732 230072 20.4456 22.6533 22.8090 21.9640 230075 22.5866 22.3632 22.4692 22.4739 230076 24.7010 26.9662 * 25.7305 230077 20.2823 22.6781 23.6116 22.2277 230078 17.9868 19.1638 20.5427 19.2537 230080 20.2104 19.1810 20.4095 19.9313 230081 19.0199 20.0464 20.4289 19.7958 230082 19.0419 18.2165 21.0552 19.3344 230085 23.4996 24.5765 24.2802 24.1339 230086 20.1730 20.1461 25.1139 21.7587 230087 19.9700 20.6619 22.2688 20.9389 230089 22.6994 23.1023 23.3847 23.0660 230092 20.7738 22.3437 22.3122 21.8236 230093 20.6314 21.0274 25.0356 22.3197 230095 17.6444 18.0582 19.1810 18.3175 230096 22.7785 24.3004 26.5685 24.5818 230097 21.1254 22.5006 22.9902 22.2246 230099 21.7513 22.3422 23.5490 22.5510 230100 17.3842 18.2477 19.8016 18.4668 230101 20.5315 22.5159 22.3310 21.7559 230103 11.3429 18.5254 19.4434 16.3738 230104 24.1238 25.5606 27.7635 25.8605 230105 22.6098 23.0086 23.9851 23.2114 230106 21.6825 22.9909 23.1961 22.6494 230107 17.1386 18.9985 * 18.1307 230108 20.3437 21.4592 19.9763 20.6173 230110 19.7262 21.0925 21.8501 20.8760 230115 19.6281 21.0361 * 20.3009 230116 14.5692 15.6064 20.1283 16.4365 230117 25.6797 25.5154 28.1220 26.4781 230118 20.6797 20.2770 23.2432 21.3687 230119 22.6555 23.9898 24.7999 23.8287 230120 20.3306 20.6105 22.7243 21.0521 230121 21.3342 21.4615 24.6973 22.4295 230124 18.9981 20.9641 22.0096 20.6756 230128 24.0724 24.4952 * 24.2953 230130 22.1775 23.5123 23.7854 23.1764 230132 26.1946 27.3637 29.0292 27.5003 230133 17.1058 19.0770 20.2461 18.8268 230135 20.5637 18.4193 19.8290 19.6840 230141 22.4570 24.4560 23.9885 23.6151 230142 23.5621 25.0282 22.9036 23.7956 230143 16.7948 18.2700 19.5446 18.1583 230144 23.4237 23.3295 23.6959 23.4486 230145 19.2638 17.9811 15.8192 17.6120 230146 21.2260 22.3838 21.3539 21.6475 230147 23.2755 26.5260 * 24.7445 230149 18.8005 19.9577 20.8933 19.8319 230151 23.3967 24.3705 25.6421 24.4652 230153 18.7403 20.0098 22.8443 20.5744 230154 15.4362 16.7152 15.9001 16.0188 230155 20.5409 20.7546 18.0743 19.8594 230156 25.6228 27.2254 28.0692 26.9451 230157 17.3571 * * 17.3571 230162 21.7148 22.7984 * 22.2573 230165 23.8881 24.7959 25.9534 24.8621 230167 22.9745 24.1344 24.7967 23.9623 230169 24.3874 28.1039 24.9264 25.7012 230171 17.1282 16.1129 19.9097 17.6776 230172 21.4675 22.1709 23.0023 22.2346 230174 22.7304 23.5025 24.5090 23.5983 230175 * 14.4932 22.5965 17.8784 230176 23.8204 24.9032 24.7466 24.4760 230178 17.3030 17.3428 18.1397 17.5917 230180 18.5744 19.6062 20.9131 19.7352 230184 19.7717 20.6406 21.3426 20.5906 230186 15.7837 19.1289 21.2156 18.3800 230188 16.2975 16.8687 18.3241 17.0936 230189 17.9218 19.1990 22.7783 19.9127 230190 26.4687 24.4643 26.8284 25.9306 230191 18.4861 20.6633 * 19.5216 230193 19.8287 21.5358 22.8917 21.3669 230195 22.9228 23.4647 25.3285 23.9218 230197 24.0854 25.5312 26.9776 25.4753 230199 20.6580 22.4592 23.5942 22.1770 230201 18.0787 18.2486 * 18.1632 230204 23.4966 24.5127 24.4095 24.1113 230205 15.9314 18.1551 * 17.0325 230207 21.2483 20.9059 22.2848 21.4738 230208 16.7454 17.8118 19.0898 17.9011 230211 21.8581 21.1245 * 21.4701 230212 24.2611 24.6420 26.4825 25.1164 230213 15.5469 17.1062 18.7123 17.1022 230216 21.0710 22.2137 23.4216 22.2323 230217 22.2698 24.1455 24.3649 23.6068 230219 20.0442 18.1277 20.5935 19.6048 230222 21.9711 23.2545 24.2148 23.1524 230223 22.6887 25.2666 28.5549 25.4631 230227 22.3155 25.8826 27.7510 25.3402 230230 22.3097 22.1703 22.0423 22.1610 230235 17.7197 17.5940 19.2540 18.1724 230236 25.9676 25.3251 25.4791 25.5829 230239 17.8168 18.9790 19.8370 18.8918 230241 20.7297 21.8472 22.8539 21.9059 230244 22.2697 23.1175 23.1234 22.8331 230253 21.0433 22.7706 24.9784 22.9234 230254 22.6335 23.3714 24.2594 23.4070 230257 21.3880 23.1794 24.8070 22.9716 230259 22.3969 23.1768 24.5001 23.3910 230264 17.4864 18.6598 18.2571 18.1056 230269 24.0992 24.3772 24.9596 24.4951 230270 22.5985 25.2665 22.9002 23.5673 230273 22.8715 24.1278 25.8466 24.2438 230275 20.8985 32.0037 29.4179 26.3638 230276 25.8709 22.3313 25.4127 24.3279 230277 23.9771 24.3351 25.3381 24.5552 230279 17.8074 18.3256 21.2467 19.1913 230280 18.3497 * * 18.3498 230283 22.5082 * 25.0038 23.8515 230286 * 47.5925 * 47.5929 230287 * 22.5420 * 22.5420 230288 * * 30.5931 30.5929 240001 25.6936 26.6372 28.2239 26.9164 240002 23.2307 24.2214 24.3916 23.9674 240004 24.4030 25.6238 26.8197 25.6037 240005 20.3193 20.2389 22.7873 21.0896 240006 23.0715 25.7288 29.5789 26.1049 240007 19.0850 20.7189 21.4367 20.4240 240008 23.3783 22.7437 26.3213 24.1118 240009 17.1187 17.4518 * 17.2880 240010 25.4752 28.3796 29.0956 27.7014 240011 21.5875 22.5188 24.0365 22.7468 240013 21.7544 25.1560 27.2049 24.6443 240014 24.2610 25.2306 26.5144 25.3969 240016 22.2011 23.3772 25.2629 23.6323 240017 18.9272 19.3431 21.6243 19.9559 240018 18.4268 23.6092 27.3634 22.7452 240019 23.1477 24.0613 25.1331 24.1004 240020 20.8849 20.6819 24.7719 22.0019 240021 20.1457 19.0469 23.9570 20.9424 240022 21.3234 23.0394 23.4702 22.5966 240023 22.8224 22.3002 24.4609 23.2632 240025 20.0308 20.7672 21.2597 20.6915 240027 16.7758 18.3837 18.3340 17.8317 240028 25.1934 * * 25.1933 240029 20.0164 23.0440 21.2343 21.3892 240030 20.1653 20.9799 22.0200 21.0838 240031 19.3983 21.7620 23.4390 21.5566 240036 22.1721 22.5436 23.3926 22.7261 240037 20.1195 21.4275 21.8392 21.1496 240038 24.3957 26.4513 29.0330 26.6099 240040 23.1352 22.8191 21.3870 22.2562 240041 21.8655 21.9054 22.8511 22.2064 240043 16.9859 18.0186 19.5532 18.2400 240044 20.3339 22.5750 22.7043 21.8646 240045 24.1557 24.2936 25.9223 24.7977 240047 23.8098 25.3233 29.6184 26.0294 240050 21.6499 23.1109 24.7589 23.1788 240051 22.5855 23.2612 25.5603 23.8542 240052 * 22.3485 23.5899 22.9828 240053 23.8693 24.4191 26.6015 24.9787 240056 23.7139 24.8549 28.5169 25.8728 240057 24.8686 25.3984 27.7600 26.0180 240058 18.4009 19.0506 19.6784 19.0102 240059 23.7808 25.3847 27.0517 25.4242 240061 25.9951 27.9151 28.6098 27.5450 240063 24.4031 25.8594 26.7645 25.6926 240064 22.8578 24.6785 24.9928 24.2158 240065 14.8734 14.4623 15.3825 14.9036 240066 24.1143 25.5163 27.4066 25.7241 240069 21.7991 23.3373 25.7439 23.6631 240071 21.2463 22.6332 24.8036 22.9056 240072 20.9529 21.5455 22.9244 21.8214 240073 17.3559 17.9013 20.1334 18.4502 240075 21.3357 21.9160 24.4084 22.5903 240076 22.3280 23.6159 26.8682 24.3772 240077 20.3445 22.1509 18.9735 20.4406 240078 25.1082 26.2576 27.5066 26.3275 240079 18.8345 18.2929 20.6644 19.2023 240080 25.5619 26.3071 27.8058 26.5849 240082 18.7995 20.2018 21.4727 20.1735 240083 21.0317 22.3484 24.4855 22.6030 240084 21.7421 23.1951 23.9942 22.9738 240085 20.9778 20.7535 17.4712 19.7663 240086 18.1401 18.1497 17.7594 18.0222 240087 21.3323 21.2116 20.1003 20.8883 240088 23.1056 24.6260 25.5587 24.4549 240089 21.1989 21.3949 23.4029 21.9959 240090 19.2166 21.0856 22.6601 21.1189 240093 20.2400 20.7138 22.3968 21.1802 240094 22.0247 22.5923 24.4166 23.1169 240096 21.0417 20.2992 23.8171 21.7632 240097 27.9496 29.7597 31.8726 29.9039 240098 24.2296 23.9626 * 24.0891 240099 15.4964 18.8139 43.7548 21.0887 240100 20.8325 24.1875 24.7500 23.2514 240101 19.9837 22.1329 24.3455 22.2487 240102 16.3659 15.5114 14.5842 15.5365 240103 18.7510 21.0182 20.2325 19.9774 240104 23.5351 25.1139 27.5745 25.4425 240106 23.5005 23.9677 25.5890 24.4099 240107 20.9004 21.2163 24.5581 22.1688 240108 18.2427 17.6500 19.2516 18.3839 240109 16.3216 15.1369 14.5891 15.2649 240110 21.0277 21.7340 22.9718 21.9757 240111 17.8617 19.9712 20.0499 19.2908 240112 16.6244 17.2437 * 16.9303 240114 17.3682 18.3415 21.7910 19.3128 240115 23.8675 24.6529 26.8906 25.1535 240116 18.3520 17.3460 19.2400 18.3173 240117 17.9941 18.6677 19.7047 18.8229 240119 21.8289 23.0230 23.4148 22.7820 240121 22.2266 22.4858 24.5455 23.1566 240122 21.2876 20.7795 23.5331 21.8695 240123 18.3941 18.9494 20.0721 19.1239 240124 20.4728 21.2023 23.5138 21.7551 240125 14.9708 17.3846 * 16.1716 240127 17.9724 16.4294 19.3859 17.7982 240128 16.3608 17.5611 20.1960 17.9593 240129 16.5209 17.7242 20.2001 18.1562 240130 16.4271 17.7634 17.8752 17.3622 240132 23.1452 24.5633 26.7031 24.8511 240133 19.5293 20.8958 23.6068 21.3584 240135 15.7015 15.6298 17.8575 16.3349 240137 21.5073 21.6644 23.1752 22.1872 240138 16.7332 19.1676 17.4235 17.7313 240139 20.5496 21.0163 22.4472 21.2707 240141 23.1009 23.6498 25.1597 24.0447 240142 29.2238 24.0719 25.5197 26.0657 240143 20.4266 20.7307 18.9442 20.0050 240144 21.4469 23.1661 23.3501 22.6969 240145 19.0689 17.6747 22.6062 19.4589 240146 16.5412 17.3275 18.1744 17.4437 240148 19.5204 19.5372 * 19.5281 240150 20.8331 23.3857 * 21.8697 240152 22.4744 24.1818 25.4031 24.1733 240153 19.3336 18.6556 20.3880 19.4726 240154 21.5052 21.5859 21.3809 21.4857 240155 20.9385 23.6944 24.4892 23.0432 240157 13.7309 20.0571 16.7563 16.8353 240160 15.9014 16.4990 17.3072 16.5799 240161 16.8809 18.0542 19.1144 18.0796 240162 19.1542 19.3296 20.4807 19.6719 240163 20.4760 22.2009 23.0778 21.9095 240166 19.4131 19.4496 21.5002 20.1541 240169 16.3958 * * 16.3959 240170 20.3779 21.5994 22.4313 21.4955 240171 18.5172 19.6732 20.5124 19.5729 240172 20.8606 20.3699 20.9068 20.7077 240173 18.5187 18.3183 20.6286 19.1672 240179 20.4004 17.7557 19.8250 19.2836 240184 16.8917 17.6979 19.7471 18.1054 240187 21.2736 23.2471 24.9027 23.1511 240193 18.4664 26.6381 23.6164 23.0709 240196 25.3479 26.2793 27.3313 26.3610 240200 14.9076 18.7517 18.8396 17.3476 240207 25.2814 26.0927 27.4330 26.3128 240210 24.5664 25.6060 26.6231 25.6397 240211 30.6260 34.7849 32.8805 32.7909 240213 * * 27.4812 27.4811 250001 19.2756 20.2019 20.9338 20.1232 250002 18.6938 19.6081 21.6643 20.0536 250003 16.7570 18.7331 19.3864 18.3353 250004 18.3860 19.2913 20.9295 19.5583 250005 12.5834 13.7341 11.3971 12.5195 250006 17.5192 19.4531 20.3061 19.0833 250007 19.7562 20.9757 21.2226 20.6508 250008 15.8506 15.8096 16.4863 16.0657 250009 17.7283 18.0463 19.7610 18.4932 250010 14.6101 16.0233 17.6204 16.0381 250012 16.7579 17.4032 15.6117 16.4987 250015 11.7249 16.6522 19.3794 15.3452 250017 20.5976 18.8850 19.0435 19.5747 250018 13.1687 14.7291 16.8783 14.8458 250019 18.0956 19.9070 22.9085 20.3396 250020 16.2698 19.6575 19.1877 18.3910 250021 10.5844 12.7242 15.8485 12.9174 250023 12.3434 13.8210 14.7354 13.5480 250024 12.9899 14.8394 12.1862 13.2855 250025 20.3625 21.9075 21.2651 21.1983 250027 14.5445 15.1790 17.5936 15.6987 250029 16.0682 14.8216 14.8043 15.2287 250030 26.6173 25.5089 27.2140 26.4270 250031 18.3825 19.8779 21.7605 20.4551 250032 17.5957 * * 17.5957 250033 15.0941 16.9132 * 15.9970 250034 17.0399 18.8231 20.3681 18.7749 250035 16.8349 18.3861 17.1071 17.4370 250036 16.1913 17.6247 17.0469 16.9644 250037 12.7156 14.3994 16.6348 14.4707 250038 17.7019 18.8434 16.8610 17.7868 250039 15.1409 16.4502 16.8729 16.1389 250040 18.3364 19.6513 20.8178 19.5733 250042 17.6531 18.3858 19.4367 18.4780 250043 16.6500 18.4025 17.7554 17.5544 250044 16.7321 19.0321 20.3711 18.6909 250045 21.8988 22.7225 25.3236 23.3569 250047 14.7461 16.0109 * 15.2694 250048 17.6649 19.4976 19.3636 18.8723 250049 12.1635 12.8275 13.4396 12.7838 250050 15.1159 16.0234 16.6723 15.9407 250051 10.4900 10.1212 10.5027 10.3736 250057 16.1838 16.6316 19.0571 17.2494 250058 15.7197 16.2623 16.3813 16.1275 250059 16.6494 17.9507 19.0813 17.8285 250060 16.1804 12.6893 14.0155 14.2269 250061 11.5108 12.0186 11.4573 11.6591 250063 13.3092 15.0894 15.9383 14.6934 250065 13.6904 15.0507 16.2010 14.9097 250066 16.1742 17.2711 16.1044 16.5014 250067 16.8522 18.3773 20.0430 18.4322 250068 13.4127 13.2644 16.3759 14.2410 250069 16.8980 18.5782 21.2111 18.7309 250071 12.3488 13.1934 13.7055 13.0670 250072 18.9487 21.0602 20.7704 20.1290 250077 13.7404 13.9479 14.0318 13.8984 250078 15.9739 17.4118 17.4212 16.9775 250079 16.5835 16.1483 21.3505 18.0112 250081 19.0358 18.1848 20.1214 19.0803 250082 17.1427 17.3096 19.5962 18.0482 250083 16.6065 16.3054 19.5217 17.6288 250084 20.6429 21.0870 22.4632 21.3407 250085 15.4477 16.7377 18.0100 16.7072 250088 18.2736 19.3976 20.3019 19.3083 250089 14.3027 15.0238 16.0202 15.0666 250093 16.1506 16.8647 17.6906 16.8800 250094 18.5063 18.9681 19.9288 19.0932 250095 17.4217 18.4944 18.6616 18.1868 250096 19.0584 19.3630 20.5923 19.6554 250097 15.5741 16.3328 18.8398 16.9174 250098 18.3874 18.8163 17.9562 18.4324 250099 15.1265 15.9867 18.2504 16.5120 250100 17.8688 19.7559 18.8877 18.8640 250101 17.7194 17.6704 41.5335 17.7745 250102 18.9348 19.8487 21.3213 20.0396 250104 18.7651 19.0165 20.5035 19.4465 250105 15.5133 16.1480 17.0135 16.2367 250107 15.0737 16.5635 16.7104 16.0939 250109 21.3867 24.5760 16.4965 20.5154 250112 16.3640 16.6447 16.8696 16.6208 250117 16.9787 15.9335 18.8863 17.1858 250119 16.1218 16.5700 17.1373 16.5802 250120 16.7182 18.1428 22.3897 18.8266 250122 19.2990 19.8033 19.7966 19.6361 250123 18.7863 22.1376 22.2184 21.1030 250124 13.2490 14.4008 15.3772 14.3481 250125 21.2660 21.9366 25.3415 22.8644 250126 21.9101 19.0168 20.1117 20.3133 250128 16.1418 15.9958 15.8352 15.9898 250131 12.4557 11.2470 11.5396 11.7049 250134 18.5142 21.4489 22.0310 20.5243 250136 21.3497 20.0333 21.9977 21.1329 250138 20.4550 19.3446 21.2489 20.3584 250141 19.6692 21.6835 19.8982 20.4335 250145 11.2120 11.2021 * 11.2080 250146 14.7781 15.4061 16.9341 15.6577 250148 19.4233 23.1459 * 21.1903 250149 15.2318 15.7537 16.4228 15.8106 250150 21.8599 * * 21.8600 250151 * * 20.4581 20.4581 260001 20.1560 20.9620 22.6646 21.2406 260002 21.6597 23.4259 24.6812 23.4142 260003 15.4482 16.2023 16.5931 16.0798 260004 13.7035 15.2735 16.4424 15.0947 260005 23.9681 22.5860 24.3624 23.6476 260006 20.0994 22.1692 24.1078 22.0536 260008 16.8893 18.2114 15.9656 17.1196 260009 18.2863 19.0654 20.1679 19.1754 260011 19.5059 20.3279 21.1624 20.3470 260012 17.1662 17.3810 17.7853 17.4521 260013 16.1825 17.3772 18.4857 17.3402 260015 17.8817 18.3849 21.7581 19.2237 260017 16.9914 17.9796 20.8258 18.6436 260018 12.5301 13.6120 14.3278 13.5417 260019 * 18.3629 * 18.3629 260020 20.2241 21.0314 22.4643 21.2460 260021 21.6237 23.3527 27.2478 23.9117 260022 17.7772 18.7707 20.5417 18.9739 260023 17.8649 18.5665 19.2256 18.5565 260024 15.7815 15.6095 16.9515 16.1624 260025 17.0965 18.2804 19.3535 18.2493 260027 22.0362 23.1505 22.9973 22.7247 260029 21.1858 20.1832 22.0390 21.1257 260030 11.9215 12.8349 12.7803 12.5162 260031 19.7249 22.5379 24.3626 22.0014 260032 19.6728 20.3847 * 20.0208 260034 20.4902 20.5439 21.6108 20.9281 260035 13.0071 15.1611 15.0710 14.4258 260036 18.8104 20.1242 19.4559 19.4803 260039 14.6644 15.9689 13.9705 14.9145 260040 18.0140 18.5132 19.7196 18.7876 260042 18.7514 20.8821 * 19.9434 260044 15.9206 16.7879 18.2413 17.0028 260047 19.2247 20.2724 22.4013 20.5664 260048 21.0602 22.4800 20.1127 21.0958 260050 16.8520 17.8142 20.8510 18.4171 260052 18.0914 19.1044 21.1297 19.4548 260053 16.5166 17.4110 18.9606 17.6806 260054 20.6242 23.0188 * 21.7799 260055 15.4214 17.9547 18.8793 17.4012 260057 19.7144 16.5704 15.8404 17.4526 260059 17.0546 16.2074 17.2807 16.8654 260061 15.7112 17.1343 18.7280 17.2320 260062 21.3138 22.0091 25.1582 22.8328 260063 18.8973 19.7231 21.1284 19.8962 260064 17.8033 18.3749 17.5188 17.8922 260065 20.0975 20.6671 22.0073 20.9514 260066 15.3460 15.3139 * 15.3302 260067 15.1837 14.5499 15.0354 14.9154 260068 19.4240 20.7947 22.0951 20.7923 260070 13.9510 18.7384 11.2251 14.4396 260073 15.9182 16.9496 17.9000 16.9733 260074 19.8915 20.4033 18.7639 19.6422 260077 19.4482 20.5830 21.6257 20.5610 260078 14.9463 16.0586 16.9217 15.9818 260079 16.1453 16.4816 17.3871 16.6399 260080 14.6832 13.1617 13.6815 13.7659 260081 20.3053 20.2471 22.4329 21.0085 260082 15.9858 18.2853 18.7527 17.6725 260085 20.7051 21.5137 22.7394 21.6591 260086 15.2927 16.7579 17.2049 16.4038 260091 21.5464 22.0772 23.8702 22.5033 260094 18.5395 19.7308 20.0014 19.4593 260095 20.7292 21.6999 22.8156 21.7294 260096 22.5972 22.8259 23.5009 22.9961 260097 19.0632 18.6965 19.6203 19.1454 260100 16.6523 16.5439 16.6168 16.6045 260102 20.6361 21.2133 24.1041 22.0613 260103 19.7146 19.9144 * 19.8156 260104 20.3176 21.6624 22.1805 21.4297 260105 24.8181 22.8005 24.6572 24.0540 260107 20.4269 22.5214 23.1564 21.9109 260108 20.0034 20.9029 22.4665 21.1879 260109 14.8181 15.9724 16.7734 15.8460 260110 18.3227 19.5633 * 18.9410 260113 16.2223 16.1346 16.3440 16.2356 260115 17.4698 19.3873 20.1706 18.9712 260116 14.9812 16.0187 16.9807 15.9921 260119 17.2942 18.0725 18.7958 18.0259 260120 16.4904 17.6811 18.7651 17.6553 260122 16.0931 16.3700 16.1637 16.2077 260123 14.6822 15.2926 17.7996 15.9122 260127 18.4026 18.1342 19.7946 18.7879 260128 12.6414 13.2942 * 12.9660 260131 18.4154 18.0395 * 18.2242 260134 17.5127 17.1341 18.4511 17.6303 260137 19.4697 19.5976 20.7638 19.9765 260138 23.2364 23.6502 25.4515 24.0813 260141 19.1893 19.0444 21.1469 19.7400 260142 17.3084 18.2023 18.6412 18.0732 260143 13.9040 15.4688 16.0479 15.1578 260147 14.7769 15.8522 16.1172 15.5706 260148 11.3524 12.6651 15.1916 13.0421 260158 12.7699 13.9790 15.0140 13.9277 260159 19.7951 20.9636 22.5169 20.9886 260160 16.5792 18.4007 18.8723 17.9546 260162 21.4099 20.7331 22.3038 21.5147 260163 15.8593 16.8300 18.1311 16.9540 260164 15.1211 16.3874 16.9403 16.1072 260166 21.1224 22.4071 22.8409 22.1650 260172 16.0772 16.4854 17.1504 16.5822 260173 14.2090 15.5733 17.0117 15.5933 260175 17.5625 18.3632 19.7939 18.5994 260176 21.6044 23.2414 25.7802 23.6435 260177 21.9014 22.9112 24.0679 23.0194 260178 20.2796 20.8189 21.2846 20.7937 260179 22.7185 21.4470 23.1610 22.4301 260180 18.9881 19.5983 21.4226 19.9994 260183 21.3175 23.7057 24.2330 23.0675 260186 19.6026 21.0675 21.6620 20.8448 260188 22.5060 23.7475 * 23.0915 260189 16.4233 * * 16.4232 260190 19.3419 21.6994 24.5014 21.8167 260191 18.1604 19.6784 20.8030 19.6078 260193 20.2577 22.2030 22.9556 21.8741 260195 19.7068 * 20.0889 19.9145 260197 20.5453 * * 20.5453 260198 19.7552 21.7926 25.3390 22.1557 260200 20.6888 21.7031 21.9868 21.5369 260207 * * 18.5247 18.5247 260208 * * 30.6259 30.6261 270002 19.2387 19.0221 19.7588 19.3381 270003 22.5019 20.7277 23.0396 22.0300 270004 19.4834 20.1821 21.0202 20.3215 270006 17.0715 15.1006 18.2057 16.6954 270007 13.8824 15.5780 12.8055 13.9488 270009 20.8238 20.7031 21.5655 21.0425 270011 21.1653 21.8086 21.4031 21.4583 270012 19.7878 20.7913 21.7634 20.7748 270014 19.9859 20.4321 20.3456 20.2664 270016 18.6149 17.9984 21.0198 19.0996 270017 20.0152 22.1046 23.2320 21.7798 270019 15.4128 18.5111 19.6625 17.8208 270021 16.9457 18.0515 21.1624 18.5631 270023 22.7181 22.7162 23.7486 23.1141 270026 18.0568 20.1673 19.9669 19.4168 270027 17.2091 17.2005 17.4500 17.3066 270028 19.1177 19.6212 20.4877 19.7233 270029 17.3710 18.2097 17.9731 17.8617 270032 18.7811 19.3937 20.1801 19.4478 270033 18.4876 20.7060 25.0179 21.1320 270035 16.4302 17.9822 19.1036 17.8465 270036 16.8552 16.1031 18.8787 17.3089 270039 19.6796 20.3800 19.6505 19.8960 270040 20.1242 20.1887 20.7239 20.3415 270041 25.8153 * * 25.8151 270044 17.5137 19.2939 18.6533 18.4293 270048 18.0666 17.4506 18.1269 17.8742 270049 22.2540 22.0263 22.9524 22.4171 270050 19.9356 19.6317 21.0901 20.2259 270051 20.1950 20.0386 22.2580 20.8285 270052 14.7009 17.1932 13.3673 15.1086 270057 20.6714 20.1507 21.9997 20.9799 270058 16.1412 18.4780 17.7905 17.3778 270059 19.1808 16.9303 17.4365 17.7389 270060 20.4148 21.3776 18.3386 20.1127 270063 15.1049 16.4553 19.7307 16.9992 270073 16.1937 16.6083 15.6319 16.1437 270079 16.7048 19.5493 * 18.0578 270080 15.0705 16.6010 20.6145 17.2851 270081 16.7389 18.0543 15.6834 16.8629 270082 23.1245 23.3209 21.0150 22.5579 270083 17.8554 16.8420 19.1381 17.8988 270084 16.2958 15.7062 19.6105 17.1115 280001 18.1831 18.7137 18.9480 18.6168 280003 23.0213 23.6058 26.0937 24.2580 280005 23.6949 22.8981 23.9753 23.5311 280009 20.9643 23.2300 23.8046 22.6996 280010 20.0462 22.0137 23.8324 22.0012 280011 15.9614 16.2281 * 16.0965 280013 22.5163 24.0852 23.4920 23.3630 280014 16.8368 16.7109 * 16.7707 280015 16.6939 18.0207 19.1420 17.9018 280017 13.9939 16.9884 15.8099 15.6454 280018 15.4496 16.6439 17.0625 16.3884 280020 21.2467 21.9587 23.4658 22.2728 280021 17.6345 19.1263 21.5215 19.4605 280022 16.8184 15.3785 * 16.0620 280023 22.3433 21.5761 19.6265 21.1633 280024 15.0380 15.8747 18.1544 16.1976 280025 21.4764 22.2214 * 21.8488 280026 16.5851 18.7258 * 17.6496 280028 18.0793 19.1080 * 18.5723 280029 24.4359 17.1351 * 20.5379 280030 24.7723 26.3542 26.2806 25.7410 280031 9.6321 9.6951 14.3030 11.3451 280032 19.1191 20.5246 21.5150 20.4101 280033 17.4745 17.9841 * 17.7291 280035 16.6872 18.6089 * 17.5717 280037 17.1064 14.8049 * 15.9325 280038 18.2503 18.9305 * 18.5950 280039 16.1587 17.0153 18.3375 17.1382 280040 20.9896 21.5426 23.7407 22.1421 280041 16.5503 16.6889 14.4252 15.9446 280042 16.6239 16.4684 * 16.5457 280043 17.5937 16.8186 * 17.2004 280045 15.7630 17.7408 15.2407 16.1990 280046 17.3214 17.9752 17.5600 17.6110 280047 17.4735 21.3143 19.5815 19.4044 280048 15.8100 17.9319 18.6882 17.5211 280049 18.4365 19.4589 20.1665 19.3973 280050 20.0379 * * 20.0378 280051 17.1942 19.6206 * 18.3037 280052 14.1201 14.9903 15.4041 14.8495 280054 18.7575 19.4049 23.1191 20.4732 280055 13.8129 14.2046 15.2426 14.4185 280056 15.6135 15.6442 * 15.6285 280057 20.0686 21.4754 22.5480 21.4261 280058 21.4868 22.8105 17.7506 20.7067 280060 20.7022 22.4677 22.7755 21.9926 280061 18.6370 20.2066 21.2901 20.0793 280062 15.6018 16.1708 17.2218 16.3363 280064 16.8330 18.2196 * 17.5260 280065 20.7370 21.6999 23.8128 22.1199 280066 11.7207 12.2225 10.6969 11.4854 280068 10.5987 10.5103 11.6283 10.9064 280070 22.6201 18.7211 * 20.3601 280073 17.7698 18.3496 * 18.0596 280074 17.3143 13.6025 18.6064 16.1704 280075 13.2230 13.3154 18.0464 14.6143 280076 16.7488 16.1939 18.2504 17.1042 280077 20.0148 21.1883 22.7244 21.3192 280079 16.6117 17.1519 17.7968 17.1767 280080 16.9487 16.1902 * 16.5447 280081 20.9606 23.3805 25.2237 23.2090 280082 14.6173 15.4420 15.2322 15.0937 280083 21.5336 20.8995 * 21.2308 280084 13.6536 13.2158 14.3005 13.7432 280085 20.4825 20.8532 * 20.6808 280089 18.9567 19.9003 20.7438 19.8619 280090 15.1274 * * 15.1274 280091 16.1866 16.3456 * 16.2669 280092 14.7912 13.3032 16.5893 14.8029 280094 16.3474 16.9180 18.5068 17.3100 280097 13.8223 14.1870 * 14.0071 280098 12.5875 12.4995 * 12.5457 280101 16.9973 10.5153 * 12.9714 280104 16.2167 15.5949 14.8257 15.4728 280105 21.0735 23.7103 26.1112 23.6557 280106 16.0679 16.3564 * 16.2080 280107 14.4679 * * 14.4678 280108 17.1961 18.5134 20.9016 18.8959 280109 12.4408 * * 12.4408 280110 14.2136 13.0278 * 13.5867 280111 19.6283 19.7688 20.7398 20.0680 280114 17.3076 17.1154 * 17.2096 280115 18.1480 18.3464 19.7797 18.7967 280117 18.8279 20.3819 20.5464 19.9214 280118 18.6524 17.8891 19.3465 18.6584 280123 11.8582 23.6682 24.3539 18.1396 280125 16.3944 17.2718 19.7871 17.7870 280126 * * 35.5895 35.5900 290001 22.7450 24.3681 25.9590 24.4242 290002 16.5419 16.7948 16.8363 16.7281 290003 24.2175 25.4303 27.2718 25.6701 290005 21.9814 22.7804 24.6877 23.2224 290006 22.4063 22.4832 24.2211 23.1190 290007 30.9075 34.9911 33.7208 33.2446 290008 24.1255 26.9216 27.0115 25.8955 290009 23.9373 24.8816 26.9020 25.2711 290010 16.4476 20.8387 25.4598 20.8166 290011 21.1234 19.7410 21.7835 20.8924 290012 25.0430 25.5647 25.4791 25.3714 290013 15.7932 20.2914 21.1487 18.7341 290014 18.7829 20.2762 25.6155 21.5373 290015 19.4504 20.2336 22.3653 20.5695 290016 23.8656 21.8030 17.9615 20.7686 290019 22.2045 22.5584 25.1684 23.3359 290020 21.2380 19.5039 24.2374 21.4763 290021 22.9488 24.1397 26.0430 24.3771 290022 25.5011 25.3914 27.5364 26.1224 290027 13.3769 13.1463 * 13.2560 290032 23.9504 26.9846 27.1791 26.2060 290036 12.9074 * * 12.9073 290038 27.7030 26.0836 30.0397 27.9572 290039 25.5024 26.6283 28.5925 26.9886 290041 25.9905 27.7740 28.6294 27.7224 290042 18.7527 18.7669 * 18.7611 290043 27.9053 * * 27.9053 290045 * * 26.4843 26.4843 300001 23.8567 25.7142 26.8650 25.5285 300003 24.1297 25.3252 26.7859 25.4284 300005 22.2858 22.3258 22.8163 22.4895 300006 18.9745 22.2642 22.0188 21.0625 300007 20.6325 21.3633 23.6919 21.9920 300008 19.6149 20.9207 23.1085 21.2699 300009 20.0938 20.1486 22.7539 20.9686 300010 20.2130 21.0316 24.6296 21.8421 300011 23.0279 23.8390 25.0979 24.0124 300012 24.5619 25.8581 26.1792 25.6027 300013 20.1669 20.0269 21.3396 20.4889 300014 20.1774 21.6705 23.7144 21.9343 300015 19.6627 22.8966 24.4870 22.4848 300016 17.8148 15.1311 19.6529 17.5958 300017 22.7191 23.9651 26.0604 24.3780 300018 21.6385 22.8379 25.7851 23.5726 300019 19.6728 20.5801 23.8076 21.3279 300020 22.6627 23.0806 24.8189 23.5472 300021 19.3101 20.2585 19.0918 19.5659 300022 19.1875 20.1209 22.3918 20.6206 300023 22.7649 22.1896 24.9992 23.3536 300024 21.5842 22.2235 22.4882 22.1265 300028 20.0778 21.4207 21.7975 21.0588 300029 22.6013 23.8415 24.5772 23.7645 300033 17.1632 17.4836 20.4502 18.3308 300034 24.4975 25.2355 26.9093 25.5558 310001 27.4730 31.1568 29.6344 29.4408 310002 27.9728 28.7786 33.9058 30.2896 310003 27.5624 29.3522 31.1739 29.3684 310005 22.9712 23.9477 25.6120 24.1650 310006 22.0894 24.1538 25.9000 24.0238 310008 24.7618 26.4989 28.0970 26.4414 310009 21.7094 23.2420 24.6353 23.1866 310010 23.1060 24.5471 26.5921 24.8321 310011 24.2885 25.4900 26.1586 25.3131 310012 26.6772 28.1367 31.1705 28.7006 310013 22.5603 23.2424 25.0951 23.6575 310014 23.1956 31.0834 29.1931 27.3029 310015 27.9684 29.1340 29.3681 28.8346 310016 24.5206 26.0738 25.7368 25.3848 310017 24.5976 25.1634 25.2577 25.0191 310018 22.4779 24.1428 25.9108 24.1664 310019 24.9914 28.5952 26.4492 26.6564 310020 24.4152 25.0803 25.0147 24.8332 310021 25.4393 27.8958 29.2267 27.4313 310022 20.8258 23.3412 26.7487 23.5627 310024 24.9521 27.0459 26.9499 26.3252 310025 24.1812 25.5227 26.8719 25.4915 310026 22.1997 23.2895 24.6697 23.2693 310027 22.5696 24.4437 22.1935 23.0737 310028 23.9428 26.1931 25.7246 25.2908 310029 23.6610 24.4290 25.9606 24.6455 310031 26.6831 26.7174 29.5581 27.5915 310032 24.7404 24.9133 25.7088 25.2148 310034 24.1150 24.8567 26.4468 25.1211 310036 21.7187 23.0320 * 22.3716 310037 28.1289 28.7738 29.9732 28.9646 310038 28.4893 28.1756 32.3865 29.6794 310039 22.7317 23.6605 24.6045 23.6772 310040 26.3573 26.5769 27.2418 26.7140 310041 23.5559 23.8857 26.8145 24.8018 310042 24.7678 24.9702 26.9695 25.5501 310043 21.6128 24.0238 * 22.6515 310044 23.1549 23.1489 25.1618 23.8298 310045 28.9274 29.4877 31.7376 30.0182 310047 26.1921 25.9777 26.0860 26.0841 310048 25.2870 23.4189 28.4136 25.6301 310049 27.0842 25.6732 26.3666 26.3559 310050 24.7988 23.7735 25.3772 24.6345 310051 27.5378 28.6248 28.3783 28.1725 310052 23.3973 24.9773 26.8158 24.9554 310054 27.7376 27.6290 27.2303 27.5237 310057 22.2572 22.2630 26.3903 23.6641 310058 26.3765 25.3983 25.6526 25.8266 310060 20.0997 21.4455 22.1914 21.1757 310061 33.9582 23.4283 24.9678 26.7631 310063 22.1080 21.2619 22.9871 22.1071 310064 25.4822 25.9350 27.8388 26.4138 310067 23.9278 24.1943 26.3624 24.7328 310069 24.2329 25.3464 25.7690 25.1083 310070 28.2220 29.5101 30.1917 29.3042 310072 22.5611 24.4480 25.3145 24.0886 310073 26.2937 26.7954 28.7528 27.2829 310074 22.3588 24.2009 27.6789 24.7835 310075 24.4788 23.9771 24.9752 24.4724 310076 27.9918 29.6667 32.5424 30.0825 310077 26.1251 26.7092 28.7352 27.1831 310078 24.0587 24.5862 24.7606 24.4553 310081 22.4086 23.3310 24.6557 23.4816 310083 24.8204 25.0191 25.2465 25.0205 310084 24.6049 25.4946 27.3680 25.8446 310086 23.1719 23.4966 25.2725 23.9596 310087 21.1215 20.6847 * 20.9048 310088 23.1722 23.0610 23.7846 23.3408 310090 24.8986 23.6661 25.3640 24.6461 310091 23.2969 24.5357 25.6405 24.4610 310092 21.6964 22.9721 23.2226 22.6239 310093 23.7251 23.9404 24.6942 24.1032 310096 24.5759 26.6588 28.4705 26.4515 310105 26.2537 28.1317 28.7333 27.6263 310108 23.8308 25.1368 24.4096 24.4558 310110 23.2146 23.3461 26.4175 24.4668 310111 22.1151 23.3646 26.2496 23.9377 310112 24.7914 24.2999 27.8796 25.6804 310113 23.1961 24.2708 25.9143 24.5219 310115 21.1645 23.5148 24.5413 23.0976 310116 23.6366 24.2696 25.1189 24.3065 310118 26.1315 26.8760 28.0517 26.9540 310119 32.7858 29.1045 33.2731 31.6276 310120 23.3200 22.6526 24.7079 23.4981 320001 20.6225 21.5564 23.0290 21.8122 320002 23.0983 25.5144 26.4847 25.1115 320003 16.4642 16.4961 20.7939 17.8265 320004 19.6642 21.3681 19.4799 20.2196 320005 21.0411 22.4178 22.1677 21.9174 320006 20.3863 19.8672 21.1222 20.4529 320009 19.3500 20.3783 21.5870 20.3252 320011 18.5222 19.1476 20.7713 19.4939 320012 17.1764 17.1317 * 17.1558 320013 24.5543 25.5403 19.4487 22.2842 320014 16.8412 22.9026 19.5032 19.7029 320016 18.8519 18.8763 19.9200 19.2582 320017 19.4498 20.4390 22.5460 20.8081 320018 19.2336 20.3141 20.9400 20.1778 320019 26.9637 25.1210 26.6900 26.3394 320021 19.1265 20.0089 21.0913 20.0920 320022 18.0606 20.9797 20.7919 20.0415 320023 17.8419 * * 17.8418 320030 18.6859 18.1556 16.8696 17.8853 320031 25.1715 18.2244 19.0519 20.5648 320032 20.6871 21.4815 21.2528 21.1396 320033 21.0621 21.9804 24.2703 22.4984 320035 15.0612 17.8058 * 16.5303 320037 17.8280 17.6724 19.6466 18.4044 320038 22.2664 23.1987 19.2962 21.6253 320046 18.9607 19.4732 21.5914 20.0169 320048 16.8769 * 31.6800 24.0471 320063 17.9089 18.5600 20.4936 18.8302 320065 18.6525 22.5428 19.9012 20.1608 320067 15.3228 16.8015 17.7799 16.4113 320068 18.5103 15.6864 15.7757 16.5793 320069 14.4212 15.7350 18.5375 16.2248 320074 20.2290 22.3403 28.3085 22.7142 320079 19.8555 20.2473 21.9090 20.6661 320083 * * 25.7539 25.7539 330001 27.3996 28.6214 30.7042 28.9537 330002 26.9341 27.1811 28.2184 27.4257 330003 18.9211 19.3972 20.6509 20.4183 330004 20.9501 22.5082 24.3703 22.6203 330005 22.1957 22.6137 24.3474 23.0406 330006 25.8006 26.2970 28.3904 26.7950 330008 19.2341 19.6770 20.6816 19.8702 330009 31.3435 30.9087 33.3605 31.8514 330010 16.6508 17.8935 19.8211 18.0647 330011 18.6748 18.7995 19.8035 19.0860 330013 19.6269 19.0995 20.9282 19.8689 330014 36.8669 32.4496 31.9524 33.5779 330016 16.8016 18.7194 18.1603 17.8636 330019 33.5369 31.5927 31.9042 32.2626 330020 1142 16.6952 16.8234 16.1733 330023 25.6512 26.6997 29.4353 27.3255 330024 37.3316 35.7485 35.3598 36.0893 330025 16.8687 17.6169 18.7663 17.7638 330027 35.5255 35.1046 34.1273 34.9301 330028 29.5294 31.7699 31.2424 30.9471 330029 17.0016 19.4377 18.4354 18.2976 330030 19.1085 18.0866 28.7083 22.0491 330033 17.4444 19.5836 18.4160 18.4656 330034 27.7738 38.2451 * 31.2246 330036 25.2820 25.5888 27.0970 25.9905 330037 16.4866 18.3260 18.3557 17.7256 330038 17.3429 16.2997 * 16.8497 330041 31.4871 29.5305 34.5461 31.7315 330043 27.4661 28.9622 31.7873 29.4079 330044 19.5219 19.9808 22.0465 20.8006 330045 27.9919 28.5267 30.9046 29.1458 330046 35.2703 38.1184 41.6759 38.2919 330047 18.5536 19.5561 20.1646 19.4202 330048 19.1093 19.6129 * 19.3678 330049 20.5731 22.1523 24.0154 22.2469 330053 17.8082 17.9161 18.1728 17.9636 330055 32.8910 34.2159 34.9709 34.0397 330056 30.0945 29.8377 32.0982 30.6226 330057 19.3643 20.0995 20.5575 20.0172 330058 17.7672 18.1007 19.1379 18.3260 330059 34.2426 35.0121 36.4176 35.2563 330061 25.4082 26.8580 28.6136 26.9092 330062 18.1318 18.4662 20.0222 18.7978 330064 33.6447 35.1422 36.0976 34.9476 330065 19.9305 20.1615 20.5958 20.2322 330066 18.8707 19.3644 20.9990 19.7359 330067 22.1065 23.6836 24.8927 23.5465 330072 30.4171 30.3737 32.9665 31.2232 330073 16.4518 16.5166 18.4162 17.3766 330074 17.7308 18.9326 21.5724 19.3819 330075 17.6385 19.2938 19.9781 18.9556 330078 18.7884 18.0362 20.7304 19.1607 330079 18.7622 18.9398 21.1153 19.6188 330080 31.4424 34.6880 29.5529 31.9593 330084 19.3216 19.0261 19.2135 19.1805 330085 20.6203 20.9332 21.8271 21.1349 330086 23.6496 26.2979 27.1585 25.5888 330088 25.7940 26.7583 29.5181 27.3384 330090 19.2112 20.1344 20.9327 20.1124 330091 19.7776 21.6004 22.9396 21.4093 330092 13.3723 17.2083 17.7246 16.0609 330094 18.1582 18.8941 20.7039 19.2157 330095 21.1096 21.1809 28.8428 22.1947 330096 18.5149 20.0370 21.1648 19.9256 330097 16.4433 16.1945 18.5608 17.0345 330100 29.0916 28.9956 31.5775 29.8728 330101 31.5914 35.3618 37.9069 34.7542 330102 19.0058 21.0057 23.5253 21.0029 330103 16.8110 17.3511 17.9017 17.3639 330104 31.2074 31.9746 * 31.5864 330106 35.3775 36.2526 38.4384 36.6836 330107 27.7797 28.9225 29.7378 29.5391 330108 18.0786 18.5849 20.2536 18.9350 330111 15.9321 13.3352 17.7020 15.4904 330114 17.0581 19.1162 19.2566 18.4674 330115 17.4684 18.5911 18.5544 18.2257 330116 14.9610 16.8567 17.0561 16.2974 330119 33.1179 33.5653 34.6591 33.7652 330121 16.3385 17.1869 17.9757 17.1336 330122 20.2417 23.0384 25.6500 22.9753 330125 19.7638 20.5922 21.5769 20.6209 330126 23.8957 25.1175 27.5394 25.5273 330127 30.7356 40.0112 30.6030 33.9644 330128 30.8242 34.3468 33.5504 32.9063 330132 14.3673 14.8704 16.0311 15.1074 330133 35.3576 37.5192 35.9692 35.9945 330135 22.2670 23.5662 25.1802 23.5883 330136 20.1043 20.4124 21.2943 20.6129 330140 19.3615 21.1841 21.1787 20.5922 330141 26.7096 27.5960 29.3037 27.9129 330144 16.2517 17.1513 17.3920 16.9610 330148 16.2782 16.7251 17.6560 16.8727 330151 15.7594 15.2233 16.1354 15.7000 330152 30.8314 33.5587 32.9336 32.8160 330153 18.1776 19.4417 22.0179 21.5648 330157 22.3804 23.1743 23.5522 23.0369 330158 27.1228 29.3163 32.3534 29.4900 330159 19.4998 20.2753 22.7512 20.8227 330160 29.5885 30.7893 32.1266 30.7976 330162 27.6010 27.9705 29.4475 28.3208 330163 20.7456 21.4143 21.1517 21.0818 330164 20.9003 22.0699 23.9635 23.6195 330166 15.4420 17.0637 18.4262 17.0093 330167 30.2346 32.0541 30.7301 30.9496 330169 35.4794 36.3690 36.2725 36.0426 330171 24.8035 25.1567 25.9946 25.3030 330175 18.3116 18.8701 20.4056 19.1653 330177 16.3704 16.6059 19.0005 17.2818 330179 13.8953 16.0113 15.0665 14.9370 330180 17.9877 19.2670 19.8951 19.0453 330181 33.0908 34.6065 36.8062 34.8035 330182 33.6531 33.3363 35.0496 34.0319 330183 20.6164 20.3520 * 20.4865 330184 31.3706 28.4726 31.1286 30.9549 330185 26.8612 27.8894 28.8893 27.8982 330188 18.8000 20.2849 21.0098 20.0662 330189 18.4498 23.5589 19.0726 20.2279 330191 19.0348 19.5623 20.8876 19.8341 330193 30.2260 32.5496 36.2427 32.8255 330194 35.2036 35.6486 38.3174 36.4467 330195 34.8966 34.4689 36.4249 35.2744 330196 30.5799 28.9488 28.1590 29.2904 330197 18.3527 19.2237 20.8386 19.4333 330198 24.8590 25.6669 25.3622 25.3000 330199 30.5409 28.0374 30.2655 29.6011 330201 28.7861 30.0524 29.3745 29.3679 330202 31.2575 35.4943 41.7560 36.1208 330203 25.0345 25.9211 24.7422 25.2170 330204 32.2005 31.1366 32.4850 31.9448 330205 22.3490 24.9040 28.7587 25.2768 330208 26.6682 27.3170 30.6158 28.1551 330209 25.1281 27.0257 27.7071 26.6630 330211 19.5405 20.0006 20.8224 20.1312 330212 24.7681 24.8554 24.9434 24.8488 330213 19.6796 20.1166 20.7889 20.1990 330214 32.4292 32.3130 31.1205 31.9124 330215 17.9863 19.0726 19.9226 18.9889 330218 21.1890 21.4747 20.6012 21.0785 330219 23.4310 25.1792 28.6712 25.6596 330221 33.3796 32.5044 34.9345 33.6092 330222 18.5571 19.3148 23.5491 20.4196 330223 17.8306 19.1604 18.8253 18.6087 330224 20.4309 20.5881 22.5695 21.2048 330225 27.0379 28.0523 29.1744 28.0410 330226 23.1859 21.6368 20.6413 21.6149 330229 17.5326 18.2554 18.5590 18.1157 330230 29.6283 30.6937 32.5997 30.9389 330231 32.7200 32.4163 31.0944 32.0731 330232 19.1787 20.0924 21.1277 20.1536 330233 44.1265 43.1186 39.5133 42.2764 330234 35.0720 35.8327 37.7135 36.1847 330235 19.5880 20.1255 21.4643 20.3704 330236 31.3463 32.1246 31.8491 31.7633 330238 17.3976 17.8867 18.3846 17.8977 330239 18.5079 18.9953 19.7561 19.0658 330240 30.7321 35.6576 35.8530 33.9196 330241 23.8638 24.7545 26.7598 25.1593 330242 27.6384 28.3561 30.5172 28.8163 330245 18.5161 20.7605 20.3764 19.9316 330246 28.1205 29.8777 31.4120 29.6840 330247 27.3937 32.5858 25.6063 28.6111 330249 17.1320 17.6846 19.1469 18.0226 330250 19.9619 20.8742 22.5523 21.1636 330254 15.9123 15.7864 * 15.8547 330258 31.8910 32.6745 * 32.2903 330259 25.9994 26.3620 27.1632 26.5007 330261 27.9766 30.0489 30.2305 29.4148 330263 18.7378 19.5057 20.0831 19.4473 330264 22.8099 24.9714 22.9348 23.5396 330265 17.6301 21.1215 18.2547 19.0141 330267 24.5939 27.8255 28.9459 27.1596 330268 15.9060 16.8358 18.7991 17.2148 330270 36.0824 33.0375 35.7375 34.9492 330273 26.0565 27.0454 28.8548 27.3093 330275 18.7268 * * 18.7268 330276 19.0228 19.6572 20.7973 19.8310 330277 19.1761 20.7851 21.8865 20.6281 330279 20.7107 21.7827 22.2342 21.5603 330285 24.0491 24.5388 26.1367 24.9296 330286 27.7762 28.0994 31.1802 29.0328 330290 30.4706 34.3439 35.5617 33.3907 330293 16.9238 17.3180 17.6507 17.2993 330304 27.3562 29.2207 30.7428 29.1068 330306 29.5937 29.6641 30.4426 29.9146 330307 21.7257 23.2838 23.8583 22.9902 330314 25.9937 25.5405 26.2954 25.9412 330316 27.9543 27.9277 33.7857 29.8270 330327 20.3874 20.1705 19.3465 20.0015 330331 33.1276 32.3249 34.3554 33.2559 330332 25.3689 27.6955 30.5104 28.0245 330333 * 28.8819 29.7725 29.3003 330336 29.8294 27.9163 32.9548 30.2195 330338 21.2670 23.6142 25.4319 23.4256 330339 20.1028 20.2382 20.8423 20.3907 330340 28.4129 28.2732 27.6209 28.0963 330350 30.9763 33.5493 35.5656 33.4000 330353 34.2431 34.2260 35.6821 34.7146 330357 34.1846 36.8598 36.5461 35.8671 330372 33.3771 23.5381 28.2490 27.9598 330381 31.8602 * * 31.8602 330385 33.2246 37.5523 29.0854 33.5264 330386 20.4231 21.4363 25.2063 22.3343 330389 37.3749 33.1192 32.2112 34.0979 330390 30.8744 31.7344 32.5948 31.7185 330393 27.8352 31.9272 32.9411 30.8719 330394 18.9343 19.6892 21.1737 19.9249 330395 32.7494 33.2318 32.1089 32.8033 330396 30.7961 32.8517 30.2150 31.2942 330397 32.6068 34.6435 40.0884 35.3787 330398 29.2872 * * 29.2871 330399 33.3012 32.7149 32.1248 32.6847 330400 16.2707 16.8168 16.7483 16.6259 330401 * * 33.9685 33.9685 340001 19.7093 22.0257 21.4870 21.0947 340002 20.5253 22.9425 23.8010 22.5969 340003 19.5145 19.6545 20.4109 19.8596 340004 20.9863 23.0890 23.1514 22.4225 340005 16.7176 16.6909 19.9094 17.7865 340006 16.5709 16.1379 18.3980 17.0420 340007 18.3399 18.3760 19.5204 18.7397 340008 20.4157 22.6570 23.7394 22.3196 340009 20.9178 20.6155 * 20.8194 340010 19.4302 20.6547 21.3024 20.4707 340011 14.4798 17.4534 18.1926 16.7010 340012 17.5112 19.3651 19.6350 18.7911 340013 19.4613 21.5130 21.0066 20.6934 340014 27.7888 21.9804 14.6001 20.4859 340015 19.4676 20.3493 24.3410 21.2831 340016 18.8958 19.4160 20.2859 19.5502 340017 20.2775 20.6263 21.5523 20.8419 340018 18.1751 16.4611 17.3480 17.2851 340019 15.2887 15.9037 16.7102 15.9597 340020 18.0897 19.2392 21.3385 19.6156 340021 20.5813 22.0220 22.9499 21.8152 340022 18.7714 20.6484 19.9078 19.7763 340023 19.3146 19.9023 * 19.6217 340024 17.9130 19.1430 20.4906 19.1924 340025 18.4628 19.1770 20.2864 19.3249 340027 19.4548 19.4907 20.8946 19.9262 340028 19.9403 20.6496 21.9837 20.9344 340030 22.4709 23.9505 27.9759 24.5972 340031 14.6370 15.4935 * 15.0325 340032 20.7444 22.0245 22.7382 21.8244 340035 18.9930 18.5883 16.4821 17.7616 340036 17.7619 18.4203 20.8313 18.9871 340037 17.5829 18.3655 17.1949 17.6512 340038 18.1493 20.3091 13.9936 16.9604 340039 21.3711 22.4020 24.8246 22.8823 340040 20.7237 21.1397 23.6131 21.8157 340041 15.5873 16.3200 15.2995 15.7337 340042 17.0034 19.1386 21.0806 19.0573 340044 18.0863 18.9562 18.2154 18.4256 340045 13.6182 20.2641 17.4067 16.7851 340047 20.0744 21.5178 23.3831 21.6665 340049 19.5127 17.2986 21.2734 19.3901 340050 19.6726 20.6831 20.3262 20.2425 340051 19.3627 19.0282 20.3057 19.5812 340052 23.2134 26.2243 31.1678 25.9648 340053 19.9915 23.2410 25.2543 22.6238 340054 15.5090 16.6208 * 15.9979 340055 19.4035 20.8253 23.1390 21.1444 340060 19.3410 20.8570 19.4707 19.8979 340061 22.1175 23.7173 25.1081 23.6221 340063 16.7377 26.4132 * 21.1044 340064 18.5069 17.6106 19.4523 18.4891 340065 17.3530 23.2606 20.2174 19.9588 340067 19.7187 22.4054 22.2565 21.2710 340068 17.8065 18.8758 18.9555 18.5436 340069 21.6728 22.5995 24.4650 22.9542 340070 20.6829 21.3511 22.4458 21.5104 340071 18.0767 19.3679 19.8571 19.1466 340072 17.7129 18.7920 19.2773 18.5813 340073 23.5832 24.0794 26.6829 24.9327 340075 20.0081 19.7450 22.9365 20.9263 340080 18.2061 * * 18.2061 340084 19.0103 19.6087 20.8175 19.7922 340085 18.3179 20.3684 21.7019 20.1735 340087 18.2255 20.2445 19.7815 19.4322 340088 22.2322 22.6462 22.9486 22.6109 340089 15.4760 16.1321 16.5968 16.0500 340090 18.5287 18.7701 20.3261 19.2336 340091 20.3861 21.2665 22.4370 21.4299 340093 16.8903 16.5452 17.2910 16.9100 340094 * 21.0091 * 21.0091 340096 19.4696 20.9686 22.1174 20.8605 340097 18.2399 20.0302 20.9190 19.7534 340098 21.9578 23.4949 24.1099 23.2572 340099 15.3752 16.9979 17.3123 16.5041 340101 15.6509 20.7841 * 17.9177 340104 11.5169 12.1845 12.9949 12.2095 340106 18.1211 19.1147 20.1076 19.1527 340107 19.3197 20.7601 21.0070 20.3722 340109 19.0532 19.3357 19.0067 19.1328 340111 16.5976 17.2127 19.4520 17.8152 340112 15.5142 16.9592 17.0230 16.4908 340113 21.9883 24.4222 24.9180 23.7927 340114 20.7261 21.7750 19.5543 20.5793 340115 21.7586 24.7924 21.2336 22.4360 340116 20.6800 21.6744 23.9643 22.1286 340119 19.5827 20.5394 21.2239 20.4881 340120 15.8240 16.9847 19.3990 17.3770 340121 17.8771 19.0420 19.9862 18.9987 340123 18.9078 21.5041 22.2199 20.9298 340124 17.4185 17.5411 17.5691 17.5084 340125 20.2748 * * 20.2748 340126 19.3734 21.2045 21.3106 20.5788 340127 19.3842 21.4797 22.0597 21.0110 340129 20.6521 21.0773 22.3260 21.4712 340130 19.8707 20.5851 22.7449 21.1193 340131 21.3849 23.2478 24.1370 22.9644 340132 17.5711 17.7110 17.8771 17.7237 340133 17.2138 17.5170 22.9471 18.7909 340137 31.7702 39.9826 33.5581 34.6438 340138 * * 27.2610 27.2610 340141 21.4986 23.2961 24.1329 23.0207 340142 18.0766 18.1824 20.2062 18.8388 340143 24.4098 21.9304 22.5250 22.9058 340144 22.9183 22.8634 25.4597 23.8048 340145 19.9233 21.5958 21.8120 21.1598 340146 17.3051 19.1306 20.7252 19.1365 340147 20.5520 21.5912 22.3744 21.5004 340148 18.9912 20.6790 20.8025 20.1744 340151 18.4733 19.0779 19.6254 19.0740 340153 20.7533 21.7375 23.7537 22.0653 340155 23.1021 25.0965 25.7472 24.6273 340158 19.0843 20.0921 21.7830 20.4524 340159 19.0338 19.4992 21.2983 19.9832 340160 16.7170 17.1963 18.7802 17.6409 340164 21.5769 * * 21.5769 340166 20.8270 22.0519 22.7235 21.9492 340168 15.6071 15.4250 16.8277 15.9431 340171 22.4779 22.7304 25.9865 23.8198 340173 21.0898 23.3690 23.7037 22.7805 340176 * * 26.5277 26.5277 350001 16.6551 15.6193 * 16.1279 350002 18.3459 19.1931 20.4398 19.3340 350003 19.2840 20.0663 21.0585 20.1107 350004 23.7016 25.1976 28.3773 25.5370 350005 19.9156 20.7467 22.5590 21.0499 350006 19.0343 19.1257 19.7577 19.2916 350007 13.8824 13.9966 13.0050 13.5839 350008 22.3783 23.4052 20.7952 22.2417 350009 18.3688 19.3668 20.2558 19.3312 350010 16.6272 16.7774 17.2489 16.8799 350011 19.1944 20.6809 21.1006 20.1738 350012 18.2524 16.0990 17.2775 17.4137 350013 17.2596 17.8145 19.3705 18.1038 350014 18.0999 18.6786 16.1719 17.7037 350015 17.1071 17.5658 18.5437 17.7151 350017 17.5124 18.0840 19.1952 18.2584 350018 16.4939 16.3210 17.1545 16.6530 350019 20.1608 20.6743 21.3589 20.7389 350021 17.7123 16.3394 17.6652 17.2178 350023 17.4983 18.3253 16.7124 17.5523 350024 15.4788 15.7510 17.0685 16.1028 350025 15.0469 14.6099 * 14.8289 350027 15.5178 17.5882 17.6730 16.8430 350029 14.6173 * * 14.6173 350030 18.1131 18.7993 18.8822 18.5954 350033 16.0870 16.0903 16.4715 16.2067 350034 19.6445 * * 19.6446 350035 11.7675 12.6496 * 12.2147 350038 19.6854 19.5497 18.4963 19.2761 350039 16.6278 14.8599 13.8504 15.1678 350041 19.1341 23.1150 19.7477 20.6986 350042 19.3309 19.3370 20.6599 19.7491 350043 16.7433 17.6722 18.8378 17.7606 350044 11.0601 10.9690 13.3406 11.6826 350047 18.0094 19.9749 14.4742 17.4738 350049 18.1993 16.8322 15.3488 16.7860 350050 12.2183 25.2747 * 15.7885 350051 17.0653 16.9201 13.8030 16.0076 350053 15.9160 16.7456 * 16.3628 350055 15.7916 16.1691 19.2523 16.9922 350056 15.0995 15.7752 16.2553 15.6926 350058 16.7034 16.1013 15.0197 15.9830 350060 10.3076 10.5325 10.5055 10.4468 350061 18.8790 19.6460 18.8494 19.1278 360001 19.6655 20.3515 22.2387 20.7565 360002 18.2613 19.6145 20.7436 19.4695 360003 22.7521 23.2905 24.4144 23.4719 360006 22.4436 22.6333 23.8087 22.9695 360007 14.8213 15.3656 19.1316 16.2099 360008 18.7961 19.8034 21.3795 20.0267 360009 18.9935 19.6277 21.6966 20.1251 360010 19.1852 20.5934 20.6291 20.1715 360011 21.3659 19.5383 21.4293 20.6951 360012 20.0525 23.0125 24.3521 22.5181 360013 21.3690 22.3407 24.4232 22.7482 360014 20.7419 22.9930 22.9372 22.2320 360016 21.2505 21.3967 22.8430 21.8319 360017 22.2740 22.7446 23.4603 22.8364 360018 24.6686 24.6694 29.9085 26.0220 360019 20.6480 21.4708 24.1469 22.0806 360020 22.1751 21.6607 21.5085 21.7901 360024 20.1352 20.9408 22.5356 21.2300 360025 20.2531 20.9266 21.6676 20.9599 360026 17.9523 18.6739 20.6765 19.1093 360027 21.7650 22.8098 22.6956 22.4249 360028 18.7174 * * 18.7174 360029 19.2928 19.7466 20.5687 19.8808 360030 17.6058 19.0551 20.1051 18.9454 360031 21.0687 21.0481 24.3482 22.0734 360032 19.8020 19.8367 20.6535 20.1098 360034 17.9594 19.4982 21.5621 19.7369 360035 21.0674 22.6982 24.0810 22.6341 360036 20.9916 21.4486 22.3567 21.6200 360037 23.1674 23.7504 32.6245 25.9190 360038 19.9415 21.4804 23.4855 21.6060 360039 19.0013 19.3703 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18.5382 19.3142 17.4363 360070 18.8406 19.4700 21.8228 20.0184 360071 19.0302 19.6873 21.4478 20.0864 360072 19.0166 20.8819 21.3735 20.4642 360074 18.5889 19.9947 22.9962 20.5125 360075 26.0663 27.6992 23.8492 26.5296 360076 20.3317 21.0402 22.5863 21.3489 360077 21.5517 22.2964 23.3686 22.4049 360078 22.6490 22.7743 22.9324 22.7880 360079 21.6644 23.9491 25.3134 23.6069 360080 17.6369 18.0392 18.7213 18.1448 360081 20.4614 20.7477 22.0134 21.0714 360082 20.7610 22.9390 25.2254 23.0000 360084 22.0492 22.1699 23.3257 22.5390 360085 21.5151 24.8010 24.6618 23.5397 360086 19.3701 20.5858 21.6902 20.5374 360087 20.7969 21.1621 23.9638 22.0097 360088 24.0822 20.5703 21.4608 21.9345 360089 18.1941 19.5260 21.0229 19.5818 360090 20.8971 21.2072 22.6236 21.6097 360091 21.8447 22.6510 23.5759 22.6962 360092 21.5073 20.9588 21.9732 21.4976 360093 19.0261 21.0134 21.4911 20.5156 360094 20.1227 21.1952 22.7772 21.2684 360095 19.8521 21.3505 22.6758 21.2848 360096 19.6726 20.9838 22.0673 20.9264 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360134 20.9564 21.6081 24.3117 22.2074 360136 18.2194 18.5687 19.6063 18.7820 360137 22.3648 23.1867 23.7795 23.0881 360140 21.2881 18.3463 21.0006 20.1760 360141 23.5343 23.5980 25.1442 24.0943 360142 18.3188 19.6189 21.2072 19.7570 360143 21.0336 20.9158 22.2275 21.3979 360144 20.9033 20.9386 24.7973 22.2165 360145 20.0513 21.2931 22.4813 21.2645 360147 17.6779 18.7258 20.0409 18.8813 360148 19.1393 20.3120 21.3211 20.2546 360150 22.3620 23.1858 24.8485 23.4439 360151 19.2788 20.5594 21.6234 20.4589 360152 21.6005 20.9704 22.4839 21.6726 360153 16.7399 16.1021 16.5065 16.4436 360154 14.3593 14.9606 16.1719 15.1150 360155 22.2112 22.3347 23.0020 22.5355 360156 18.9095 19.9382 21.2853 20.0637 360159 21.5695 22.7992 23.3359 22.5729 360161 20.6160 19.6266 21.5045 20.5807 360163 21.2689 22.1012 23.1500 22.1757 360165 18.2417 19.6205 21.7785 19.8643 360170 20.4407 19.7980 21.5572 20.5841 360172 19.8909 22.3294 22.6475 21.5601 360174 20.5399 20.5874 20.7719 20.6325 360175 21.5450 22.0274 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19.3386 18.3281 370025 18.4815 19.1013 20.2845 19.2928 370026 18.0412 18.6982 21.9141 19.5712 370028 21.1292 22.1765 24.3775 22.5815 370029 18.2580 19.3285 19.6977 19.1304 370030 16.5803 18.4568 18.6541 17.9169 370032 18.1538 18.9050 20.0827 19.0803 370033 11.3210 15.3857 15.7468 13.9159 370034 15.6288 16.2204 16.1541 15.9959 370036 12.4070 11.7667 16.5843 13.2363 370037 18.9556 20.6493 20.9598 20.1863 370038 13.0210 15.4551 16.7597 14.9832 370039 19.4498 22.7015 20.3137 20.7707 370040 15.5109 16.8127 18.9981 17.0372 370041 16.2316 14.7346 19.0064 16.6382 370042 15.2764 15.9005 14.0899 15.1360 370043 17.0892 20.0991 20.2929 18.9889 370045 11.3560 11.6163 12.6613 11.8767 370047 17.8769 18.4743 19.4856 18.6175 370048 15.6803 17.0785 15.4768 16.0450 370049 19.4868 20.3405 20.4826 20.0887 370051 12.5171 11.4943 12.0397 11.9839 370054 18.0787 19.2294 20.3788 19.2048 370056 18.1432 19.2867 20.4872 19.2536 370057 15.1228 16.0301 17.3020 16.1401 370059 18.3314 21.3103 20.7160 20.0337 370060 19.3051 17.9469 23.1897 20.1750 370063 16.7342 * 12.7634 16.0398 370064 11.9954 11.6347 11.9044 11.8446 370065 18.1349 18.2406 18.3966 18.2581 370071 16.4567 * * 16.4568 370072 13.6519 12.5765 12.5766 12.8934 370076 14.3555 15.4067 19.0231 16.2477 370078 19.2412 15.2513 22.0344 18.4513 370079 16.9201 17.5915 17.9942 17.4569 370080 14.7323 14.3546 16.1445 15.0543 370082 15.0669 16.9715 12.6060 14.8254 370083 13.1810 15.6824 18.5669 15.6441 370084 13.1197 15.6184 16.1277 15.0212 370085 48.1271 13.7216 15.8930 17.6461 370086 11.1900 * * 11.1900 370089 17.2638 17.9243 18.0505 17.7472 370091 20.1822 20.8536 23.8502 21.5141 370092 15.7678 16.8432 * 16.3152 370093 19.7008 22.1966 23.5685 21.8046 370094 19.5462 19.5565 20.7290 19.9736 370095 13.4202 14.5909 14.3563 14.1246 370097 23.2056 19.3793 20.3218 20.7266 370099 19.4646 18.1467 20.2001 19.2453 370100 18.8274 12.9784 13.0682 14.6358 370103 18.2685 23.1347 15.6109 19.0349 370105 20.7890 25.1252 22.4493 22.5846 370106 20.3651 21.8937 24.0117 22.1004 370108 12.7470 14.0190 13.8170 13.5126 370112 15.3039 14.3384 16.5964 15.3556 370113 17.6107 20.3439 21.4267 19.8197 370114 17.8941 17.9757 19.3383 18.4232 370121 21.3099 20.5488 20.1393 20.6498 370122 15.4375 * * 15.4374 370123 19.0313 19.7958 20.5180 19.7729 370125 13.9436 14.4664 17.9240 15.3291 370126 15.8020 * * 15.8021 370131 15.7261 * * 15.7262 370133 12.9545 16.1855 17.4258 15.5834 370138 17.5551 17.4574 19.0403 18.0470 370139 14.9964 16.0898 16.3223 15.8016 370140 17.1393 17.4950 20.2255 18.2466 370141 20.7798 19.8606 24.0523 21.4638 370146 13.0399 13.9900 * 13.5128 370148 20.6612 22.6237 22.8526 22.0700 370149 17.0929 18.0699 18.2260 17.8047 370153 16.4669 16.5267 17.9692 16.9732 370154 15.6093 16.6687 17.4760 16.6039 370156 14.5696 15.4303 15.9647 15.3521 370158 15.6994 16.3637 17.3412 16.4535 370159 21.1267 25.5592 * 22.6485 370163 20.4217 * * 20.4216 370165 13.0375 12.9569 16.1893 13.8212 370166 21.0797 19.4219 21.3003 20.6013 370169 12.7138 14.8384 16.5607 14.5408 370176 18.9951 19.6537 21.7871 20.1373 370177 14.6481 14.1304 14.0279 14.2494 370178 11.6200 9.8655 12.9636 11.3085 370179 21.3002 23.8404 21.9673 22.2749 370183 16.9318 16.6061 * 16.7678 370186 15.4533 16.3671 16.3879 16.0737 370190 19.3570 20.6398 22.3326 20.7903 370192 19.6967 21.8343 24.3832 21.9053 370200 22.5299 18.3941 16.7164 18.9908 370201 * 18.2548 18.9906 18.6571 370202 * 16.5384 24.0239 20.2030 370203 * 23.5454 19.8772 21.4569 370204 * * 17.5518 17.5517 370205 * * 20.7828 20.7830 370206 * * 22.3471 22.3471 370207 * * 26.3745 26.3746 380001 26.4822 25.1542 20.9585 23.8121 380002 21.9185 23.2479 25.2629 23.4657 380003 20.9007 23.8074 24.6377 23.1951 380004 23.3609 24.5418 26.7995 24.9862 380005 25.0750 24.7476 26.3472 25.4394 380006 21.3520 20.5914 24.7492 22.3626 380007 32.2678 25.9239 30.0497 29.1804 380008 22.3004 21.6133 24.6149 22.8464 380009 24.3851 25.1040 25.9993 25.1907 380010 22.7276 24.1931 * 23.4887 380011 20.3357 20.6759 21.9382 20.9633 380013 19.8180 19.9606 24.1491 21.3157 380014 25.9828 26.6038 28.4536 27.0598 380017 25.3954 21.9236 29.2543 25.5247 380018 22.9822 24.8661 27.5171 25.1199 380019 20.8176 21.1743 23.9736 22.0144 380020 22.9568 23.9978 23.7066 23.5720 380021 23.8499 24.4365 28.0334 25.5509 380022 24.5974 25.6255 26.4793 25.6210 380023 21.3831 23.4328 23.0079 22.7334 380025 26.9346 26.9398 28.8525 27.6239 380026 20.6972 22.7561 23.8666 22.4738 380027 21.5490 22.2573 21.5822 21.7906 380029 20.1471 22.0371 24.2939 22.3500 380031 20.3396 23.7634 25.2963 23.2221 380033 27.1343 26.6899 30.4783 28.1499 380035 23.9719 25.6016 26.2434 25.3543 380036 27.2157 * * 27.2157 380037 22.1774 23.4798 25.0199 23.6781 380038 26.7759 28.1436 29.1804 28.0609 380039 22.8048 25.7614 26.3917 24.8782 380040 22.5477 22.6412 21.5958 22.2243 380042 24.4172 21.6793 15.2050 19.3932 380047 24.2524 25.2591 26.5017 25.3895 380048 18.3005 18.2773 22.0609 19.6514 380050 20.3205 22.1089 23.1332 21.8624 380051 22.3207 24.4081 26.2384 24.3019 380052 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21.5105 18.5545 20.7764 20.3109 390035 22.3591 21.9325 23.2173 22.4923 390036 19.7671 20.2103 20.5751 20.1842 390037 20.4263 19.9175 20.1665 20.1659 390039 17.5300 17.6181 18.4580 17.8792 390040 16.6876 17.4451 20.5371 18.2001 390041 20.4397 19.6159 21.0074 20.3638 390042 22.5775 22.0668 21.8863 22.1699 390043 17.4764 17.6739 19.8094 18.3425 390044 20.9831 21.3382 22.0362 21.4586 390045 19.4677 20.2107 19.8137 19.8315 390046 21.7445 21.3960 23.0279 22.0786 390047 26.9709 * * 26.9709 390048 19.7992 18.9776 20.3523 19.7014 390049 22.1586 22.8196 23.9058 22.9608 390050 22.2639 24.9156 22.5851 23.1577 390051 28.1385 * * 28.1385 390052 20.1195 21.2729 22.1380 21.1379 390054 18.4975 19.4686 19.8602 19.2479 390055 23.4017 25.7327 22.2112 23.7101 390056 19.3901 21.4121 21.4239 20.7360 390057 20.2395 21.6693 24.5245 22.1897 390058 20.3520 20.7930 22.0113 21.0507 390061 23.8722 22.8728 24.3816 23.6939 390062 17.3750 17.4710 17.6303 17.4968 390063 19.4965 20.1696 21.7120 20.4817 390065 20.0473 20.2930 23.1698 21.2264 390066 18.9296 19.0132 21.7717 19.8676 390067 20.8162 21.9885 23.2161 21.9824 390068 19.1109 21.6408 21.8596 20.7014 390070 21.8549 22.7909 24.4403 23.0308 390071 16.0100 18.9416 17.8117 17.5040 390072 16.9232 16.9445 20.6881 18.0993 390073 21.2623 22.2703 22.7073 22.0769 390074 18.3093 19.7446 21.8456 19.9484 390075 18.7695 19.5840 19.8576 19.3638 390076 21.3290 19.7719 * 20.5305 390078 19.0156 20.6483 21.1894 20.2451 390079 18.9269 19.5982 20.0240 19.5384 390080 21.4707 22.2449 23.0615 22.2544 390081 24.7461 25.6575 27.3952 25.9933 390083 * 26.1660 * 26.1660 390084 20.2529 17.0197 18.3551 18.4310 390086 18.3563 19.7645 19.5253 19.2361 390088 23.9506 * * 23.9506 390090 21.3759 20.5433 21.8543 21.2676 390091 18.3770 19.0355 19.7361 19.0422 390093 18.4442 20.0135 19.9209 19.4590 390095 16.6930 17.9697 18.3939 17.6811 390096 22.4382 22.2974 22.6176 22.4533 390097 25.2845 24.7853 24.6090 24.8791 390100 20.9263 21.1186 22.9484 21.6940 390101 18.5039 19.0180 19.7332 19.0899 390102 21.5496 19.3111 19.9809 20.2918 390103 18.8667 20.4422 26.5769 21.5409 390104 16.3255 16.2440 16.5081 16.3661 390106 16.8439 17.4747 18.2013 17.4917 390107 20.9841 20.6024 21.1104 20.9018 390108 21.3142 22.0444 23.6644 22.2895 390109 16.5299 17.4540 17.2667 17.0836 390110 21.6464 21.6005 23.2166 22.1164 390111 33.3971 27.1429 30.5237 30.4448 390112 15.0065 14.8634 15.6710 15.1640 390113 19.3634 19.9496 20.1160 19.8009 390114 20.9533 19.8004 23.0501 21.2575 390115 21.4287 22.3545 24.1951 22.7320 390116 21.3671 22.6783 24.0492 22.6706 390117 18.0769 18.9764 18.3341 18.4618 390118 18.9507 17.2668 17.8460 18.0300 390119 18.8815 19.3946 20.3034 19.5629 390121 19.1315 20.6253 20.8017 20.2031 390122 17.7734 15.5438 18.5130 17.2135 390123 21.3974 21.8897 23.2750 22.1809 390125 17.5446 17.0975 18.2411 17.6363 390127 22.4555 22.8787 25.0836 23.5152 390128 19.3165 19.9764 21.3668 20.1918 390130 18.3695 18.5519 19.4835 18.7830 390131 19.2096 19.1931 19.2964 19.2343 390132 22.8414 24.1878 24.6889 23.9106 390133 24.7561 24.1590 25.1423 24.6873 390135 22.1905 22.2501 24.0445 22.8305 390136 20.6286 16.8505 * 18.7490 390137 18.5397 19.4769 18.4551 18.8068 390138 20.6936 20.7726 21.4705 20.9891 390139 23.9757 24.8347 26.3622 25.0742 390142 28.8877 28.4680 29.9432 29.1087 390145 20.4228 20.4964 20.6603 20.5268 390146 18.6505 20.1788 21.3295 20.0284 390147 21.2492 21.7600 22.3135 21.7727 390150 20.3155 20.8970 20.0261 20.3992 390151 22.5206 23.6072 24.8175 23.6886 390152 19.4017 20.2581 21.5474 20.4133 390153 22.9707 23.9039 25.3415 24.1064 390154 16.7052 17.8774 19.1300 17.9859 390156 22.6398 24.0034 25.0732 23.9019 390157 19.1783 20.2647 20.6933 20.0398 390160 19.4463 19.4793 19.3598 19.4262 390162 21.9188 21.3379 21.3398 21.5478 390163 17.7564 18.1831 18.8585 18.2862 390164 24.9750 26.1698 23.0298 24.6107 390166 19.7978 19.8899 19.8531 19.8460 390168 18.8863 19.6875 20.6777 19.7568 390169 22.0547 22.7920 22.7695 22.5431 390170 24.7973 * * 24.7973 390173 18.6613 18.8265 20.6958 19.3949 390174 25.3307 26.3891 28.2662 26.6572 390176 20.8368 21.7650 18.0752 20.3817 390178 17.0534 17.1142 17.2384 17.1362 390179 21.8593 21.5792 24.0501 22.5243 390180 26.5541 26.7743 28.3812 27.2876 390181 19.3832 18.8681 24.1288 20.6497 390183 17.9848 17.4535 21.7091 18.9719 390184 20.9349 21.1941 21.1962 21.1056 390185 20.3877 20.3301 20.4476 20.3876 390189 20.3338 19.6186 20.0387 19.9844 390191 17.2270 17.1919 18.5972 17.6639 390192 17.6597 16.6469 19.1883 17.8533 390193 18.1209 17.3804 18.9764 18.1140 390194 21.2689 21.0549 21.5850 21.3104 390195 24.1793 24.2891 26.2024 24.9040 390197 20.7998 22.1974 22.3472 21.7925 390198 15.8833 16.6803 17.3937 16.6375 390199 17.3865 17.7782 18.9787 18.0590 390200 15.4012 18.2456 19.1728 17.6332 390201 20.3533 21.3291 22.6548 21.4708 390203 21.4989 22.4685 26.9436 23.7942 390204 22.9616 22.7282 23.9673 23.2268 390209 18.7059 16.8200 18.4248 17.9405 390211 18.4213 19.4552 21.0450 19.6873 390213 19.1553 20.1152 19.9614 19.7218 390215 21.2032 23.5953 25.2617 23.2887 390217 19.9837 19.7578 21.4058 20.3609 390219 19.6226 20.1311 20.0594 19.9347 390220 17.7916 22.7617 23.3890 21.1672 390222 22.1548 22.7491 24.9365 23.2941 390223 22.1775 18.9493 20.4623 20.4831 390224 13.7518 17.2173 15.4657 15.2280 390225 18.7290 19.0364 22.5083 20.0077 390226 21.8481 22.8588 26.4195 23.5449 390228 19.8180 19.6212 20.1219 19.8582 390231 19.4798 21.0757 24.6868 21.6606 390233 20.2309 20.5800 21.6259 20.8313 390235 21.4200 19.9925 23.7068 21.4467 390236 17.8735 19.1427 19.8687 18.9492 390237 22.3011 21.7847 23.2054 22.4279 390238 17.1055 18.1956 19.2170 18.1264 390244 15.6402 14.2136 * 14.8974 390245 24.5076 * * 24.5076 390246 25.0556 22.3892 22.0687 23.0374 390247 21.2151 * * 21.2151 390249 13.1657 14.1062 14.7215 14.0139 390256 22.2773 22.3540 22.5794 22.4081 390258 22.6852 23.8318 25.0634 23.8724 390260 21.5982 * * 21.5982 390262 * 18.8942 21.3264 20.1664 390263 20.3796 20.6348 21.9811 21.0229 390265 20.4950 20.4760 20.5948 20.5230 390266 17.1966 17.6223 18.2424 17.6964 390267 19.2665 20.2424 21.4980 20.3945 390268 22.0909 22.2046 23.1124 22.4784 390270 19.2074 20.7957 22.3861 20.7770 390278 17.7176 18.5776 21.1387 19.0743 390279 14.8655 15.8080 16.0509 15.5561 390283 22.5490 * * 22.5489 390284 34.3904 * * 34.3902 390285 * 29.1270 30.6458 29.8575 390286 * 22.9746 25.4619 24.2087 390287 * 30.3252 32.9709 31.6159 390288 * 26.9662 28.0958 27.3905 390289 * 22.8963 25.1658 23.9733 390290 * 30.5037 31.0967 30.8194 390291 * 20.0272 21.0057 20.4818 390293 * 23.5285 * 23.5284 390294 * * 33.3535 33.3537 390295 * * 26.8863 26.8862 390296 * * 25.6979 25.6981 390297 * * 27.2166 27.2167 400001 10.5757 10.7531 11.7572 11.0430 400002 13.0494 13.3684 11.6804 12.6379 400003 12.4078 11.2726 10.5963 11.4141 400004 8.5648 9.0781 11.4479 9.6254 400005 7.7432 9.7802 10.5356 9.1053 400006 10.1048 10.4988 9.2852 9.9205 400007 8.0174 8.1974 8.6022 8.2631 400009 8.8650 8.7341 9.4413 9.0139 400010 10.8011 9.1359 8.9964 9.6421 400011 8.5426 8.6252 8.9111 8.6956 400012 8.4728 8.6538 9.0740 8.7216 400013 9.2624 9.8197 9.9905 9.7250 400014 9.4798 10.2712 11.4580 10.3309 400015 14.4076 15.5827 * 14.8835 400016 13.3922 13.7001 14.5398 13.8932 400017 9.2577 9.9167 10.3892 9.8593 400018 10.6208 10.5583 10.8254 10.6669 400019 10.8940 12.1251 13.2143 12.0755 400021 12.1434 12.7462 13.2358 12.7262 400022 12.2199 13.0915 15.2904 13.4548 400024 9.2409 9.0826 9.8650 9.4011 400026 5.8335 7.4280 5.9207 6.3366 400028 9.1794 8.9567 9.5266 9.2275 400032 10.0448 10.1898 10.7100 10.3326 400044 11.9486 12.8671 9.0275 11.6261 400048 15.1405 11.5104 10.8618 12.2444 400061 13.0988 10.3664 17.0566 13.1015 400079 9.7203 8.7218 8.7218 8.9772 400087 9.8534 8.6480 10.5762 9.7829 400094 7.9187 9.4600 9.1442 8.8371 400098 9.7791 10.4312 13.5901 11.0612 400102 9.9903 8.5290 10.9973 9.8471 400103 11.5359 11.8454 11.5797 11.6448 400104 10.7292 7.9552 7.1781 8.8476 400105 9.0556 10.6028 11.5608 10.1248 400106 9.2187 9.8694 10.1240 9.7589 400109 11.8760 12.2080 12.8750 12.3225 400110 10.5277 10.7228 12.0159 11.1009 400111 10.9665 12.3311 12.7701 12.0404 400112 10.8694 11.0634 11.8808 11.2717 400113 8.3168 9.3000 10.1440 9.3104 400114 7.0510 9.9477 9.7444 8.8440 400115 8.5487 7.2203 7.0336 7.5134 400117 10.8756 11.3351 9.6471 10.6080 400118 11.4051 11.4317 12.0855 11.6542 400120 10.6584 10.9315 11.8837 11.1482 400121 9.8322 8.7584 8.3575 8.9176 400122 7.6413 9.1638 9.6644 8.8133 400123 10.2367 10.9047 10.4081 10.5188 400124 12.2452 12.7323 14.1198 13.0556 400125 10.2056 10.5997 10.0698 10.2676 410001 23.1738 22.4972 24.0033 23.2235 410004 21.0638 23.5408 24.7607 23.1523 410005 22.7170 24.0086 24.6202 23.7588 410006 23.8700 22.8959 26.1234 24.3211 410007 23.1325 24.9846 27.7171 25.1159 410008 24.9726 24.4792 25.4183 24.9582 410009 24.3895 24.3760 26.1891 24.9832 410010 28.4589 29.7315 30.4061 29.5287 410011 26.1183 27.4880 29.2039 27.5568 410012 24.1695 26.4570 28.1791 26.2184 410013 24.8800 25.3688 28.4954 26.2187 420002 20.7804 22.6182 25.1067 22.8141 420004 20.9588 22.4680 23.4275 22.2200 420005 17.9694 17.8202 19.5521 18.4820 420006 19.1760 18.7153 22.7896 19.8079 420007 18.6456 19.0199 22.0134 19.8792 420009 19.9586 21.2566 18.6866 19.8536 420010 18.0252 19.3267 19.1545 18.8686 420011 18.0970 16.7523 17.3200 17.3563 420014 18.0519 19.0455 20.4975 19.1969 420015 20.1164 20.8736 22.7776 21.3355 420016 15.5485 16.6448 17.0051 16.4309 420018 21.8775 20.7779 20.4649 20.9903 420019 17.1726 19.0199 19.7118 18.6106 420020 20.3193 20.5801 22.1616 21.0728 420023 20.4053 20.8600 22.9004 21.4470 420026 21.8749 23.3072 23.6914 22.9839 420027 19.2594 19.7322 20.7327 19.9443 420030 20.6448 22.5159 22.5925 21.9394 420031 8.2516 15.3605 16.8518 12.3011 420033 23.1303 23.7974 26.0792 24.3733 420036 21.3222 19.8285 20.6780 20.5493 420037 22.7099 23.5244 25.3863 23.9574 420038 18.6568 19.9829 21.6132 20.0798 420039 18.3017 18.0055 21.1830 18.9968 420043 19.7570 19.6834 21.8816 20.4303 420048 18.8070 20.5531 21.9517 20.4950 420049 19.4049 20.1765 20.2320 19.9533 420051 19.1555 19.8549 20.6629 19.9007 420053 18.1657 19.0780 19.9013 19.0557 420054 20.2574 20.2275 20.7802 20.4197 420055 16.8717 18.6782 19.3056 18.2587 420056 15.1835 16.5491 19.8467 17.1664 420057 20.5266 22.1312 17.6727 20.1808 420059 17.1483 18.2093 20.2630 18.4420 420061 17.3543 17.7047 19.9789 18.3969 420062 21.7469 20.9032 17.4888 19.8336 420064 16.0794 19.7067 20.9057 19.0582 420065 19.9435 19.2150 21.9297 20.4427 420066 18.0042 19.5366 20.7713 19.3973 420067 19.7824 20.8524 22.8104 21.1856 420068 18.5481 20.2580 21.7257 20.1957 420069 18.1298 18.9017 17.6788 18.2297 420070 17.3876 19.2186 20.1378 18.9286 420071 20.3902 20.1897 21.2610 20.6237 420072 15.0158 18.2531 16.2578 16.5142 420073 19.9986 20.2697 21.4718 20.6373 420074 18.0967 18.1839 18.7011 18.3051 420075 12.8158 15.0132 15.9890 14.6306 420078 21.9082 22.7156 23.9730 22.8546 420079 21.0874 21.3177 23.0729 21.8705 420080 21.9968 23.2871 26.7489 24.1988 420082 21.7210 22.8516 28.0149 24.1640 420083 22.6376 24.4499 24.8294 24.0095 420085 21.6791 22.0071 23.8540 22.5902 420086 20.2878 23.5303 24.5760 22.8222 420087 19.8388 20.8217 21.9354 20.8793 420088 19.9919 21.8979 23.5174 21.7712 420089 20.5360 21.3954 23.3240 21.8074 420091 20.3092 21.8367 23.7544 21.8937 420093 18.3902 19.1299 21.4678 19.5913 420095 * 33.4632 * 33.4634 420096 * 26.4863 * 26.4864 430004 19.6344 19.2737 22.2198 20.3430 430005 16.4560 17.3400 18.2647 17.3726 430007 14.6331 15.1494 17.8017 15.8287 430008 18.1323 18.5234 20.0124 18.8898 430010 19.8191 16.5750 21.3978 18.9840 430011 17.4750 18.3648 19.9835 18.5721 430012 17.6997 19.2921 21.2588 19.3790 430013 18.4817 18.8978 21.3388 19.5495 430014 20.2387 20.9118 22.0285 21.0694 430015 18.2875 18.8998 20.5848 19.2456 430016 20.8850 22.7585 24.2450 22.6451 430018 16.2244 15.9424 17.9850 16.6387 430022 14.5118 14.0661 * 14.2905 430023 16.2164 16.7850 18.8816 17.1465 430024 16.1801 17.4816 18.8359 17.4068 430027 20.2591 20.8666 22.1807 21.1128 430028 17.1577 18.2829 30.0094 20.4957 430029 17.6986 17.4932 18.9463 18.0331 430031 12.4660 13.2105 15.2322 13.5804 430033 17.3652 18.3978 21.6255 19.2950 430034 14.2491 13.8535 13.6064 13.9089 430036 15.6258 16.7827 16.5848 16.2916 430037 18.1293 18.7009 19.3794 18.7558 430038 18.4078 * * 18.4078 430040 14.4509 14.7860 15.3612 14.8505 430041 14.8816 * * 14.8815 430043 14.9949 17.0193 17.9673 16.5225 430044 21.0823 * * 21.0824 430047 17.9823 17.5377 18.2773 17.9221 430048 18.7602 19.0261 20.0608 19.3158 430049 15.2237 14.9025 17.0885 15.6759 430051 18.8070 18.8697 21.2838 19.6636 430054 14.8003 15.0101 17.8870 15.8667 430056 10.3697 14.1914 15.9149 13.1642 430057 17.2805 18.8777 18.2939 18.1566 430060 10.0176 9.7678 10.6493 10.1353 430064 14.2184 13.8666 14.3407 14.1427 430066 15.6660 14.5957 18.0501 16.1260 430073 15.3776 16.5112 16.4387 16.0995 430076 13.9883 15.2453 12.6996 13.8839 430077 19.8558 20.4361 21.6786 20.6834 430079 14.1815 14.4154 15.4268 14.6345 430089 17.9790 17.5100 19.8572 18.4672 430090 21.5974 23.5180 25.6873 23.7486 430091 18.1567 21.6239 22.2824 21.1724 430092 21.3807 19.7644 19.7354 20.2342 430093 19.5013 23.3009 23.8820 22.1340 430094 * * 20.8742 20.8743 440001 15.5897 17.2282 18.9833 17.1918 440002 20.3740 21.4299 20.7715 20.8573 440003 19.3042 20.3756 21.6336 20.4509 440006 21.4055 23.1483 24.3132 22.9905 440007 14.8959 14.0612 14.1008 14.3331 440008 18.8994 20.3303 20.9238 20.0515 440009 17.4831 18.4068 19.6564 18.5235 440010 16.3283 13.3692 16.7270 15.2992 440011 18.3375 19.3165 20.5036 19.4558 440012 19.5739 19.8949 21.3573 20.2411 440014 16.1143 15.0656 * 15.5948 440015 22.0659 21.6106 23.3677 22.3025 440016 16.2964 14.6142 20.1504 16.8295 440017 20.4563 20.4705 22.3573 21.0640 440018 17.4995 18.1620 21.2242 19.0126 440019 21.5402 22.8463 24.0149 22.8001 440020 17.8879 20.2189 21.1075 19.7440 440023 16.7837 15.6603 15.5410 15.9556 440024 18.4046 18.4276 19.9751 18.8456 440025 16.3140 17.0997 18.9008 17.4832 440026 23.2566 25.6490 25.1655 24.7161 440029 20.7050 22.2889 24.1379 22.4401 440030 16.9925 17.6297 19.9056 18.2332 440031 17.0211 17.2555 17.0289 17.1002 440032 13.8140 13.9784 14.7683 14.1838 440033 13.7328 16.4679 17.2637 15.8189 440034 20.0309 21.1672 22.2382 21.1482 440035 19.3034 20.4168 21.6338 20.4652 440039 21.6536 22.4158 24.8698 22.9682 440040 16.9275 17.6781 16.9886 17.1928 440041 14.9545 14.6684 15.5784 15.0621 440046 19.3229 20.5562 22.1743 20.5985 440047 17.8092 18.7469 18.7262 18.4184 440048 21.4993 21.6132 22.5431 21.9061 440049 18.7967 19.6920 22.1252 20.0483 440050 18.2511 19.7915 21.3428 19.8422 440051 16.0421 17.7067 19.0165 17.5455 440052 19.8075 18.6589 18.1897 18.8402 440053 19.6494 21.5253 22.0063 21.0648 440054 13.3967 15.2154 15.4208 14.7050 440056 16.2742 20.4903 19.1329 18.5350 440057 13.7257 14.4363 14.1477 14.1083 440058 19.1878 20.7722 21.7512 20.5453 440059 19.6018 20.8882 22.4248 21.0016 440060 19.7916 20.7628 20.0972 20.2143 440061 22.5525 16.9234 19.5458 19.4254 440063 19.8371 18.8072 19.7468 19.4529 440064 18.9809 18.2678 19.4020 18.8736 440065 18.8296 19.2282 19.9099 19.3487 440067 17.2397 18.2973 19.6120 18.4263 440068 19.3668 19.5428 20.9188 19.9728 440070 14.0437 18.0064 18.3717 16.8031 440071 19.7836 * * 19.7836 440072 19.1522 20.0691 20.9286 20.0759 440073 19.5554 19.6290 20.7181 19.9917 440078 16.0188 17.1645 20.0509 17.7858 440081 19.3454 17.2905 18.2664 18.2167 440082 22.6855 22.5590 26.0944 23.6946 440083 13.7423 13.7630 15.7015 14.3937 440084 13.7731 13.8085 15.0510 14.2295 440091 20.1065 20.1359 22.2894 20.8482 440100 14.7113 15.9969 20.1545 16.9936 440102 14.5500 16.0783 16.6548 15.7421 440103 18.6990 * * 18.6990 440104 22.6754 21.7135 21.5501 21.9246 440105 17.1172 18.1375 19.2902 18.1888 440109 17.7443 17.6399 16.5366 17.2746 440110 17.4816 18.4998 19.9718 18.7249 440111 23.2254 23.2111 24.9666 23.7976 440114 15.0036 18.5327 20.1152 17.9248 440115 18.5457 18.7054 18.4721 18.5719 440120 16.3115 19.8997 22.4031 19.5197 440125 19.4115 20.0599 21.2173 20.2484 440130 17.4857 19.0905 20.6364 19.0816 440131 16.1214 19.9883 21.0641 18.9957 440132 16.8871 17.9186 18.9580 17.9377 440133 23.0891 22.2257 22.4872 22.5969 440135 22.2005 22.5452 23.8313 22.9298 440137 15.0070 15.3530 16.5529 15.6758 440141 15.9429 17.6819 19.2607 17.4468 440142 16.8855 17.1483 17.7587 17.2159 440143 18.2061 18.6844 19.2978 18.7274 440144 18.3859 18.8127 19.7938 19.0189 440145 18.3948 18.3850 18.1226 18.2932 440147 26.1464 25.3766 25.0779 25.5115 440148 19.4598 19.3769 20.7693 19.8862 440149 18.4281 19.8304 18.1316 18.8060 440150 20.3006 21.2942 22.8656 21.5228 440151 18.3928 19.8977 20.7681 19.6191 440152 22.7664 21.7382 27.2915 23.9903 440153 16.5716 18.1781 19.9486 18.2431 440156 21.7577 21.9374 23.7799 22.5299 440157 18.4249 15.5316 17.6241 17.2522 440159 20.9371 21.4914 20.5719 20.9737 440161 22.8816 23.6805 26.1354 24.2908 440162 15.5534 19.8075 20.3909 18.5104 440166 19.2159 19.6632 23.1692 20.6397 440168 19.1509 21.1947 21.2114 20.4537 440173 19.1812 21.0284 20.8442 20.3754 440174 18.0865 19.3966 19.2201 18.8962 440175 18.5186 19.9022 22.3331 20.2599 440176 19.2208 19.8448 20.4861 19.8829 440180 20.2184 20.2057 21.1947 20.5447 440181 17.7709 19.0915 19.5055 18.7704 440182 19.7094 18.1953 19.3928 19.0713 440183 21.3465 22.2401 24.9282 22.9040 440184 16.8880 18.6890 21.4484 18.5678 440185 21.2188 21.1226 22.2855 21.5992 440186 19.7983 20.8600 23.0193 21.1673 440187 17.5872 18.3729 19.9478 18.6211 440189 18.5252 22.2555 23.2866 21.3831 440192 19.1705 19.1976 21.3228 19.9395 440193 18.6999 19.9078 22.0345 20.2055 440194 22.4562 21.9609 24.4629 23.0062 440197 21.8503 22.5282 24.2661 22.9060 440200 19.8078 18.7302 16.7752 18.4446 440203 16.2861 16.9819 21.3888 18.3754 440210 11.9815 12.7622 * 12.3704 440214 28.0285 * * 28.0287 440215 22.2928 * * 22.2928 440217 * 19.2834 23.3544 21.1703 440218 * * 20.1377 20.1377 440219 * * 18.2762 18.2762 440220 * * 22.1222 22.1221 450002 21.4836 21.5141 24.0413 22.4014 450004 16.7850 15.9452 * 16.4042 450005 16.6396 16.6354 21.7110 18.0529 450007 19.1910 18.0269 18.3073 18.4788 450008 17.6582 19.3745 20.1817 19.0466 450010 17.6677 19.8998 20.2928 19.2457 450011 20.8102 20.2963 21.6599 20.9101 450014 17.5815 19.8846 19.4805 18.9747 450015 21.6773 22.9820 23.9140 22.8577 450016 18.3456 19.1522 19.9783 19.1667 450018 23.2293 21.9921 22.9508 22.6215 450020 19.1153 18.4642 18.8688 18.8186 450021 23.3630 23.7663 24.3718 23.8437 450023 17.6360 19.2808 19.1645 18.7230 450024 18.5985 19.5584 20.8938 19.7493 450028 19.1658 19.5905 22.7775 20.4223 450029 17.7425 19.9505 19.9198 19.2371 450031 29.6945 29.6772 21.2734 25.9517 450032 14.6530 20.8525 20.6076 18.3640 450033 21.0222 21.3766 26.0361 22.7005 450034 18.8823 19.5233 21.6149 19.9977 450035 20.3599 20.3146 24.1791 21.4800 450037 19.9140 19.6532 22.9781 20.8451 450039 19.7176 20.4660 21.8243 20.6801 450040 19.6370 24.8621 21.3097 22.1542 450042 18.8357 20.6041 21.8886 20.4547 450044 21.0909 23.4476 23.2984 22.5215 450046 17.3631 20.2917 20.9220 20.0845 450047 16.9028 15.9525 21.8840 18.0090 450050 17.7209 19.1390 19.5171 18.7476 450051 21.1008 23.0010 23.1281 22.3573 450052 15.5890 20.3702 15.9400 17.2648 450053 17.2781 19.3347 15.0735 17.2659 450054 19.2431 25.3285 23.2915 22.8358 450055 15.8526 16.4789 18.2235 16.8274 450056 21.8605 22.5341 24.4197 22.9813 450058 18.6172 20.0424 21.9588 20.1476 450059 19.8240 21.4873 22.8792 21.4779 450063 12.7211 15.1779 * 13.6764 450064 19.7682 21.3929 18.6112 19.8410 450065 23.3797 23.8471 25.0043 24.0958 450068 23.3495 22.5626 23.4435 23.1149 450072 18.0307 20.0134 20.3683 19.5324 450073 16.5942 23.7700 19.2398 20.0099 450078 13.2820 13.9324 15.0471 14.0206 450079 20.6483 22.0609 23.9209 22.1935 450080 18.6212 19.8414 21.0442 19.7978 450081 17.5737 19.0276 19.0461 18.5365 450082 16.8677 18.0688 16.6397 17.1813 450083 23.3754 20.7446 22.4764 22.1790 450085 20.0085 17.5001 18.0245 18.4510 450087 21.9320 23.4141 24.6661 23.4257 450090 15.5796 15.6090 15.5556 15.5807 450092 17.9520 17.2058 16.0808 17.0569 450094 23.2863 25.2158 31.6176 26.5357 450096 18.6802 19.4430 20.1138 19.4265 450097 19.7187 20.7653 22.2467 21.0001 450098 19.0454 19.8469 20.1606 19.7427 450099 20.4181 19.3493 21.4482 20.3831 450101 17.7928 17.6368 20.1473 18.5186 450102 19.8793 21.4361 18.0166 19.5784 450104 17.0821 17.8219 19.7126 18.2038 450107 24.1094 24.5034 23.1605 23.8913 450108 15.2797 17.9596 18.4801 17.3161 450109 10.5973 18.1085 16.0510 14.2577 450111 21.4908 * * 21.4908 450112 18.1026 17.9624 19.7041 18.5605 450113 20.8306 20.7782 37.8953 21.1550 450119 20.2030 20.1436 20.8840 20.4169 450121 21.9198 22.0485 24.6090 22.7993 450123 14.1755 17.5051 17.8629 16.2415 450124 22.5208 22.9853 24.0333 23.2184 450126 21.4789 22.9423 23.9298 22.7661 450128 18.1446 18.7067 28.0211 21.3216 450130 18.9211 20.2613 19.0153 19.4183 450131 17.4168 18.1401 19.7316 18.4406 450132 21.8089 20.8908 22.4680 21.7157 450133 26.0763 24.5319 25.3928 25.3029 450135 20.4068 21.7038 22.3664 21.5213 450137 23.4346 22.8653 21.9645 22.7576 450140 17.3370 19.6205 18.4142 18.4792 450143 15.0871 17.8206 18.4456 17.0500 450144 17.4309 21.9135 20.8064 20.0145 450145 16.1895 18.0437 16.5468 16.9581 450146 15.5030 17.4391 16.6809 16.5128 450147 19.0477 20.3019 21.4266 20.2587 450148 20.4923 21.4982 19.4973 20.4877 450149 21.7219 22.6138 * 22.1667 450150 17.8612 17.8804 * 17.8714 450151 16.4209 16.3279 18.6100 17.0520 450152 17.7265 19.6105 20.0480 19.2518 450153 18.6514 20.9651 * 19.6822 450154 13.9119 16.8748 16.3479 15.7387 450155 13.3456 20.2582 18.4020 17.1145 450157 15.3083 16.8569 17.8764 16.7446 450160 10.6852 18.7780 20.7517 15.2676 450162 21.9218 20.5032 26.0570 22.6007 450163 17.8028 19.7675 19.8290 19.0858 450164 17.7180 18.7103 22.6906 19.5847 450165 17.3283 16.1010 16.4098 16.5904 450166 11.0541 12.6627 13.5795 12.4215 450170 14.3234 15.8525 13.1142 14.3736 450176 17.2576 19.2397 19.1706 18.5577 450177 15.2419 16.4503 17.2347 16.3235 450178 16.0280 15.8597 19.1186 16.9564 450181 18.6936 18.3600 17.8882 18.3181 450184 20.0821 22.7744 24.3452 22.4382 450185 11.5228 13.2015 14.2950 12.8871 450187 18.5053 20.8105 22.3174 20.4825 450188 15.1954 16.9800 17.5351 16.6019 450191 20.9512 20.5883 23.2261 21.6512 450192 21.2497 20.8315 20.1718 20.7147 450193 23.1639 25.1215 25.6437 24.6806 450194 20.7745 20.7152 22.1151 21.2200 450196 17.8993 21.1226 20.3102 19.7302 450200 19.2228 19.6496 20.4656 19.7649 450201 17.1463 18.0646 19.2517 18.1592 450203 19.3978 19.7978 23.1036 20.7628 450209 20.0140 21.3218 23.3963 21.5758 450210 16.3470 16.8532 16.7851 16.6843 450211 18.8114 18.7305 20.0677 19.2205 450213 19.0651 19.3440 21.1280 19.7979 450214 20.5070 21.3448 22.4544 21.4482 450217 12.7647 13.1840 11.3313 12.4053 450219 17.6884 18.5534 21.3693 18.8542 450221 15.2120 16.2308 19.6778 16.9127 450222 19.8967 23.2779 23.4805 22.2795 450224 20.1579 20.1723 19.7665 20.0338 450229 16.7853 17.0346 17.9811 17.2535 450231 19.1746 20.7709 21.0986 20.3555 450234 16.3003 17.9478 21.8295 18.7188 450235 16.3115 17.0143 18.4234 17.2758 450236 16.4957 18.4551 17.1250 17.3256 450237 19.0325 21.6497 21.6752 20.8141 450239 17.8401 18.8416 19.3655 18.6917 450241 16.4240 16.6046 17.4151 16.8266 450243 13.6416 11.2035 17.7821 13.8172 450246 16.7959 22.7940 20.7893 19.8488 450249 11.7658 10.6467 13.1223 11.8062 450250 13.6787 18.3361 12.8229 14.7303 450253 13.2177 14.5492 16.6365 14.6878 450258 16.7337 17.0724 18.3136 17.3431 450264 14.5956 17.2825 13.5346 14.9127 450269 12.7717 12.2970 13.4838 12.8458 450270 14.4792 13.8881 12.3962 13.5856 450271 16.7831 17.9570 18.3659 17.7341 450272 18.4344 20.5888 21.3492 20.1697 450276 14.0745 14.0779 12.8895 13.6150 450278 15.2950 14.3931 15.2944 14.9802 450280 22.2936 22.2648 22.3781 22.3117 450283 15.1950 15.8224 16.9843 16.1315 450288 18.8935 17.4817 17.4214 17.9418 450289 20.3460 22.4656 19.9906 20.9466 450292 20.5335 21.1511 22.8905 21.4277 450293 16.2721 16.4077 17.7673 16.8504 450296 22.3430 21.5998 20.4483 21.4253 450299 * 21.2754 22.9849 22.1397 450303 12.8996 14.3353 16.1330 14.3646 450306 14.2047 13.6333 15.5980 14.3658 450307 17.0691 17.6757 19.6952 18.1345 450309 13.3771 16.0363 16.5770 15.2473 450315 21.4684 23.8151 26.4677 23.7712 450320 20.6596 24.8602 24.7457 23.2764 450321 14.7344 17.2289 17.4628 16.2569 450322 29.1884 28.9834 17.9071 25.3849 450324 19.1692 20.9081 24.0112 21.3590 450327 13.3639 11.0983 14.3848 12.7752 450330 19.8066 21.0921 22.9948 21.3142 450334 13.8392 13.9812 14.2209 14.0138 450337 25.5708 * * 25.5709 450340 * 19.2611 18.7179 18.9746 450341 * 20.8814 * 20.8814 450346 18.9475 19.2769 20.1921 19.5923 450347 19.3475 20.1899 21.7603 20.4764 450348 13.3585 15.0069 15.3299 14.5667 450351 19.3159 21.2842 21.6640 20.7344 450352 20.1871 21.2035 21.8138 21.1211 450353 16.0003 17.3274 19.5263 17.5681 450355 11.8933 12.8876 13.9234 12.8974 450358 23.0206 25.5767 25.9233 24.7613 450362 18.1983 18.7687 20.6340 19.2155 450369 15.3122 16.0667 16.5636 15.9500 450370 16.1369 18.7539 17.0463 17.3593 450371 16.0236 17.7591 17.3415 16.8971 450372 22.0746 21.4050 23.1343 22.1317 450373 17.9554 18.5716 17.7025 18.0874 450374 15.1750 15.0146 15.2532 15.1489 450378 23.4599 24.4143 25.8048 24.6304 450379 22.8756 25.1931 29.0865 25.7747 450381 16.7112 16.7237 18.7899 17.5371 450388 19.7408 20.7989 22.4439 21.1046 450389 18.8448 19.3156 20.7206 19.6586 450393 22.4992 21.4405 23.5336 22.4798 450395 18.0024 17.5236 18.6664 18.0895 450399 15.3491 16.3333 19.1571 16.9654 450400 18.6668 19.1345 20.1376 19.3717 450403 22.8430 24.7657 24.6273 24.1287 450411 15.1121 15.9165 16.9559 15.9781 450417 15.3591 15.2713 16.1956 15.6177 450418 21.9690 22.2511 25.1306 23.1136 450419 23.2551 22.9522 26.4121 24.0600 450422 28.0257 28.0395 28.5834 28.2238 450424 18.7895 20.7634 22.0682 20.6438 450431 22.0361 22.6766 22.7459 22.4890 450438 15.4553 21.0474 18.4891 18.0730 450446 20.7592 13.8011 14.1684 15.5340 450447 18.0377 19.7532 21.0247 19.5725 450451 18.2988 18.9519 20.1738 19.1894 450457 19.6569 * * 19.6569 450460 14.6523 15.9446 17.9487 16.1581 450462 22.1144 22.5413 20.6169 21.6907 450464 15.5908 15.8121 16.1987 15.8774 450465 15.4731 19.3928 19.6579 17.7347 450467 17.0004 18.9388 18.0994 17.9285 450469 22.1930 22.0389 22.7741 22.3634 450473 19.7148 18.3813 18.6003 18.8420 450475 16.9269 19.0010 19.7305 18.5518 450484 18.9825 19.5505 23.2881 20.6738 450488 19.2173 22.0927 22.5650 21.2542 450489 16.3584 17.8779 18.5941 17.5105 450497 16.2997 15.9654 17.1327 16.4523 450498 14.4713 15.9479 19.2985 16.4927 450508 19.0991 19.3274 20.8183 19.8005 450514 20.0144 20.7064 21.0116 20.6064 450517 14.3191 17.6011 14.4247 15.4999 450518 21.4873 20.7355 21.1015 21.1171 450523 21.0393 23.8270 * 22.4523 450530 21.1634 21.8988 23.3005 22.1616 450534 20.1520 19.7410 22.7437 20.8137 450535 21.0513 21.5449 24.0628 22.1998 450537 20.1161 20.8849 22.5972 21.2300 450539 18.7559 19.3681 18.9497 19.0285 450544 23.6652 22.7282 11.0917 17.7372 450545 20.2823 21.0792 23.9646 21.6831 450547 18.1524 20.5049 23.1348 20.3331 450551 16.6237 16.1437 17.7082 16.8161 450558 20.7404 21.3116 21.4201 21.1518 450563 22.0708 21.9935 27.5446 23.9001 450565 17.3803 17.8058 17.5372 17.5748 450570 19.0336 * * 19.0336 450571 18.2784 19.5325 21.1391 19.6109 450573 17.3518 17.6157 18.6233 17.8792 450574 14.6128 14.8549 16.4851 15.3348 450575 22.5621 24.0386 23.4900 23.3951 450578 18.0925 17.2863 17.3010 17.5480 450580 16.7374 17.8224 18.5657 17.7062 450583 14.4411 15.9430 16.2818 15.5666 450584 14.6735 14.9237 16.9020 15.4896 450586 13.8248 14.7433 14.0478 14.1931 450587 18.0219 18.0014 17.6532 17.8908 450591 17.7795 18.6714 19.6229 18.7114 450596 21.6729 21.9445 24.3714 22.6695 450597 17.6179 19.0641 19.5574 18.7397 450603 23.5572 23.4924 20.6138 22.5917 450604 17.6582 18.7465 19.6304 18.7047 450605 19.4580 19.7400 22.0210 20.3694 450609 17.0986 14.1776 16.6870 15.9595 450610 21.5191 23.5626 24.0548 23.1995 450614 16.5754 * 18.5895 17.6527 450615 15.2956 15.0621 17.3288 15.9012 450617 20.8919 21.5004 22.7025 21.7511 450620 16.0987 16.4330 17.1624 16.5652 450623 23.1270 25.1122 25.4030 24.5910 450626 18.4349 20.5225 17.7454 18.8435 450628 18.6093 20.0411 17.8201 18.7790 450630 20.9605 23.1840 24.7324 23.0079 450631 21.6736 21.8940 22.6786 22.1007 450632 13.9147 15.1416 14.8913 14.6301 450633 19.4949 * * 19.4949 450634 22.9877 23.0470 24.8258 23.7101 450638 22.1704 23.8335 26.3653 24.1319 450639 21.6421 23.0496 23.3156 22.6779 450641 15.7578 15.3652 16.5960 15.8967 450643 16.8152 18.9088 20.2000 18.7134 450644 22.7721 24.5834 25.8182 24.5287 450646 19.1433 23.1240 21.8489 21.2674 450647 24.2763 25.0549 26.7193 25.3639 450648 15.0305 14.4884 16.9698 15.5262 450649 16.6577 16.8505 17.5760 17.0475 450651 22.7112 25.4679 26.9228 25.1265 450652 17.2445 * * 17.2446 450653 19.2349 20.2436 22.7236 20.7352 450654 14.5423 15.5858 16.3616 15.4967 450656 18.2606 18.5874 20.7824 19.2080 450658 17.2630 19.4139 19.2521 18.6539 450659 23.0108 22.9344 26.0224 24.0406 450661 18.9071 19.5504 20.0716 19.5103 450662 19.3152 20.7973 26.1213 22.0200 450665 16.1319 14.5158 15.8149 15.5054 450666 20.2549 * * 20.2549 450668 21.0972 21.2002 24.0081 22.0964 450669 21.6746 22.5150 25.0200 23.1112 450670 20.2632 19.7696 19.7416 19.8975 450672 21.4927 23.2623 25.3111 23.3562 450673 13.7005 14.9115 16.8250 15.1732 450674 22.2426 21.9624 24.7431 23.0384 450675 21.4479 23.3954 24.8661 23.3355 450677 20.6556 21.7366 23.2841 21.9181 450678 24.1301 25.1841 28.1917 25.8918 450683 22.8699 22.1965 24.3566 23.1268 450684 21.9962 22.2380 23.8945 22.7570 450686 16.4632 17.4746 17.9181 17.2988 450688 20.1831 21.7691 21.7922 21.3124 450690 22.4707 27.2399 33.1576 27.0095 450694 18.1872 18.5520 21.4785 19.2847 450697 19.4949 19.4424 20.8952 19.9640 450698 15.4750 16.5111 18.1764 16.7102 450700 15.9050 14.2055 17.3457 15.8451 450702 21.3739 19.8094 22.2953 21.1028 450704 20.7987 18.1835 * 19.2723 450705 22.1809 18.7138 19.4435 19.9245 450706 22.0884 22.4329 * 22.2641 450709 22.1490 22.0123 23.4246 22.5690 450711 19.8581 20.8047 23.6594 21.4663 450712 15.9298 11.1086 18.4546 14.6487 450713 22.6986 23.6189 24.4002 23.6310 450715 22.5988 24.8068 14.9630 19.6234 450716 20.9074 20.8913 24.8614 22.2839 450717 20.6551 22.0243 * 21.3435 450718 22.1765 23.0051 23.6180 22.9900 450723 20.8213 22.0633 22.8048 21.9009 450724 20.3706 23.3799 19.6335 21.4203 450727 17.9172 24.6125 16.0843 19.3135 450728 19.8879 14.9265 10.3991 14.3301 450730 23.0054 24.5952 27.8476 25.3002 450733 20.2199 21.9921 23.8143 22.0738 450742 21.8392 22.8135 25.1295 23.3180 450743 19.6015 20.5017 23.6131 21.3065 450746 30.2657 14.6683 11.1672 15.8134 450747 20.3914 20.3870 21.5883 20.8604 450749 19.1678 18.7138 17.6324 18.4286 450750 13.8098 * * 13.8098 450751 19.9995 19.8170 25.5869 21.1754 450754 16.7145 17.8497 17.9189 17.5560 450755 19.8743 20.0667 18.6084 19.5138 450757 14.9434 15.6425 17.2683 15.9355 450758 19.0221 22.6196 22.8713 21.5676 450760 19.2225 20.4209 23.2959 20.7991 450761 15.7681 14.6511 15.3222 15.2265 450763 18.6092 18.9713 19.8939 19.1937 450766 23.3879 25.4057 27.1863 25.3095 450769 18.4163 17.9879 18.3030 18.2402 450770 19.0183 20.0632 18.7369 19.2440 450771 21.8268 21.6946 22.9736 22.1610 450774 16.2948 * 21.7906 18.6936 450775 21.3504 22.6526 23.5785 22.5291 450776 14.1720 13.4263 14.6695 14.0866 450777 19.0380 18.3119 21.4240 19.6554 450779 21.6642 22.6216 27.8925 23.9052 450780 19.0914 20.0824 21.6549 20.3201 450788 19.6469 19.9817 21.4368 20.3148 450795 22.5753 27.0250 19.1371 22.4874 450796 19.2059 26.8539 19.9522 22.5780 450797 16.4923 20.2356 18.6839 18.3681 450801 17.9548 18.0598 19.7124 18.5711 450802 17.1435 18.2460 * 17.6977 450803 21.6653 37.0925 23.8343 26.2012 450804 19.0893 20.5225 22.7169 20.8248 450806 * 20.7906 * 20.7906 450807 13.4306 18.4410 16.8928 15.8881 450808 17.4917 18.1728 18.6555 18.1215 450809 19.7899 21.9845 23.1978 21.6113 450811 19.9168 21.6115 22.7583 21.5237 450813 14.5392 15.3780 21.7208 16.6296 450815 21.2741 * * 21.2742 450819 16.5521 * * 16.5521 450820 26.8348 24.6542 26.9120 26.1797 450822 22.8556 24.8702 26.7821 24.9818 450823 * 17.9756 13.0130 14.5379 450824 * 25.7488 * 25.7488 450825 * 16.0793 18.2159 17.2695 450827 * 20.1310 29.5838 24.8201 450828 * 19.2902 20.8735 20.1257 450829 * 14.7121 14.4463 14.5541 450830 * * 23.0204 23.0205 450832 * * 24.8572 24.8572 450833 * * 18.3195 18.3196 450834 * * 21.7217 21.7217 450835 * * 24.2285 24.2285 450837 * * 31.8430 31.8432 460001 22.2735 23.5485 24.8844 23.5856 460003 22.6289 22.9549 26.5141 23.9755 460004 21.7234 23.1289 24.3409 23.0686 460005 22.5252 23.0189 25.0063 23.5075 460006 21.0700 22.1648 23.4200 22.2290 460007 21.1922 22.0409 23.3603 22.2561 460008 19.1153 22.6808 24.8233 22.3133 460009 22.5295 23.1933 24.5865 23.4290 460010 22.4948 24.0907 25.1240 23.9360 460011 19.7674 25.3818 21.2634 21.8917 460013 20.1936 21.2360 23.1467 21.5125 460014 18.5370 * 22.5784 20.9623 460015 21.0470 22.4872 23.1068 22.2481 460016 21.9105 19.0910 18.7453 19.8107 460017 18.9929 19.0724 20.7789 19.6010 460018 17.0063 17.0385 16.7143 16.9128 460019 17.8690 19.3442 18.1995 18.4514 460020 17.2663 18.1542 15.2162 16.7463 460021 21.5174 23.1368 23.8565 22.9024 460022 21.3614 20.7539 21.8443 21.3226 460023 22.9265 24.1825 25.0874 24.0957 460025 17.3494 17.4070 22.3100 18.8099 460026 20.2576 21.1759 21.9316 21.1444 460027 22.2955 21.4833 22.7488 22.1620 460029 20.8366 23.7148 24.4379 23.0146 460030 17.1383 18.7655 21.2546 18.9564 460032 21.4832 21.0286 21.2715 21.2538 460033 19.2664 20.2389 21.7215 20.4433 460035 16.1685 15.6979 16.9657 16.2272 460036 23.4573 24.2651 23.9909 23.9286 460037 17.7399 19.0115 20.0323 18.9515 460039 24.4808 24.5134 26.3795 25.1512 460041 20.2035 21.6676 23.5132 21.8727 460042 19.5662 19.7531 22.0844 20.5371 460043 23.2819 25.1366 26.0277 24.8166 460044 21.8485 23.6604 24.7139 23.4328 460047 22.7524 23.5447 22.8135 23.0271 460049 20.8283 21.5241 21.9358 21.5104 460051 22.1758 21.8950 22.7540 22.2835 460052 19.8961 20.1989 23.1718 21.0691 460053 * * 23.2273 23.2274 470001 21.3817 21.7774 23.5882 22.3065 470003 22.0563 23.3612 24.1739 23.1995 470004 18.1879 17.3576 18.4943 18.0068 470005 23.1808 22.6589 24.9625 23.6347 470006 20.2829 21.0835 21.6036 21.0098 470008 20.1969 20.3833 20.7659 20.4458 470010 21.0616 22.3913 23.2072 22.2567 470011 22.2415 24.1306 24.6034 23.6561 470012 18.9444 19.8831 20.5072 19.7941 470015 20.2125 21.8204 25.6286 22.6045 470018 21.2406 24.8493 21.2904 22.3634 470020 21.5688 21.9911 22.0333 21.8520 470023 21.7139 22.5334 24.1395 22.7760 470024 21.9807 23.2738 22.4659 22.5822 490001 20.0570 21.4952 22.1209 21.2627 490002 15.7365 16.5198 17.5098 16.5736 490003 20.3237 20.7688 20.9782 20.6753 490004 19.7074 20.7616 22.7571 21.0703 490005 21.3318 23.1708 25.2213 23.2687 490006 12.3253 19.8977 13.4277 15.2731 490007 19.8938 20.7896 22.2638 20.9786 490009 23.7659 24.7602 25.2181 24.6030 490011 19.8042 19.8179 19.9733 19.8664 490012 15.2965 16.0994 15.8346 15.7118 490013 18.2396 18.3901 19.5094 18.7096 490014 23.5266 27.8907 * 25.5759 490015 20.0667 21.4500 21.2557 20.9648 490017 19.3854 19.6594 20.7691 19.9104 490018 18.5508 19.8955 22.0810 20.2089 490019 21.0124 21.6790 23.3077 22.0282 490020 19.3424 20.9212 21.2094 20.4866 490021 20.0496 21.2263 22.2537 21.2008 490022 22.3380 24.3008 24.5122 23.7681 490023 21.5683 22.8400 24.9733 23.1948 490024 18.4314 19.7491 21.2619 19.8335 490027 16.7556 17.5178 20.3644 18.2452 490030 8.6446 * * 8.6446 490031 16.0003 17.4262 18.4826 17.3314 490032 21.4037 22.2041 23.5691 22.3503 490033 19.2908 23.2088 24.4370 22.3633 490037 17.0113 17.2117 17.5103 17.2485 490038 17.6324 18.6012 18.1405 18.1142 490040 24.1266 25.5461 27.0513 25.6394 490041 18.7987 17.9942 19.9314 18.8986 490042 17.0972 18.1864 19.5127 18.3230 490043 22.1068 23.5367 25.4354 23.6479 490044 19.7842 18.4845 20.8739 19.7388 490045 20.5558 22.5238 24.7131 22.7244 490046 19.9102 19.8518 21.9164 20.5668 490047 18.7614 20.1660 19.8220 19.5730 490048 19.5417 20.9110 22.3255 20.9493 490050 23.3668 23.8519 26.1521 24.5290 490052 16.4787 18.5693 19.2480 18.1097 490053 16.8410 17.7363 18.6541 17.7531 490054 19.5780 22.5136 18.7738 20.4647 490057 20.3160 21.1871 22.1945 21.2773 490059 21.4801 24.1516 23.3895 22.9645 490060 18.5917 19.3525 20.6028 19.5408 490063 26.1930 28.0906 30.4267 28.2207 490066 19.8352 21.5920 22.1034 21.2122 490067 17.8487 18.6469 20.4058 18.9938 490069 20.7582 18.8335 20.6957 20.1008 490071 23.3511 24.1882 25.4677 24.4329 490073 26.0957 * 27.6711 26.9865 490075 19.2156 20.5801 22.3229 20.7337 490077 22.6504 21.9175 22.2643 22.2859 490079 17.7016 17.5839 19.2196 18.1709 490084 18.0555 18.9679 19.8598 18.9692 490085 17.6158 19.4261 20.6383 19.2465 490088 17.9141 19.1924 19.7646 18.9625 490089 18.2290 19.7936 21.1522 19.7626 490090 17.5799 19.2094 20.3015 19.0319 490091 25.0272 23.7493 * 24.4545 490092 16.4360 27.1805 23.8364 21.5391 490093 17.8275 19.1131 20.7412 19.2089 490094 22.3033 20.2020 21.9886 21.4787 490097 16.9518 16.6563 17.9929 17.2212 490098 16.0488 18.5133 19.7116 18.0649 490099 18.3985 19.2604 20.7724 19.4805 490101 23.5553 25.7804 28.5200 26.0299 490104 40.2529 17.1683 28.0286 24.6486 490105 21.4428 28.7831 40.6822 26.6520 490106 26.3821 31.8566 31.6541 29.5471 490107 22.9283 23.9962 26.5312 24.6073 490108 24.1232 24.8596 28.7277 25.7440 490109 25.9475 23.0609 28.0978 25.5419 490110 18.1561 18.8042 23.6080 20.0833 490111 17.8510 19.9552 19.4041 19.0697 490112 22.1162 23.2843 23.6028 23.0255 490113 23.9043 26.1840 28.0893 26.0992 490114 18.0359 18.8920 19.9725 18.9850 490115 16.8537 18.4499 19.9150 18.4166 490116 17.2040 18.2935 19.7007 18.4196 490117 14.7944 17.1723 15.6078 15.8681 490118 23.2022 24.2668 25.2230 24.2345 490119 18.6046 18.9535 20.0944 19.1567 490120 20.5777 20.6828 22.2389 21.1886 490122 23.8198 26.6681 27.3509 25.9831 490123 19.3056 20.0920 20.9506 20.1282 490124 21.3818 23.6526 21.3713 22.1870 490126 20.4294 19.0782 20.3266 19.9000 490127 16.5993 17.6437 17.8070 17.3281 490129 28.6868 * * 28.6863 490130 17.6943 18.6406 18.6038 18.3141 490132 18.4671 19.1742 19.5850 19.0428 500001 24.4829 25.3478 25.8406 25.2431 500002 19.8476 22.9942 * 21.4076 500003 24.4333 25.1200 27.6238 25.7781 500005 24.3870 26.2066 29.9352 26.8369 500007 21.9911 24.7889 * 23.2199 500008 26.1737 27.2852 28.9380 27.5261 500011 24.6554 25.7263 27.6762 26.0196 500012 24.2799 24.5450 25.4367 24.7615 500014 24.0990 25.0490 27.4189 25.5343 500015 24.9923 25.9465 27.4387 26.1498 500016 24.9439 25.1227 27.7863 25.9574 500019 23.2054 23.5730 25.7691 24.2429 500021 27.6490 25.9403 26.4648 26.6119 500023 27.1025 32.3079 23.9513 27.3082 500024 26.6452 26.2113 27.2884 26.7211 500025 24.4825 27.3697 27.6755 26.4578 500026 26.9884 26.6108 28.7532 27.4597 500027 25.1125 27.7429 28.7063 27.2499 500028 18.9556 19.0261 19.9288 19.3024 500029 18.5042 19.3130 19.7750 19.2311 500030 26.3828 28.5297 29.0458 28.0229 500031 23.6099 25.8542 26.0740 25.1801 500033 22.5462 23.8994 25.4345 23.9873 500036 23.6333 25.1255 25.4753 24.7809 500037 21.4059 22.1774 23.3808 22.3148 500039 24.0007 25.4225 26.0196 25.1368 500041 25.4376 24.7070 24.9005 25.0014 500043 22.0466 24.1745 26.6451 24.4187 500044 24.2212 24.7816 27.0880 25.3901 500045 24.0526 24.6265 8.0818 14.8642 500048 20.3207 20.6333 22.9938 21.3649 500049 24.5997 26.5857 25.9142 25.6732 500050 22.6563 23.0804 25.0907 23.6590 500051 25.9447 26.7628 26.9538 26.5713 500053 22.8399 24.2492 25.7217 24.2895 500054 23.8089 25.7815 27.1634 25.6068 500055 23.8622 23.7988 25.3095 24.3502 500057 19.0479 20.5812 21.0357 20.2825 500058 24.1106 26.5679 27.2582 26.0406 500059 26.6270 25.3528 26.1943 26.0221 500060 28.3655 29.6030 32.2049 30.0629 500061 20.8624 24.5908 27.5845 24.2316 500062 19.0557 19.1685 20.9284 19.6775 500064 26.7000 27.5791 29.5696 27.9754 500065 23.5671 24.0966 26.5881 24.7506 500068 19.2638 20.9278 20.2336 20.1549 500069 21.4542 22.4158 24.2983 22.7883 500071 19.1428 22.3253 23.2071 21.4408 500072 25.2001 25.7734 27.5706 26.2080 500073 21.7698 22.5222 21.0414 21.7592 500074 19.5981 20.6120 21.9018 20.7646 500077 23.9410 24.5695 26.6614 25.0769 500079 23.1041 24.7946 27.1775 25.0691 500080 18.3883 18.8188 21.1121 19.4633 500084 24.4044 25.0556 26.3627 25.3208 500085 20.4517 20.7422 21.0707 20.7661 500086 22.8829 24.2556 25.9705 24.3779 500088 25.2478 26.4212 30.1689 27.0767 500089 19.7166 20.3478 21.0601 20.3618 500090 20.4429 21.7716 * 21.0547 500092 19.2028 20.3058 20.8601 20.1437 500094 15.7866 17.6625 * 16.7064 500096 23.3564 25.1135 25.9490 24.7500 500097 20.8774 21.4423 21.8841 21.3903 500098 15.2040 17.8453 17.1392 16.7726 500101 15.8000 19.8614 * 17.6277 500102 21.8963 23.1307 * 22.5307 500104 24.9389 24.7875 26.8007 25.5111 500106 19.1465 17.1066 21.5532 19.1127 500107 17.9489 17.4641 20.4959 18.5615 500108 28.6229 26.1609 27.6367 27.4719 500110 22.9775 23.5941 24.8448 23.8174 500118 24.8034 24.7875 26.1971 25.2739 500119 22.1192 23.9939 25.1576 23.7715 500122 23.5264 24.4462 22.2238 23.3778 500123 19.6646 21.7133 24.4350 21.6023 500124 23.7742 24.6591 26.2994 25.0718 500125 14.7910 15.6304 18.4512 16.1340 500129 25.4685 25.2082 27.1253 25.9641 500132 23.1822 21.9915 22.5293 22.5899 500134 17.2430 15.9791 25.9538 18.4162 500139 22.3053 23.7993 27.7067 24.5705 500141 29.9695 28.1014 28.1441 28.6426 500143 18.2570 18.7523 19.0982 18.7216 510001 20.0429 20.2514 21.4247 20.5803 510002 17.6392 19.1517 21.0299 19.3055 510005 13.8621 13.8641 14.7332 14.1611 510006 19.9609 19.9760 21.0214 20.3316 510007 21.6761 22.9326 23.1306 22.5933 510008 19.0513 19.9176 22.7595 20.6320 510012 15.6089 15.8596 16.7710 16.1127 510013 19.5798 18.3486 19.7937 19.2416 510015 16.7311 17.1595 17.9040 17.2636 510018 18.5358 18.3023 19.9490 18.9487 510020 14.1211 15.7512 * 14.9242 510022 21.5770 21.4336 22.0584 21.7005 510023 16.7777 17.6516 17.9267 17.4783 510024 18.7461 19.6521 20.7521 19.7179 510026 13.7952 14.8785 16.5389 14.9496 510027 18.5945 20.5222 19.8205 19.6589 510028 19.9208 22.4826 24.6543 22.2359 510029 18.4668 18.9000 19.8048 19.0629 510030 17.7603 19.2558 19.8220 18.9626 510031 18.6341 19.3049 20.5742 19.5716 510033 18.4718 19.6900 19.6921 19.3132 510035 18.3164 21.8290 * 20.0924 510036 13.8786 15.0266 14.0926 14.3186 510038 15.5576 15.9821 16.1016 15.8882 510039 17.1461 17.4002 17.6190 17.3855 510043 13.1308 14.4202 15.5857 14.3831 510046 18.5896 18.7424 19.2806 18.8709 510047 20.8101 21.2885 22.1953 21.4251 510048 17.1647 15.2886 16.3761 16.2789 510050 18.4036 18.3964 18.9990 18.5986 510053 17.5798 18.1046 18.1054 17.9357 510055 24.2133 25.6333 27.7422 25.8187 510058 18.4501 18.6025 20.1104 19.0814 510059 16.1044 17.3844 18.1544 17.1696 510061 14.1968 14.6774 14.8848 14.5883 510062 18.1588 19.7202 21.0482 19.6174 510067 17.3067 17.8816 18.0113 17.7501 510068 23.0452 19.4299 19.9056 20.6790 510070 18.7091 18.6226 20.0974 19.1353 510071 18.0278 18.8766 19.4029 18.7564 510072 15.9257 16.5279 18.4566 16.9820 510077 18.2947 20.4521 20.9153 19.8338 510080 16.3453 19.7131 21.5661 18.8545 510081 11.9701 10.4972 * 11.2092 510082 13.5946 16.0014 17.2891 15.5840 510084 13.5339 14.9683 16.1904 14.8887 510085 18.6227 19.0175 20.6364 19.4471 510086 14.2241 16.3413 16.3051 15.6167 510088 14.8854 16.2850 16.4373 15.8902 520002 19.6755 20.2691 21.9073 20.6570 520003 18.7956 18.7507 20.4234 19.3853 520004 20.4591 21.1549 22.6309 21.4055 520006 21.4884 22.4099 22.0238 21.9690 520007 18.4629 18.3959 19.4507 18.7649 520008 24.9395 24.4927 26.0931 25.2072 520009 21.4638 19.8142 20.5615 20.5741 520010 22.3311 25.5623 26.4047 24.7952 520011 21.5223 21.6945 22.7880 22.0154 520013 20.5944 22.1009 23.1173 21.9777 520014 18.0841 19.2760 20.4282 19.2712 520015 19.7672 21.0428 22.8094 21.2438 520016 18.4320 19.5656 * 18.9788 520017 19.4780 21.1409 21.7542 20.8166 520018 21.5279 22.1929 22.3315 22.0344 520019 20.9164 21.8870 22.6895 21.8682 520021 21.9531 22.8484 24.1284 23.0293 520024 14.4750 16.4879 17.5368 16.1948 520025 20.3838 21.9529 23.3835 21.9488 520026 20.8546 22.4779 25.0504 22.8714 520027 21.5868 22.1450 23.6595 22.5109 520028 22.5941 22.0333 24.3592 23.0143 520029 21.4197 21.5561 22.8724 21.9345 520030 21.6311 22.7239 23.9474 22.8336 520031 20.9875 21.2809 22.9721 21.7580 520032 21.1069 24.1092 22.7220 22.6429 520033 20.2520 21.0088 22.2650 21.1839 520034 20.4307 21.5275 18.8561 20.0847 520035 18.7135 19.8917 20.8563 19.8607 520037 21.6017 23.0801 25.0587 23.2977 520038 20.6130 21.4208 23.1036 21.7099 520039 23.3687 21.1719 22.9348 22.4321 520040 21.2023 23.0710 21.5671 21.9307 520041 18.4117 18.2997 22.6216 19.7373 520042 19.5466 20.6354 21.9935 20.7535 520044 19.1877 21.4913 22.7626 21.1506 520045 21.2427 21.9812 24.1624 22.4304 520047 20.3487 21.0370 22.5686 21.3314 520048 19.8926 20.3488 19.3461 19.8547 520049 20.1667 21.8271 22.7424 21.6003 520051 24.0460 23.4366 25.0827 24.1747 520053 18.0851 18.9512 20.8040 19.2839 520054 16.8363 16.6278 18.1045 17.2001 520057 19.8492 20.6959 20.4601 20.3548 520058 21.2500 23.6794 23.2907 22.7126 520059 21.5796 22.1618 24.1863 22.6609 520060 18.8232 20.3357 21.1271 20.1183 520062 19.7038 21.2865 23.7166 21.6639 520063 20.5262 21.2774 23.3037 21.7486 520064 22.0917 23.8181 21.6302 22.5247 520066 24.0087 25.4528 23.9212 24.4126 520068 19.6855 20.6112 21.4413 20.5790 520069 20.1770 21.7233 32.6484 21.3815 520070 19.4261 20.0096 22.0590 20.5199 520071 19.9866 22.0066 23.4832 21.8338 520074 20.9007 21.6636 21.9124 21.4827 520075 20.7301 22.1894 23.7322 22.2613 520076 19.5878 20.6155 22.2993 20.8518 520077 18.7119 18.1077 * 18.3984 520078 21.7545 21.7414 23.0727 22.1680 520083 23.5787 24.2401 25.3591 24.3864 520084 23.5446 21.8102 24.7909 23.3951 520087 20.7821 22.2579 22.8173 21.9819 520088 21.8931 22.3921 23.8938 22.6992 520089 22.1055 23.2335 24.4411 23.2699 520090 20.3645 20.9069 21.9482 21.0730 520091 20.9440 22.2218 19.2575 20.7952 520092 18.6248 19.7181 21.8662 20.1341 520094 20.6179 21.3082 22.3925 21.4517 520095 18.6425 21.9177 25.1402 21.7601 520096 20.6668 21.6803 21.2295 21.2059 520097 20.8016 22.2375 23.6512 22.2609 520098 23.4707 25.0055 25.5111 24.6770 520100 19.4788 20.5366 21.7072 20.6024 520101 19.9875 20.0164 19.5272 19.8623 520102 21.0138 22.3640 23.7739 22.4092 520103 20.1092 22.2765 23.5984 22.0082 520107 21.7907 23.8421 25.0837 23.5365 520109 19.7609 20.3208 20.0009 20.0293 520110 21.0055 22.3923 23.4435 22.3140 520111 17.7673 18.2744 26.9667 20.3598 520112 18.9577 17.6226 17.8738 18.0211 520113 21.8852 23.1852 24.2508 23.1332 520114 17.8476 18.5767 21.9848 19.3865 520115 19.2248 21.4279 23.4674 21.4477 520116 20.6922 22.2741 23.9066 22.2707 520117 18.3963 19.3653 21.9443 19.9279 520118 14.8626 13.9920 * 14.4086 520121 20.8492 20.9422 23.1869 21.6934 520122 16.9335 16.9905 18.8016 17.5509 520123 17.7986 19.8134 21.0426 19.6355 520124 17.9205 19.2621 21.1327 19.4570 520130 16.6873 18.8845 20.0277 18.5254 520131 20.2591 21.0400 22.4994 21.3057 520132 18.1630 18.2634 19.5140 18.6382 520134 18.8150 19.6881 20.8502 19.7907 520135 17.3476 18.1026 18.8254 18.0936 520136 20.9050 21.3966 22.9085 21.7252 520138 22.5599 23.1498 25.1434 23.6620 520139 21.4042 22.8070 23.7727 22.6778 520140 22.3671 22.5459 23.5622 22.8201 520142 21.9432 21.4120 24.1969 22.4917 520144 19.9120 20.5864 22.3985 20.9729 520145 18.7958 20.3461 25.0771 20.8014 520146 18.2370 18.6337 19.4025 18.7800 520148 19.1502 20.5075 22.4299 20.7682 520149 12.8928 13.8614 * 13.3481 520151 18.7070 19.3362 20.1995 19.4436 520152 22.5980 26.2402 21.1817 22.9787 520153 17.0863 18.5986 18.7375 18.1335 520154 19.5994 21.0486 23.2635 21.3043 520156 20.9638 20.7808 23.7157 21.8343 520157 19.6008 21.6821 23.1495 21.4552 520159 17.7649 21.8783 * 19.8043 520160 20.5154 21.5871 22.9475 21.7239 520161 20.1102 21.4038 22.1857 21.2456 520170 21.9857 23.0867 25.0744 23.3943 520171 18.0785 18.1844 11.2340 15.1101 520173 20.9209 23.2955 24.4722 22.8643 520177 24.0139 25.0908 27.5560 25.5340 520178 20.9010 23.1509 22.3193 22.0890 520189 * 22.0889 23.1658 22.6212 530002 21.0560 23.0582 23.8852 22.6216 530003 15.9523 17.1646 * 16.5866 530004 13.3788 17.4672 * 15.3173 530005 15.3255 18.4391 19.2049 17.7470 530006 19.1305 20.7661 21.3429 20.4783 530007 17.7897 18.5286 22.3309 19.6133 530008 19.0113 19.5386 21.8714 20.1106 530009 21.7795 23.5839 22.0451 22.4288 530010 13.9536 17.8687 21.7124 17.2974 530011 19.4606 19.9212 22.5720 20.6678 530012 21.1854 22.5084 22.4716 22.0976 530014 18.4900 20.0422 21.7314 20.1695 530015 23.4040 24.6527 25.3915 24.5334 530016 19.3205 20.3647 21.0666 20.2058 530017 17.7736 20.9408 19.5631 19.3707 530018 19.5986 20.1226 * 19.8663 530019 20.1097 18.1492 * 19.0248 530022 19.6136 19.7902 21.0631 20.1718 530023 20.0677 21.6352 * 20.8681 530025 22.0300 22.4816 25.4693 23.3672 530026 19.8969 20.9919 21.0733 20.6804 530027 25.5067 * * 25.5069 530029 19.3361 20.3046 19.9692 19.8988 530031 20.1734 23.2766 16.8825 20.2555 530032 20.0132 20.9856 19.4450 20.0811 *Denotes wage data not available for the provider for that year. **Based on the sum of the salaries and hours computed for Federal FYs 2002, 2003, and 2004. Table 3A.—FY 2004 and 3-Year* Average Hourly Wage for Urban Areas [*Based on the sum of the Salaries and Hours Computed for Federal Fiscal Years 2002, 2003, and 2004] Urban area FY 2004 average hourly wage 3-Year average hourly wage Abilene, TX 18.8450 18.2266 Aguadilla, PR 10.6399 10.5889 Akron, OH 22.5797 22.3022 Albany, GA 26.6004 24.9847 Albany-Schenectady-Troy, NY 21.3352 20.4496 Albuquerque, NM 23.1465 22.1931 Alexandria, LA 19.8057 18.6706 Allentown-Bethlehem-Easton, PA 23.5026 22.8687 Altoona, PA 21.7576 21.1859 Amarillo, TX 22.0107 20.8001 Anchorage, AK 30.1827 29.0196 Ann Arbor, MI 27.1674 25.8704 Anniston, AL 19.9785 19.0507 Appleton-Oshkosh-Neenah, WI 21.7216 21.0819 Arecibo, PR 10.1377 10.1850 Asheville, NC 23.8010 22.5969 Athens, GA 23.7190 23.1681 Atlanta, GA 24.6106 23.4279 Atlantic-Cape May, NJ 26.6595 25.8131 Auburn-Opelika, AL 20.9608 19.6182 Augusta-Aiken, GA-SC 23.8679 23.3090 Austin-San Marcos, TX 23.4418 22.4440 Bakersfield, CA 24.2171 22.8241 Baltimore, MD 24.4226 23.1526 Bangor, ME 24.4261 22.6849 Barnstable-Yarmouth, MA 31.6457 30.9398 Baton Rouge, LA 20.3139 19.2932 Beaumont-Port Arthur, TX 20.8687 19.6759 Bellingham, WA 29.0458 28.0229 Benton Harbor, MI 21.8083 20.8961 Bergen-Passaic, NJ 28.6051 27.6355 Billings, MT 21.8179 21.2445 Biloxi-Gulfport-Pascagoula, MS 22.3087 20.4967 Binghamton, NY 20.6972 19.6313 Birmingham, AL 22.7049 21.2110 Bismarck, ND 19.6799 18.6613 Bloomington,IN 22.0106 20.8739 Bloomington-Normal, IL 21.8206 21.0629 Boise City, ID 22.7551 21.5706 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 27.6581 26.3949 Boulder-Longmont, CO 24.8370 23.1361 Brazoria, TX 20.1054 19.4362 Bremerton, WA 26.0196 25.1368 Brownsville-Harlingen-San Benito, TX 25.1120 21.8429 Bryan-College Station, TX 22.1966 21.2204 Buffalo-Niagara Falls, NY 23.5611 22.1052 Burlington, VT 23.9756 23.1273 Caguas, PR 10.2735 10.3098 Canton-Massillon, OH 22.4034 21.0476 Casper, WY 22.4716 22.0976 Cedar Rapids, IA 21.9242 20.8155 Champaign-Urbana, IL 24.3163 23.2596 Charleston-North Charleston, SC 22.8428 21.6027 Charleston, WV 21.4843 20.9535 Charlotte-Gastonia-Rock Hill, NC-SC 23.9685 22.5648 Charlottesville, VA 24.7694 24.2141 Chattanooga, TN-GA 22.0529 21.2905 Cheyenne, WY 21.7314 20.1695 Chicago, IL 27.0271 25.7822 Chico-Paradise, CA 25.1160 23.2448 Cincinnati, OH-KY-IN 23.1946 22.0301 Clarksville-Hopkinsville, TN-KY 20.4075 19.5286 Cleveland-Lorain-Elyria, OH 23.8495 22.4215 Colorado Springs, CO 21.6129 22.1293 Columbia, MO 21.4630 20.1694 Columbia, SC 21.9871 21.6143 Columbus, GA-AL 21.3541 19.8797 Columbus, OH 23.6823 22.5560 Corpus Christi, TX 21.0218 19.9937 Corvallis, OR 28.4536 27.0598 Cumberland, MD-WV 20.1850 18.9617 Dallas, TX 23.8893 23.1075 Danville, VA 22.3229 20.7337 Davenport-Moline-Rock Island, IA-IL 21.4787 20.4142 Dayton-Springfield, OH 23.1119 21.7481 Daytona Beach, FL 22.5989 21.2728 Decatur, AL 21.8004 20.7771 Decatur, IL 19.7294 18.7678 Denver, CO 26.4474 24.7190 Des Moines, IA 22.2079 20.6796 Detroit, MI 24.7828 24.1254 Dothan, AL 19.4261 18.7019 Dover, DE 24.2251 22.9785 Dubuque, IA 21.9559 20.4460 Duluth-Superior, MN-WI 24.9669 24.0017 Dutchess County, NY 26.9158 25.0907 Eau Claire, WI 22.3936 21.0371 El Paso, TX 22.7448 21.6387 Elkhart-Goshen, IN 24.1721 22.8091 Elmira, NY 20.6973 19.6769 Enid, OK 21.1469 19.7375 Erie, PA 21.1970 20.4552 Eugene-Springfield, OR 28.3045 26.4658 Evansville, Henderson, IN-KY 20.7198 19.5383 Fargo-Moorhead, ND-MN 23.6839 22.0993 Fayetteville, NC 21.9837 20.9595 Fayetteville-Springdale-Rogers, AR 19.7281 19.1438 Flagstaff, AZ-UT 28.0003 25.5509 Flint, MI 26.8246 25.6472 Florence, AL 19.0755 18.2277 Florence, SC 21.5072 20.4490 Fort Collins-Loveland, CO 25.0356 23.6228 Fort Lauderdale, FL 25.0241 23.9929 Fort Myers-Cape Coral, FL 24.2424 22.5718 Fort Pierce-Port St. Lucie, FL 24.6789 23.4336 Fort Smith, AR-OK 18.9977 18.4272 Fort Walton Beach, FL 21.9145 21.5304 Fort Wayne, IN 23.7450 22.1024 Fort Worth-Arlington, TX 22.7469 21.8925 Fresno, CA 24.9304 23.6658 Gadsden, AL 20.3125 19.9081 Gainesville, FL 20.9218 21.6396 Galveston-Texas City, TX 22.9723 22.5896 Gary, IN 23.2237 22.2411 Glens Falls, NY 20.8876 19.5296 Goldsboro, NC 21.3024 20.4707 Grand Forks, ND-MN 21.3373 20.7295 Grand Junction, CO 23.7749 22.3911 Grand Rapids-Muskegon-Holland, MI 23.0656 22.5364 Great Falls, MT 21.7634 20.7748 Greeley, CO 23.1548 21.9595 Green Bay, WI 23.3746 22.0316 Greensboro-Winston-Salem-High Point, NC 20.9324 21.2497 Greenville, NC 23.6131 21.8157 Greenville-Spartanburg-Anderson, SC 22.7994 21.5334 Hagerstown, MD 22.6614 20.9120 Hamilton-Middletown, OH 22.6679 21.7796 Harrisburg-Lebanon-Carlisle, PA 22.5260 21.6636 Hartford, CT 27.9285 26.8084 Hattiesburg, MS 17.9684 17.4987 Hickory-Morganton-Lenoir, NC 22.3095 21.3983 Honolulu, HI 27.4202 26.5871 Houma, LA 19.0543 18.7854 Houston, TX 23.5421 22.6783 Huntington-Ashland, WV-KY-OH 23.6117 22.4903 Huntsville, AL 22.6733 21.0476 Indianapolis, IN 24.4154 22.8765 Iowa City, IA 23.5738 22.6166 Jackson, MI 22.1953 21.6761 Jackson, MS 20.6436 19.8499 Jackson, TN 21.1120 20.9308 Jacksonville, FL 22.9896 21.8027 Jacksonville, NC 21.0806 19.0573 Jamestown, NY 19.1768 18.5426 Janesville-Beloit, WI 22.9321 22.5285 Jersey City, NJ 27.4955 26.1092 Johnson City-Kingsport-Bristol, TN-VA 20.5450 19.6615 Johnstown, PA 20.5535 19.7661 Jonesboro, AR 18.8016 18.5268 Joplin, MO 21.4481 20.3222 Kalamazoo-Battlecreek, MI 25.9045 24.7622 Kankakee, IL 27.1800 24.7161 Kansas City, KS-MO 23.4414 22.4424 Kenosha, WI 24.1159 22.6827 Killeen-Temple, TX 22.6330 22.0648 Knoxville, TN 22.0574 20.9173 Kokomo, IN 22.3466 21.1444 La Crosse, WI-MN 22.7241 21.7520 Lafayette, LA 20.3031 19.7004 Lafayette, IN 22.2163 21.3798 Lake Charles, LA 20.8032 18.7394 Lakeland-Winter Haven, FL 20.8790 20.9460 Lancaster, PA 22.8876 21.5784 Lansing-East Lansing, MI 22.7517 22.3069 Laredo, TX 19.9917 19.1033 Las Cruces, NM 20.9400 20.1778 Las Vegas, NV-AZ 28.1201 26.6705 1 Lawrence, KS Lawton, OK 20.4263 19.7110 Lewiston-Auburn, ME 23.0437 21.7003 Lexington, KY 21.1620 20.2378 Lima, OH 23.2114 22.1607 Lincoln, NE 24.7917 23.5197 Little Rock-North Little Rock, AR 21.8575 20.9688 Longview-Marshall, TX 22.4348 20.5074 Los Angeles-Long Beach, CA 28.5648 27.6989 Louisville, KY-IN 22.5165 21.7940 Lubbock, TX 20.4449 20.4788 Lynchburg, VA 22.5852 21.4509 Macon, GA 22.1616 21.1692 Madison, WI 25.1207 24.1736 Mansfield, OH 22.2335 20.8233 Mayaguez, PR 11.7315 11.3138 McAllen-Edinburg-Mission, TX 22.2965 20.2067 Medford-Ashland, OR 26.6156 24.7374 Melbourne-Titusville-Palm Bay, FL 24.0574 23.3611 Memphis, TN-AR-MS 22.8875 21.1855 Merced, CA 23.9422 23.0370 Miami, FL 24.2692 23.0684 Middlesex-Somerset-Hunterdon, NJ 28.0716 26.5525 Milwaukee-Waukesha, WI 24.2703 23.1731 Minneapolis-St. Paul, MN-WI 27.1544 25.6571 Missoula, MT 21.5392 21.2648 Mobile, AL 19.5085 18.7864 Modesto, CA 27.8424 25.5333 Monmouth-Ocean, NJ 26.9085 25.3164 Monroe, LA 19.5806 18.9433 Montgomery, AL 19.2813 17.8049 Muncie, IN 21.4993 21.7481 Myrtle Beach, SC 21.9670 20.8646 Naples, FL 24.2154 22.8672 Nashville, TN 24.1409 22.7215 Nassau-Suffolk, NY 31.9339 31.1765 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 30.6450 28.9030 New London-Norwich, CT 28.7588 27.3098 New Orleans, LA 22.5126 21.2103 New York, NY 34.0359 33.2980 Newark, NJ 28.0215 26.7812 Newburgh, NY-PA 27.7682 26.3667 Norfolk-Virginia Beach-Newport News, VA-NC 21.2530 20.1058 Oakland, CA 36.9259 35.4131 Ocala, FL 24.0225 22.3877 Odessa-Midland, TX 23.1872 22.5143 Oklahoma City, OK 22.1744 20.7685 Olympia, WA 27.0728 25.9774 Omaha, NE-IA 23.9161 22.9252 Orange County, CA 27.5748 26.3219 Orlando, FL 23.5921 22.5423 Owensboro, KY 20.6888 19.5760 Panama City, FL 21.2992 20.7203 Parkersburg-Marietta, WV-OH 19.8623 19.0009 Pensacola, FL 20.6255 19.7879 Peoria-Pekin, IL 21.5796 20.4881 Philadelphia, PA-NJ 26.8676 25.3554 Phoenix-Mesa, AZ 25.0656 23.1490 Pine Bluff, AR 18.7641 18.2815 Pittsburgh, PA 21.5682 21.5505 Pittsfield, MA 25.2831 23.9826 Pocatello, ID 22.3412 21.7279 Ponce, PR 11.6867 11.7774 Portland, ME 24.5068 22.7835 Portland-Vancouver, OR-WA 27.4708 25.7362 Providence-Warwick, RI 27.0592 25.4242 Provo-Orem, UT 24.6487 23.2777 Pueblo, CO 21.6891 20.4756 Punta Gorda, FL 23.3618 21.6509 Racine, WI 21.8176 21.4880 Raleigh-Durham-Chapel Hill, NC 24.7888 23.2945 Rapid City, SD 21.7579 20.7364 Reading, PA 22.1933 21.7267 Redding, CA 28.0292 26.2652 Reno, NV 26.3682 24.8415 Richland-Kennewick-Pasco, WA 26.0849 25.7185 Richmond-Petersburg, VA 23.0767 22.2287 Riverside-San Bernardino, CA 27.7914 26.2909 Roanoke, VA 21.4970 20.0809 Rochester, MN 28.9664 27.6257 Rochester, NY 23.4531 22.1985 Rockford, IL 23.8815 22.2381 Rocky Mount, NC 22.2321 21.3362 Sacramento, CA 29.2332 27.4459 Saginaw-Bay City-Midland, MI 23.6103 22.4738 St. Cloud, MN 23.3992 22.6517 1 St. Joseph, MO 24.1078 24.1078 St. Louis, MO-IL 22.2105 20.8148 Salem, OR 25.8986 24.0695 Salinas, CA 35.4282 34.0968 Salt Lake City-Ogden, UT 24.2956 23.1582 San Angelo, TX 20.3421 19.4654 San Antonio, TX 21.7859 20.4173 San Diego, CA 27.5034 26.1832 San Francisco, CA 35.2175 33.1623 San Jose, CA 35.9382 33.4495 San Juan-Bayamon, PR 12.0353 11.2034 San Luis Obispo-Atascadero-Paso Robles, CA 28.1871 26.3232 Santa Barbara-Santa Maria-Lompoc, CA 25.7977 24.7645 Santa Cruz-Watsonville, CA 31.9363 31.6115 Santa Fe, NM 26.1125 24.6586 Santa Rosa, CA 31.5034 30.3104 Sarasota-Bradenton, FL 24.1015 22.8397 Savannah, GA 23.4542 22.5461 Scranton-Wilkes Barre-Hazleton, PA 20.5178 19.9473 Seattle-Bellevue-Everett, WA 28.3651 26.8159 Sharon, PA 19.1498 18.3866 Sheboygan, WI 21.3074 20.1274 Sherman-Denison, TX 23.3354 21.9733 Shreveport-Bossier City, LA 22.4424 21.1518 Sioux City, IA-NE 22.2184 20.9019 Sioux Falls, SD 22.9990 21.6460 South Bend, IN 24.2656 23.1221 Spokane, WA 26.9242 25.3258 Springfield, IL 22.0988 20.5053 Springfield, MO 20.7882 19.8503 Springfield, MA 25.1820 24.9487 State College, PA 21.5944 20.9171 Steubenville-Weirton, OH-WV 20.7491 20.1726 Stockton-Lodi, CA 25.9615 24.8099 Sumter, SC 20.1378 18.9286 Syracuse, NY 23.2731 22.4502 Tacoma, WA 25.0655 25.4358 Tallahassee, FL 20.9393 19.9194 Tampa-St. Petersburg-Clearwater, FL 22.3623 21.0795 Terre Haute, IN 20.5894 19.8434 Texarkana, AR-Texarkana, TX 20.1201 19.1440 Toledo, OH 23.4422 22.6911 Topeka, KS 22.1410 21.1325 Trenton, NJ 25.9088 24.4803 Tucson, AZ 21.9871 20.8658 Tulsa, OK 22.4262 20.4923 Tuscaloosa, AL 20.2222 19.1231 Tyler, TX 21.5724 21.7219 Utica-Rome, NY 20.8155 19.7105 Vallejo-Fairfield-Napa, CA 33.0023 31.4386 Ventura, CA 25.7022 25.3153 Victoria, TX 19.8941 19.6059 Vineland-Millville-Bridgeton, NJ 25.7088 24.0750 Visalia-Tulare-Porterville, CA 24.2540 22.5528 Waco, TX 20.7383 19.2135 Washington, DC-MD-VA-WV 26.2793 25.3284 Waterloo-Cedar Falls, IA 20.6706 19.0431 Wausau, WI 23.9474 22.8336 West Palm Beach-Boca Raton, FL 24.0146 22.9860 Wheeling, OH-WV 18.4694 18.0317 Wichita, KS 22.8265 22.1175 Wichita Falls, TX 20.6347 19.2942 Williamsport, PA 19.8237 19.6398 Wilmington-Newark, DE-MD 26.8874 25.7166 Wilmington, NC 23.5730 22.3755 Yakima, WA 25.3298 24.5057 Yolo, CA 22.7290 22.1106 York, PA 22.3891 21.4937 Youngstown-Warren, OH 22.7587 21.9477 Yuba City, CA 25.1911 24.0864 Yuma, AZ 21.9766 20.7166 1 The MSA is empty for FY 2004. The hospital(s) in the MSA received rural status under section 401 of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113). The MSA is assigned the statewide rural wage index ( *see* Table 4B). Table 3B.—FY 2004 and 3-Year* Average Hourly Wage for Rural Areas [*Based on the sum of the Salaries and Hours Computed for Federal Fiscal Years 2002, 2003, and 2004] Nonurban area FY 2004 average hourly wage 3-Year average hourly wage Alabama 18.3348 17.4929 Alaska 29.3667 28.1193 Arizona 22.1917 20.4444 Arkansas 19.0502 17.8283 California 24.5014 22.9050 Colorado 22.3036 20.8977 Connecticut 29.9411 28.5998 Delaware 22.7759 21.8259 Florida 21.7703 20.5939 Georgia 20.6405 19.3893 Hawaii 24.6034 24.3938 Idaho 22.1883 20.5704 Illinois 20.4777 19.1094 Indiana 21.6124 20.4406 Iowa 20.7491 19.3057 Kansas 19.7860 18.4560 Kentucky 19.5747 18.6825 Louisiana 18.3330 17.5766 Maine 22.1139 20.6732 Maryland 22.5202 21.0708 Massachusetts 26.6580 26.1016 Michigan 21.6556 20.8571 Minnesota 22.9622 21.3937 Mississippi 19.2263 17.9212 Missouri 19.2927 18.4558 Montana 21.6718 20.0795 Nebraska 21.7533 19.3579 Nevada 24.0509 22.6017 New Hampshire 24.8141 23.0661 1 New Jersey New Mexico 20.3060 20.0956 New York 21.0328 19.9757 North Carolina 20.5716 19.9126 North Dakota 19.2168 18.1538 Ohio 21.6481 20.3023 Oklahoma 18.6273 17.6874 Oregon 24.6521 23.6537 Pennsylvania 20.7089 19.8599 Puerto Rico 10.2273 9.9080 1 Rhode Island South Carolina 20.8645 19.9708 South Dakota 20.2488 18.5076 Tennessee 19.5008 18.5022 Texas 18.9842 18.1045 Utah 22.1698 21.3594 Vermont 22.9948 21.9226 Virginia 20.9873 19.7038 Washington 25.9055 23.9310 West Virginia 19.7553 18.7353 Wisconsin 22.6498 21.3482 Wyoming 22.6090 20.9331 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 1Abilene, TX 0.7678 0.8345 Taylor, TX 0060 Aguadilla, PR 0.4335 0.5642 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH 0.9445 0.9617 Portage, OH Summit, OH 0120 Albany, GA 1.0838 1.0567 Dougherty, GA Lee, GA 0160 Albany-Schenectady-Troy, NY 0.8693 0.9085 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM 0.9431 0.9607 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA 0.8087 0.8647 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA 0.9576 0.9708 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA 0.8886 0.9223 Blair, PA 0320 Amarillo, TX 0.8968 0.9281 Potter, TX Randall, TX 0380 Anchorage, AK 1.2433 1.1608 Anchorage, AK 0440 Ann Arbor, MI 1.1069 1.0720 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL 0.8140 0.8686 Calhoun, AL 0460 2 Appleton-Oshkosh-Neenah, WI 0.9130 0.9396 Calumet, WI Outagamie, WI Winnebago, WI 0470 Arecibo, PR 0.4130 0.5458 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC 0.9697 0.9792 Buncombe, NC Madison, NC 0500 Athens, GA 0.9664 0.9769 Clarke, GA Madison, GA Oconee, GA 0520 1 Atlanta, GA 1.0027 1.0018 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 1.0862 1.0583 Atlantic, NJ Cape May, NJ 0580 Auburn-Opelika, AL 0.8540 0.8976 Lee, AL 0600 Augusta-Aiken, GA-SC 0.9725 0.9811 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 1 Austin-San Marcos, TX 0.9551 0.9690 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 2 Bakersfield, CA 0.9907 0.9936 Kern, CA 0720 1 Baltimore, MD 0.9951 0.9966 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME 0.9750 0.9828 Penobscot, ME 0743 Barnstable-Yarmouth, MA 1.2893 1.1901 Barnstable, MA 0760 Baton Rouge, LA 0.8271 0.8781 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX 0.8503 0.8949 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA 1.1834 1.1222 Whatcom, WA 0870 Benton Harbor, MI 0.8949 0.9268 Berrien, MI 0875 1 Bergen-Passaic, NJ 1.1655 1.1106 Bergen, NJ Passaic, NJ 0880 Billings, MT 0.8889 0.9225 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS 0.9089 0.9367 Hancock, MS Harrison, MS Jackson, MS 0960 2 Binghamton, NY 0.8530 0.8968 Broome, NY Tioga, NY 1000 Birmingham, AL 0.9251 0.9481 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND 0.8101 0.8657 Burleigh, ND Morton, ND 1020 Bloomington, IN 0.8968 0.9281 Monroe, IN 1040 Bloomington-Normal, IL 0.8954 0.9271 McLean, IL 1080 Boise City, ID 0.9295 0.9512 Ada, ID Canyon, ID 1123 1 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 1.1269 1.0853 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 1.0119 1.0081 Boulder, CO 1145 Brazoria, TX 0.8324 0.8819 Brazoria, TX 1150 Bremerton, WA 1.0601 1.0408 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX 1.0231 1.0158 Cameron, TX 1260 Bryan-College Station, TX 0.9044 0.9335 Brazos, TX 1280 1 Buffalo-Niagara Falls, NY 0.9600 0.9724 Erie, NY Niagara, NY 1303 Burlington, VT 0.9768 0.9841 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR 0.4229 0.5547 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320 Canton-Massillon, OH 0.9128 0.9394 Carroll, OH Stark, OH 1350 Casper, WY 0.9239 0.9472 Natrona, WY 1360 Cedar Rapids, IA 0.8933 0.9256 Linn, IA 1400 Champaign-Urbana, IL 0.9907 0.9936 Champaign, IL 1440 Charleston-North Charleston, SC 0.9307 0.9520 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV 0.8753 0.9128 Kanawha, WV Putnam, WV 1520 1 Charlotte-Gastonia-Rock Hill, NC-SC 0.9766 0.9839 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 1540 Charlottesville, VA 1.0092 1.0063 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA 0.8985 0.9293 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 2 Cheyenne, WY 0.9137 0.9401 Laramie, WY 1600 1 Chicago, IL 1.1012 1.0682 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 Chico-Paradise, CA 1.0147 1.0100 Butte, CA 1640 1 Cincinnati, OH-KY-IN 0.9452 0.9621 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 0.8410 0.8882 Christian, KY Montgomery, TN 1680 1 Cleveland-Lorain-Elyria, OH 0.9686 0.9784 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 2 Colorado Springs, CO 0.8897 0.9231 El Paso, CO 1740 Columbia, MO 0.8745 0.9123 Boone, MO 1760 Columbia, SC 0.8958 0.9274 Lexington, SC Richland, SC 1800 Columbus, GA-AL 0.8700 0.9090 Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 1840 1 Columbus, OH 0.9649 0.9758 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX 0.8565 0.8994 Nueces, TX San Patricio, TX 1890 Corvallis, OR 1.1593 1.1065 Benton, OR 1900 2 Cumberland, MD-WV (MD Hospitals) 0.9175 0.9427 Allegany, MD Mineral, WV 1900 Cumberland, MD-WV (WV Hospitals) 0.8224 0.8747 Allegany, MD Mineral, WV 1920 1 Dallas, TX 0.9733 0.9816 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA 0.9095 0.9371 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL 0.8727 0.9110 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH 0.9432 0.9607 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL 0.9208 0.9451 Flagler, FL Volusia, FL 2030 Decatur, AL 0.8882 0.9220 Lawrence, AL Morgan, AL 2040 2 Decatur, IL 0.8282 0.8789 Macon, IL 2080 1 Denver, CO 1.0776 1.0525 Adams, CO Arapahoe, CO Broomfield, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA 0.9053 0.9341 Dallas, IA Polk, IA Warren, IA 2160 1 Detroit, MI 1.0097 1.0066 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL 0.7931 0.8532 Dale, AL Houston, AL 2190 Dover, DE 0.9870 0.9911 Kent, DE 2200 Dubuque, IA 0.8946 0.9266 Dubuque, IA 2240 Duluth-Superior, MN-WI 1.0133 1.0091 St. Louis, MN Douglas, WI 2281 Dutchess County, NY 1.0966 1.0652 Dutchess, NY 2290 Eau Claire, WI 0.9141 0.9403 Chippewa, WI Eau Claire, WI 2320 El Paso, TX 0.9267 0.9492 El Paso, TX 2330 Elkhart-Goshen, IN 0.9848 0.9896 Elkhart, IN 2335 2 Elmira, NY 0.8530 0.8968 Chemung, NY 2340 Enid, OK 0.8616 0.9030 Garfield, OK 2360 Erie, PA 0.8636 0.9045 Erie, PA 2400 Eugene-Springfield, OR 1.1212 1.0815 Lane, OR 2440 2 Evansville-Henderson, IN-KY (IN Hospitals) 0.8770 0.9140 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2440 Evansville-Henderson, IN-KY (KY Hospitals) 0.8442 0.8905 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN 0.9650 0.9759 Clay, MN Cass, ND 2560 Fayetteville, NC 0.8957 0.9273 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR 0.8038 0.8611 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT 1.1283 1.0862 Coconino, AZ Kane, UT 2640 Flint, MI 1.0929 1.0627 Genesee, MI 2650 Florence, AL 0.7824 0.8453 Colbert, AL Lauderdale, AL 2655 Florence, SC 0.8763 0.9135 Florence, SC 2670 Fort Collins-Loveland, CO 1.0201 1.0137 Larimer, CO 2680 1 Ft. Lauderdale, FL 1.0534 1.0363 Broward, FL 2700 Fort Myers-Cape Coral, FL 0.9877 0.9916 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL 1.0227 1.0155 Martin, FL St. Lucie, FL 2720 2 Fort Smith, AR-OK (AR Hospitals) 0.7746 0.8395 Crawford, AR Sebastian, AR Sequoyah, OK 2720 Fort Smith, AR-OK (OK Hospitals) 0.7740 0.8391 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL 0.8929 0.9254 Okaloosa, FL 2760 Fort Wayne, IN 0.9674 0.9776 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800 1 Forth Worth-Arlington, TX 0.9268 0.9493 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA 1.0157 1.0107 Fresno, CA Madera, CA 2880 Gadsden, AL 0.8295 0.8798 Etowah, AL 2900 2 Gainesville, FL 0.8782 0.9149 Alachua, FL 2920 Galveston-Texas City, TX 0.9360 0.9557 Galveston, TX 2960 Gary, IN 0.9462 0.9628 Lake, IN Porter, IN 2975 2 Glens Falls, NY 0.8530 0.8968 Warren, NY Washington, NY 2980 Goldsboro, NC 0.8679 0.9075 Wayne, NC 2985 Grand Forks, ND-MN (ND Hospitals) 0.9031 0.9326 Polk, MN Grand Forks, ND 2985 2 Grand Forks, ND-MN (MN Hospitals) 0.9243 0.9475 Polk, MN Grand Forks, ND 2995 Grand Junction, CO 0.9940 0.9959 Mesa, CO 3000 1 Grand Rapids-Muskegon-Holland, MI 0.9406 0.9589 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT 0.8977 0.9288 Cascade, MT 3060 Greeley, CO 0.9516 0.9666 Weld, CO 3080 Green Bay, WI 0.9524 0.9672 Brown, WI 3120 1 Greensboro-Winston-Salem-High Point, NC 0.8533 0.8971 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC 0.9621 0.9739 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC 0.9289 0.9507 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD 0.9233 0.9468 Washington, MD 3200 Hamilton-Middletown, OH 0.9236 0.9470 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA 0.9178 0.9430 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 \1,2\ Hartford, CT 1.2199 1.1458 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 2 Hattiesburg, MS 0.7810 0.8443 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC 0.9090 0.9368 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI 1.1176 1.0791 Honolulu, HI 3350 Houma, LA 0.7763 0.8408 Lafourche, LA Terrebonne, LA 3360 1 Houston, TX 0.9591 0.9718 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH 0.9620 0.9738 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL 0.9238 0.9472 Limestone, AL Madison, AL 3480 1 Indianapolis, IN 0.9934 0.9955 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA 0.9605 0.9728 Johnson, IA 3520 Jackson, MI 0.9043 0.9334 Jackson, MI 3560 Jackson, MS 0.8459 0.8917 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN 0.8602 0.9020 Madison, TN Chester, TN 3600 1 Jacksonville, FL 0.9426 0.9603 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 Jacksonville, NC 0.8589 0.9011 Onslow, NC 3610 2 Jamestown, NY 0.8530 0.8968 Chautauqua, NY 3620 Janesville-Beloit, WI 0.9344 0.9546 Rock, WI 3640 Jersey City, NJ 1.1203 1.0809 Hudson, NJ 3660 Johnson City-Kingsport-Bristol, TN-VA (TN Hospitals) 0.8371 0.8854 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) 0.8542 0.8977 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680 2 Johnstown, PA 0.8429 0.8896 Cambria, PA Somerset, PA 3700 2 Jonesboro, AR 0.7755 0.8402 Craighead, AR 3710 Joplin, MO 0.8739 0.9118 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI 1.0554 1.0376 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL 1.1074 1.0724 Kankakee, IL 3760 1 Kansas City, KS-MO 0.9551 0.9690 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 0.9826 0.9881 Kenosha, WI 3810 Killeen-Temple, TX 0.9221 0.9460 Bell, TX Coryell, TX 3840 Knoxville, TN 0.8987 0.9295 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN 0.8963 0.9278 Howard, IN Tipton, IN 3870 La Crosse, WI-MN 0.9259 0.9486 Houston, MN La Crosse, WI 3880 Lafayette, LA 0.8271 0.8781 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN 0.9052 0.9341 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA 0.8460 0.8918 Calcasieu, LA 3980 2 Lakeland-Winter Haven, FL 0.8782 0.9149 Polk, FL 4000 Lancaster, PA 0.9325 0.9533 Lancaster, PA 4040 Lansing-East Lansing, MI 0.9270 0.9494 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX 0.8145 0.8689 Webb, TX 4100 Las Cruces, NM 0.8532 0.8970 Dona Ana, NM 4120 1 Las Vegas, NV-AZ 1.1457 1.0976 Mohave, AZ Clark, NV Nye, NV 4150 2Lawrence, KS 0.7860 0.8480 Douglas, KS 4200 Lawton, OK 0.8322 0.8818 Comanche, OK 4243 Lewiston-Auburn, ME 0.9389 0.9577 Androscoggin, ME 4280 Lexington, KY 0.8622 0.9035 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH 0.9457 0.9625 Allen, OH Auglaize, OH 4360 Lincoln, NE 1.0101 1.0069 Lancaster, NE 4400 Little Rock-North Little Rock, AR 0.8905 0.9237 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX 0.9141 0.9403 Gregg, TX Harrison, TX Upshur, TX 4480 1 Los Angeles-Long Beach, CA 1.1656 1.1106 Los Angeles, CA 4520 1 Louisville, KY-IN 0.9174 0.9427 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX 0.8330 0.8824 Lubbock, TX 4640 Lynchburg, VA 0.9202 0.9446 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA 0.9011 0.9312 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI 1.0235 1.0160 Dane, WI 4800 Mansfield, OH 0.9059 0.9346 Crawford, OH Richland, OH 4840 Mayaguez, PR 0.4780 0.6032 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX 0.9084 0.9363 Hidalgo, TX 4890 Medford-Ashland, OR 1.0844 1.0571 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL 0.9837 0.9888 Brevard, Fl 4920 1 Memphis, TN-AR-MS 0.9325 0.9533 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 2 Merced, CA 0.9907 0.9936 Merced, CA 5000 1 Miami, FL 0.9888 0.9923 Dade, FL 5015 1 Middlesex-Somerset-Hunterdon, NJ 1.1437 1.0963 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 1 Milwaukee-Waukesha, WI 0.9888 0.9923 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 1 Minneapolis-St. Paul, MN-WI 1.1064 1.0717 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 0.8943 0.9264 Missoula, MT 5160 Mobile, AL 0.7948 0.8545 Baldwin, AL Mobile, AL 5170 Modesto, CA 1.1344 1.0902 Stanislaus, CA 5190 1 Monmouth-Ocean, NJ 1.1094 1.0737 Monmouth, NJ Ocean, NJ 5200 Monroe, LA 0.7978 0.8567 Ouachita, LA 5240 Montgomery, AL 0.7856 0.8477 Autauga, AL Elmore, AL Montgomery, AL 5280 2 Muncie, IN 0.8770 0.9140 Delaware, IN 5330 Myrtle Beach, SC 0.8950 0.9268 Horry, SC 5345 Naples, FL 0.9866 0.9908 Collier, FL 5360 1 Nashville, TN 0.9836 0.9887 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 1 Nassau-Suffolk, NY 1.3011 1.1975 Nassau, NY Suffolk, NY 5483 1 New Haven-Bridgeport-Stamford-Waterbury- 1.2525 1.1667 Danbury, CT Fairfield, CT New Haven, CT 5523 2 New London-Norwich, CT 1.2199 1.1458 New London, CT 5560 1 New Orleans, LA 0.9167 0.9422 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 1.3867 1.2509 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 1 Newark, NJ 1.1417 1.0950 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA 1.1377 1.0924 Orange, NY Pike, PA 5720 1 Norfolk-Virginia Beach-Newport News, VA-NC 0.8659 0.9061 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 1.5204 1.3323 Alameda, CA Contra Costa, CA 5790 Ocala, FL 0.9788 0.9854 Marion, FL 5800 Odessa-Midland, TX 0.9447 0.9618 Ector, TX Midland, TX 5880 1 Oklahoma City, OK 0.9027 0.9323 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA 1.1030 1.0694 Thurston, WA 5920 Omaha, NE-IA 0.9744 0.9824 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 1 Orange County, CA 1.1235 1.0830 Orange, CA 5960 1 Orlando, FL 0.9612 0.9733 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY 0.8429 0.8896 Daviess, KY 6015 2 Panama City, FL 0.8782 0.9149 Bay, FL 6020 Parkersburg-Marietta, WV-OH (WV Hospitals) 0.8093 0.8651 Washington, OH Wood, WV 6020 2 Parkersburg-Marietta, WV-OH (OH Hospitals) 0.8756 0.9130 Washington, OH Wood, WV 6080 2 Pensacola, FL 0.8782 0.9149 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL 0.8811 0.9170 Peoria, IL Tazewell, IL Woodford, IL 6160 1 Philadelphia, PA-NJ 1.0947 1.0639 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 1 Phoenix-Mesa, AZ 1.0213 1.0145 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR 0.7753 0.8401 Jefferson, AR 6280 1 Pittsburgh, PA 0.8788 0.9153 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 2 Pittsfield, MA 1.1234 1.0829 Berkshire, MA 6340 Pocatello, ID 0.9103 0.9377 Bannock, ID 6360 Ponce, PR 0.4762 0.6017 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME 0.9985 0.9990 Cumberland, ME Sagadahoc, ME York, ME 6440 1 Portland-Vancouver, OR-WA 1.1193 1.0802 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 1 Providence-Warwick-Pawtucket, RI 1.1025 1.0691 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT 1.0043 1.0029 Utah, UT 6560 2 Pueblo, CO 0.8897 0.9231 Pueblo, CO 6580 Punta Gorda, FL 0.9518 0.9667 Charlotte, FL 6600 2 Racine, WI 0.9130 0.9396 Racine, WI 6640 1 Raleigh-Durham-Chapel Hill, NC 1.0084 1.0057 Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660 Rapid City, SD 0.8865 0.9208 Pennington, SD 6680 Reading, PA 0.9042 0.9334 Berks, PA 6690 Redding, CA 1.1357 1.0910 Shasta, CA 6720 Reno, NV 1.0758 1.0513 Washoe, NV 6740 Richland-Kennewick-Pasco, WA 1.0639 1.0433 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA 0.9402 0.9587 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 1.1318 1.0885 Riverside, CA San Bernardino, CA 6800 Roanoke, VA 0.8759 0.9133 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN 1.1802 1.1201 Olmsted, MN 6840 1 Rochester, NY 0.9556 0.9694 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL 0.9730 0.9814 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC 0.9058 0.9345 Edgecombe, NC Nash, NC 6920 1 Sacramento, CA 1.1911 1.1272 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI 0.9620 0.9738 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN 0.9723 0.9809 Benton, MN Stearns, MN 7000 2 St. Joseph, MO 0.7793 0.8430 Andrew, MO Buchanan, MO 7040 1 St. Louis, MO-IL 0.9049 0.9339 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 1.0594 1.0403 Marion, OR Polk, OR 7120 Salinas, CA 1.4435 1.2858 Monterey, CA 7160 1 Salt Lake City-Ogden, UT 0.9899 0.9931 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX 0.8288 0.8793 Tom Green, TX 7240 1 San Antonio, TX 0.8876 0.9216 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 1 San Diego, CA 1.1206 1.0811 San Diego, CA 7360 1 San Francisco, CA 1.4349 1.2805 Marin, CA San Francisco, CA San Mateo, CA 7400 1 San Jose, CA 1.4642 1.2984 Santa Clara, CA 7440 1 San Juan-Bayamon, PR 0.4904 0.6139 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 1.1484 1.0994 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA 1.0511 1.0347 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA 1.3012 1.1976 Santa Cruz, CA 7490 Santa Fe, NM 1.0639 1.0433 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA 1.2836 1.1865 Sonoma, CA 7510 Sarasota-Bradenton, FL 0.9834 0.9886 Manatee, FL Sarasota, FL 7520 Savannah, GA 0.9556 0.9694 Bryan, GA Chatham, GA Effingham, GA 7560 2 Scranton--Wilkes-Barre--Hazleton, PA 0.8429 0.8896 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 1 Seattle-Bellevue-Everett, WA 1.1557 1.1042 Island, WA King, WA Snohomish, WA 7610 2 Sharon, PA 0.8429 0.8896 Mercer, PA 7620 2 Sheboygan, WI 0.9130 0.9396 Sheboygan, WI 7640 Sherman-Denison, TX 0.9508 0.9660 Grayson, TX 7680 Shreveport-Bossier City, LA 0.9127 0.9394 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE 0.9052 0.9341 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD 0.9371 0.9565 Lincoln, SD Minnehaha, SD 7800 South Bend, IN 0.9887 0.9922 St. Joseph, IN 7840 Spokane, WA 1.0954 1.0644 Spokane, WA 7880 Springfield, IL 0.9004 0.9307 Menard, IL Sangamon, IL 7920 Springfield, MO 0.8470 0.8925 Christian, MO Greene, MO Webster, MO 8003 2 Springfield, MA 1.1234 1.0829 Hampden, MA Hampshire, MA 8050 State College, PA 0.8798 0.9160 Centre, PA 8080 Steubenville-Weirton, OH-WV 0.8454 0.8914 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA 1.1168 1.0786 San Joaquin, CA 8140 2 Sumter, SC 0.8489 0.8939 Sumter, SC 8160 Syracuse, NY 0.9482 0.9642 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 2 Tacoma, WA 1.0242 1.0165 Pierce, WA 8240 2 Tallahassee, FL 0.8782 0.9149 Gadsden, FL Leon, FL 8280 1 Tampa-St. Petersburg-Clearwater, FL 0.9111 0.9382 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 2 Terre Haute, IN 0.8770 0.9140 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana,AR-Texarkana, TX 0.8198 0.8728 Miller, AR Bowie, TX 8400 Toledo, OH 0.9551 0.9690 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS 0.9021 0.9319 Shawnee, KS 8480 Trenton, NJ 1.0556 1.0377 Mercer, NJ 8520 Tucson, AZ 0.8958 0.9274 Pima, AZ 8560 Tulsa, OK 0.9093 0.9370 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL 0.8239 0.8758 Tuscaloosa, AL 8640 Tyler, TX 0.8789 0.9154 Smith, TX 8680 2 Utica-Rome, NY 0.8530 0.8968 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA 1.3500 1.2282 Napa, CA Solano, CA 8735 Ventura, CA 1.0472 1.0321 Ventura, CA 8750 Victoria, TX 0.8105 0.8660 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ 1.0475 1.0323 Cumberland, NJ 8780 2 Visalia-Tulare-Porterville, CA 0.9907 0.9936 Tulare, CA 8800 Waco, TX 0.8449 0.8910 McLennan, TX 8840 1 Washington, DC-MD-VA-WV 1.0707 1.0479 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 0.8422 0.8890 Black Hawk, IA 8940 Wausau, WI 0.9806 0.9867 Marathon, WI 8960 1 West Palm Beach-Boca Raton, FL 0.9784 0.9852 Palm Beach, FL 9000 2 Wheeling, WV-OH (WV Hospitals) 0.8008 0.8589 Belmont, OH Marshall, WV Ohio, WV 9000 2 Wheeling, WV-OH (OH Hospitals) 0.8756 0.9130 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS 0.9300 0.9515 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX 0.8407 0.8880 Archer, TX Wichita, TX 9140 2 Williamsport, PA 0.8429 0.8896 Lycoming, PA 9160 Wilmington-Newark, DE-MD 1.0955 1.0645 New Castle, DE Cecil, MD 9200 Wilmington, NC 0.9604 0.9727 New Hanover, NC Brunswick, NC 9260 Yakima, WA 1.0320 1.0218 Yakima, WA 9270 2 Yolo, CA 0.9907 0.9936 Yolo, CA 9280 York, PA 0.9154 0.9413 York, PA 9320 Youngstown-Warren, OH 0.9273 0.9496 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA 1.0264 1.0180 Sutter, CA Yuba, CA 9360 Yuma, AZ 0.8954 0.9271 Yuma, AZ 1 Large urban area. 2 Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2004. Table 4B.—Wage Index and Capital Geographic Adjustment Factor
(GAF)for Rural Areas Nonurban area Wage index GAF Alabama 0.7517 0.8225 Alaska 1.1958 1.1303 Arizona 0.8906 0.9237 Arkansas 0.7746 0.8395 California 0.9907 0.9936 Colorado 0.8897 0.9231 Connecticut 1.2199 1.1458 Delaware 0.9669 0.9772 Florida 0.8782 0.9149 Georgia 0.8365 0.8849 Hawaii 0.9896 0.9929 Idaho 0.8907 0.9238 Illinois 0.8282 0.8789 Indiana 0.8770 0.9140 Iowa 0.8278 0.8786 Kansas 0.7860 0.8480 Kentucky 0.7924 0.8527 Louisiana 0.7565 0.8261 Maine 0.8995 0.9300 Maryland 0.9175 0.9427 Massachusetts 1.1234 1.0829 Michigan 0.8807 0.9167 Minnesota 0.9243 0.9475 Mississippi 0.7810 0.8443 Missouri 0.7793 0.8430 Montana 0.8530 0.8968 Nebraska 0.8326 0.8821 Nevada 0.9758 0.9834 New Hampshire 0.9944 0.9962 1 New Jersey New Mexico 0.8314 0.8812 New York 0.8530 0.8968 North Carolina 0.8355 0.8842 North Dakota 0.7536 0.8239 Ohio 0.8756 0.9130 Oklahoma 0.7577 0.8270 Oregon 0.9939 0.9958 Pennsylvania 0.8429 0.8896 Puerto Rico 0.4037 0.5373 1 Rhode Island South Carolina 0.8489 0.8939 South Dakota 0.8093 0.8651 Tennessee 0.7945 0.8542 Texas 0.7673 0.8341 Utah 0.9034 0.9328 Vermont 0.9401 0.9586 Virginia 0.8542 0.8977 Washington 1.0242 1.0165 West Virginia 0.8008 0.8589 Wisconsin 0.9130 0.9396 Wyoming 0.9137 0.9401 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 Akron, OH 0.9445 0.9617 Albany, GA 1.0643 1.0436 Albuquerque, NM 0.9431 0.9607 Alexandria, LA 0.8087 0.8647 Altoona, PA 0.8886 0.9223 Amarillo, TX 0.8814 0.9172 Anchorage, AK 1.2433 1.1608 Ann Arbor, MI 1.0859 1.0581 Anniston, AL 0.8025 0.8601 Asheville, NC 0.9503 0.9657 Athens, GA 0.9437 0.9611 Atlanta, GA 0.9912 0.9940 Atlantic-Cape May, NJ 1.0597 1.0405 Augusta-Aiken, GA-SC 0.9491 0.9649 Austin-San Marcos, TX 0.9551 0.9690 Bangor, ME 0.9750 0.9828 Barnstable-Yarmouth, MA 1.2703 1.1780 Baton Rouge, LA 0.8271 0.8781 Bellingham, WA 1.1834 1.1222 Benton Harbor, MI 0.8949 0.9268 Bergen-Passaic, NJ 1.1655 1.1106 Billings, MT 0.8889 0.9225 Biloxi-Gulfport-Pascagoula, MS 0.8449 0.8910 Binghamton, NY 0.8433 0.8898 Birmingham, AL 0.9251 0.9481 Bismarck, ND 0.8101 0.8657 Bloomington-Normal, IL 0.8954 0.9271 Boise City, ID 0.9295 0.9512 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH 1.1269 1.0853 Burlington, VT 0.9442 0.9614 Caguas, PR 0.4229 0.5547 Casper, WY 0.9239 0.9472 Champaign-Urbana, IL 0.9385 0.9575 Charleston-North Charleston, SC 0.9307 0.9520 Charleston, WV (WV Hospitals) 0.8510 0.8954 Charleston, WV (OH Hospitals) 0.8756 0.9130 Charlotte-Gastonia-Rock Hill, NC-SC 0.9636 0.9749 Charlottesville, VA 0.9946 0.9963 Chattanooga, TN-GA 0.8985 0.9293 Chicago, IL 1.0863 1.0583 Cincinnati, OH-KY-IN 0.9452 0.9621 Clarksville-Hopkinsville, TN-KY 0.8410 0.8882 Cleveland-Lorain-Elyria, OH 0.9686 0.9784 Columbia, MO 0.8607 0.9024 Columbia, SC 0.8958 0.9274 Columbus, GA-AL 0.8505 0.8950 Columbus, OH 0.9649 0.9758 Corpus Christi, TX 0.8565 0.8994 Corvallis, OR 1.1316 1.0884 Dallas, TX 0.9733 0.9816 Davenport-Moline-Rock Island, IA-IL 0.8727 0.9110 Dayton-Springfield, OH 0.9432 0.9607 Decatur, AL 0.8633 0.9042 Denver, CO 1.0581 1.0394 Des Moines, IA 0.9053 0.9341 Detroit, MI 1.0097 1.0066 Dothan, AL 0.7931 0.8532 Dover, DE 0.9669 0.9772 Duluth-Superior, MN-WI 1.0133 1.0091 Dutchess County, NY 1.0769 1.0520 Eau Claire, WI 0.9141 0.9403 Elkhart-Goshen, IN 0.9613 0.9733 Erie, PA 0.8530 0.8968 Eugene-Springfield, OR 1.0889 1.0601 Fargo-Moorhead, ND-MN 0.9444 0.9616 Fayetteville, NC 0.8957 0.9273 Flagstaff, AZ-UT 1.1086 1.0732 Flint, MI 1.0929 1.0627 Florence, AL 0.7824 0.8453 Florence, SC 0.8763 0.9135 Fort Collins-Loveland, CO 1.0201 1.0137 Ft. Lauderdale, FL 1.0534 1.0363 Fort Pierce-Port St. Lucie, FL 1.0227 1.0155 Fort Smith, AR-OK 0.7577 0.8270 Fort Walton Beach, FL 0.8700 0.9090 Forth Worth-Arlington, TX 0.9268 0.9493 Gadsden, AL 0.8295 0.8798 Grand Forks, ND-MN (ND Hospitals) 0.9031 0.9326 Grand Forks, ND-MN (MN Hospitals) 0.9243 0.9475 Grand Junction, CO 0.9940 0.9959 Grand Rapids-Muskegon-Holland, MI 0.9406 0.9589 Great Falls, MT 0.8977 0.9288 Greeley, CO 0.9516 0.9666 Green Bay, WI 0.9201 0.9446 Greensboro-Winston-Salem-High Point, NC (NC Hospitals) 0.8533 0.8971 Greensboro-Winston-Salem-High Point, NC (VA Hospitals) 0.8542 0.8977 Greenville, NC 0.9621 0.9739 Hamilton-Middletown, OH 0.9236 0.9470 Harrisburg-Lebanon-Carlisle, PA 0.9178 0.9430 Hartford, CT (MA Hospitals) 1.1234 1.0829 Hartford, CT (NY Hospitals) 1.1211 1.0814 Hattiesburg, MS 0.7810 0.8443 Hickory-Morganton-Lenoir, NC 0.8987 0.9295 Honolulu, HI 1.1176 1.0791 Houston, TX 0.9591 0.9718 Huntington-Ashland, WV-KY-OH 0.9080 0.9360 Huntsville, AL 0.8954 0.9271 Indianapolis, IN 0.9934 0.9955 Iowa City, IA 0.9460 0.9627 Jackson, MS 0.8459 0.8917 Jackson, TN 0.8602 0.9020 Jacksonville, FL 0.9426 0.9603 Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals) 0.8542 0.8977 Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals) 0.8371 0.8854 Jonesboro, AR (AR Hospitals) 0.7755 0.8402 Jonesboro, AR (MO Hospitals) 0.7793 0.8430 Joplin, MO 0.8621 0.9034 Kalamazoo-Battlecreek, MI 1.0554 1.0376 Kansas City, KS-MO 0.9551 0.9690 Knoxville, TN 0.8987 0.9295 Kokomo, IN 0.8963 0.9278 Lafayette, LA 0.8271 0.8781 Lakeland-Winter Haven, FL 0.8782 0.9149 Las Vegas, NV-AZ 1.1341 1.0900 Lawton, OK 0.8194 0.8725 Lexington, KY 0.8424 0.8892 Lima, OH 0.9457 0.9625 Lincoln, NE 0.9613 0.9733 Little Rock-North Little Rock, AR 0.8905 0.9237 Longview-Marshall, TX 0.8969 0.9282 Los Angeles-Long Beach, CA 1.1656 1.1106 Louisville, KY-IN 0.9056 0.9344 Lubbock, TX 0.8330 0.8824 Lynchburg, VA 0.9004 0.9307 Macon, GA 0.9011 0.9312 Madison, WI 1.0108 1.0074 Medford-Ashland, OR 1.0494 1.0336 Melbourne-Titusville-Palm Bay, FL 0.9837 0.9888 Memphis, TN-AR-MS 0.9010 0.9311 Miami, FL 0.9888 0.9923 Milwaukee-Waukesha, WI 0.9760 0.9835 Minneapolis-St. Paul, MN-WI 1.1064 1.0717 Missoula, MT 0.8943 0.9264 Mobile, AL 0.7948 0.8545 Modesto, CA 1.1183 1.0796 Monmouth-Ocean, NJ 1.1094 1.0737 Monroe, LA 0.7978 0.8567 Montgomery, AL 0.7856 0.8477 Nashville, TN 0.9582 0.9712 New Haven-Bridgeport-Stamford-Waterbury- Danbury, CT 1.2525 1.1667 New Orleans, LA 0.9167 0.9422 New York, NY 1.3867 1.2509 Newark, NJ 1.1417 1.0950 Newburgh, NY-PA 1.1377 1.0924 Norfolk-Virginia Beach-Newport News, VA-NC 0.8659 0.9061 Oakland, CA 1.5204 1.3323 Ocala, FL 0.9646 0.9756 Odessa-Midland, TX 0.9156 0.9414 Oklahoma City, OK 0.9027 0.9323 Olympia, WA 1.1030 1.0694 Omaha, NE-IA 0.9744 0.9824 Orange County, CA 1.1235 1.0830 Orlando, FL 0.9612 0.9733 Peoria-Pekin, IL 0.8811 0.9170 Philadelphia, PA-NJ 1.0947 1.0639 Phoenix-Mesa, AZ 1.0213 1.0145 Pine Bluff, AR 0.7810 0.8443 Pittsburgh, PA 0.8788 0.9153 Pittsfield, MA 0.9861 0.9905 Pocatello, ID (ID Hospitals) 0.9103 0.9377 Pocatello, ID (WY Hospitals) 0.9137 0.9401 Portland, ME 0.9784 0.9852 Portland-Vancouver, OR-WA 1.1193 1.0802 Provo-Orem, UT 0.9912 0.9940 Raleigh-Durham-Chapel Hill, NC 0.9756 0.9832 Rapid City, SD 0.8865 0.9208 Reading, PA 0.8910 0.9240 Redding, CA 1.1357 1.0910 Reno, NV 1.0758 1.0513 Richland-Kennewick-Pasco, WA 1.0639 1.0433 Richmond-Petersburg, VA 0.9402 0.9587 Roanoke, VA 0.8759 0.9133 Rochester, MN 1.1802 1.1201 Rockford, IL 0.9500 0.9655 Sacramento, CA 1.1911 1.1272 Saginaw-Bay City-Midland, MI 0.9470 0.9634 St. Cloud, MN 0.9723 0.9809 St. Joseph, MO 0.9694 0.9789 St. Louis, MO-IL 0.9049 0.9339 Salinas, CA 1.4435 1.2858 Salt Lake City-Ogden, UT 0.9899 0.9931 San Antonio, TX 0.8876 0.9216 Santa Fe, NM 0.9543 0.9685 Santa Rosa, CA 1.2836 1.1865 Sarasota-Bradenton, FL 0.9834 0.9886 Savannah, GA 0.9556 0.9694 Seattle-Bellevue-Everett, WA 1.1557 1.1042 Sherman-Denison, TX 0.9084 0.9363 Shreveport-Bossier City, LA 0.9127 0.9394 Sioux City, IA-NE 0.8806 0.9166 Sioux Falls, SD 0.9246 0.9477 South Bend, IN 0.9780 0.9849 Spokane, WA 1.0770 1.0521 Springfield, IL 0.9004 0.9307 Springfield, MO 0.8269 0.8780 Stockton-Lodi, CA 1.1168 1.0786 Syracuse, NY 0.9381 0.9572 Tampa-St. Petersburg-Clearwater, FL 0.9111 0.9382 Texarkana,AR-Texarkana, TX 0.8018 0.8596 Toledo, OH 0.9551 0.9690 Topeka, KS 0.8791 0.9155 Tucson, AZ 0.8958 0.9274 Tulsa, OK 0.8876 0.9216 Tuscaloosa, AL 0.8134 0.8681 Tyler, TX 0.8789 0.9154 Vallejo-Fairfield-Napa, CA 1.3500 1.2282 Victoria, TX 0.8105 0.8660 Waco, TX 0.8449 0.8910 Washington, DC-MD-VA-WV 1.0707 1.0479 Waterloo-Cedar Falls, IA 0.8422 0.8890 Wausau, WI 0.9806 0.9867 West Palm Beach-Boca Raton, FL 0.9784 0.9852 Wichita, KS 0.9053 0.9341 Wichita Falls, TX 0.8407 0.8880 Wilmington-Newark, DE-MD 1.0782 1.0529 Wilmington, NC 0.9402 0.9587 York, PA 0.9154 0.9413 Youngstown-Warren, OH 0.9273 0.9496 Rural Alabama 0.7517 0.8225 Rural Florida 0.8782 0.9149 Rural Illinois 0.8282 0.8789 Rural Kentucky 0.7924 0.8527 Rural Louisiana 0.7565 0.8261 Rural Michigan 0.8807 0.9167 Rural Minnesota 0.9243 0.9475 Rural Mississippi 0.7810 0.8443 Rural Missouri 0.7793 0.8430 Rural Nebraska 0.8326 0.8821 Rural New Hampshire 0.9944 0.9962 Rural Texas 0.7673 0.8341 Rural Washington 1.0242 1.0165 Rural Wyoming 0.9020 0.9318 Table 4F.—Puerto rico Wage Index and Capital Geographic Adjustment Factor
(GAF)Area Wage index GAF Wage index— reclassified hospitals GAF— reclassified hospitals Aguadilla, PR 0.9218 0.9458 Arecibo, PR 0.8782 0.9149 Caguas, PR 0.8992 0.9298 0.8992 0.9298 Mayaguez, PR 1.0163 1.0111 Ponce, PR 1.0124 1.0085 San Juan-Bayamon, PR 1.0426 1.0290 Rural Puerto Rico 0.8583 0.9007 Table 4G.—Pre-reclassified Wage Index for Urban Areas Urban area (constituent counties) Wage index 0040 Abilene, TX 0.7714 Taylor, TX 0060 Aguadilla, PR 0.4323 Aguada, PR Aguadilla, PR Moca, PR 0080 Akron, OH 0.9175 Portage, OH Summit, OH 0120 Albany, GA 1.0809 Dougherty, GA Lee, GA 0160 Albany-Schenectady-Troy, NY 0.8669 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 0200 Albuquerque, NM 0.9405 Bernalillo, NM Sandoval, NM Valencia, NM 0220 Alexandria, LA 0.8048 Rapides, LA 0240 Allentown-Bethlehem-Easton, PA 0.9550 Carbon, PA Lehigh, PA Northampton, PA 0280 Altoona, PA 0.8841 Blair, PA 0320 Amarillo, TX 0.8944 Potter, TX Randall, TX 0380 Anchorage, AK 1.2264 Anchorage, AK 0440 Ann Arbor, MI 1.1039 Lenawee, MI Livingston, MI Washtenaw, MI 0450 Anniston, AL 0.8118 Calhoun, AL 0460 Appleton-Oshkosh-Neenah, WI 0.9204 Calumet, WI Outagamie, WI Winnebago, WI 0470 Arecibo, PR 0.4119 Arecibo, PR Camuy, PR Hatillo, PR 0480 Asheville, NC 0.9671 Buncombe, NC Madison, NC 0500 Athens, GA 0.9638 Clarke, GA Madison, GA Oconee, GA 0520 Atlanta, GA 1.0000 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 1.0833 Atlantic, NJ Cape May, NJ 0580 Auburn-Opelika, AL 0.8517 Lee, AL 0600 Augusta-Aiken, GA-SC 0.9698 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC 0640 Austin-San Marcos, TX 0.9525 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680 Bakersfield, CA 0.9956 Kern, CA 0720 Baltimore, MD 0.9924 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733 Bangor, ME Penobscot, ME 0.9925 0743 Barnstable-Yarmouth, MA 1.2859 Barnstable, MA 0760 Baton Rouge, LA 0.8254 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840 Beaumont-Port Arthur, TX 0.8480 Hardin, TX Jefferson, TX Orange, TX 0860 Bellingham, WA 1.1802 Whatcom, WA 0870 Benton Harbor, MI 0.8862 Berrien, MI 0875 Bergen-Passaic, NJ 1.1623 Bergen, NJ Passaic, NJ 0880 Billings, MT 0.8865 Yellowstone, MT 0920 Biloxi-Gulfport-Pascagoula, MS 0.9065 Hancock, MS Harrison, MS Jackson, MS 0960 Binghamton, NY 0.8546 Broome, NY Tioga, NY 1000 Birmingham, AL 0.9226 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010 Bismarck, ND 0.7997 Burleigh, ND Morton, ND 1020 Bloomington, IN 0.8944 Monroe, IN 1040 Bloomington-Normal, IL 0.8867 McLean, IL 1080 Boise City, ID 0.9246 Ada, ID Canyon, ID 1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH Hospitals) 1.1239 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 1.0092 Boulder, CO 1145 Brazoria, TX 0.8170 Brazoria, TX 1150 Bremerton, WA 1.0573 Kitsap, WA 1240 Brownsville-Harlingen-San Benito, TX 1.0204 Cameron, TX 1260 Bryan-College Station, TX 0.9008 Brazos, TX 1280 Buffalo-Niagara Falls, NY 0.9574 Erie, NY Niagara, NY 1303 Burlington, VT 0.9742 Chittenden, VT Franklin, VT Grand Isle, VT 1310 Caguas, PR 0.4175 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320 Canton-Massillon, OH 0.9103 Carroll, OH Stark, OH 1350 Casper, WY 0.9187 Natrona, WY 1360 Cedar Rapids, IA 0.8909 Linn, IA 1400 Champaign-Urbana, IL 0.9881 Champaign, IL 1440 Charleston-North Charleston, SC 0.9282 Berkeley, SC Charleston, SC Dorchester, SC 1480 Charleston, WV 0.8730 Kanawha, WV Putnam, WV 1520 Charlotte-Gastonia-Rock Hill, NC-SC 0.9739 Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 1540 Charlottesville, VA 1.0065 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560 Chattanooga, TN-GA 0.8961 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580 Cheyenne, WY 0.9187 Laramie, WY 1600 Chicago, IL 1.0982 Cook, IL DeKalb, IL DuPage, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620 Chico-Paradise, CA 1.0206 Butte, CA 1640 Cincinnati, OH-KY-IN 0.9425 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 0.8292 Christian, KY Montgomery, TN 1680 Cleveland-Lorain-Elyria, OH 0.9691 Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH 1720 Colorado Springs, CO 0.9063 El Paso, CO 1740 Columbia, MO 0.8721 Boone, MO 1760 Columbia, SC 0.8934 Lexington, SC Richland, SC 1800 Columbus, GA-AL 0.8677 Russell, AL Chattahoochee, GA Harris, GA Muscogee, GA 1840 Columbus, OH 0.9623 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880 Corpus Christi, TX 0.8542 Nueces, TX San Patricio, TX 1890 Corvallis, OR 1.1562 Benton, OR 1900 Cumberland, MD-WV (WV Hospital) 0.8202 Allegany, MD Mineral, WV 1920 Dallas, TX 0.9703 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950 Danville, VA 0.9071 Danville City, VA Pittsylvania, VA 1960 Davenport-Moline-Rock Island, IA-IL 0.8728 Scott, IA Henry, IL Rock Island, IL 2000 Dayton-Springfield, OH 0.9391 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020 Daytona Beach, FL 0.9183 Flagler, FL Volusia, FL 2030 Decatur, AL 0.8858 Lawrence, AL Morgan, AL 2040 Decatur, IL 0.8321 Macon, IL 2080 Denver, CO 1.0747 Adams, CO Arapahoe, CO Broomfield, CO Denver, CO Douglas, CO Jefferson, CO 2120 Des Moines, IA 0.9024 Dallas, IA Polk, IA Warren, IA 2160 Detroit, MI 1.0070 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180 Dothan, AL 0.7894 Dale, AL Houston, AL 2190 Dover, DE 0.9844 Kent, DE 2200 Dubuque, IA 0.8922 Dubuque, IA 2240 Duluth-Superior, MN-WI 1.0145 St. Louis, MN Douglas, WI 2281 Dutchess County, NY 1.0937 Dutchess, NY 2290 Eau Claire, WI 0.9204 Chippewa, WI Eau Claire, WI 2320 El Paso, TX 0.9242 El Paso, TX 2330 Elkhart-Goshen, IN 0.9822 Elkhart, IN 2335 Elmira, NY 0.8546 Chemung, NY 2340 Enid, OK 0.8593 Garfield, OK 2360 Erie, PA 0.8613 Erie, PA 2400 Eugene-Springfield, OR 1.1501 Lane, OR 2440 Evansville-Henderson, IN-KY (IN Hospitals) 0.8782 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520 Fargo-Moorhead, ND-MN 0.9624 Clay, MN Cass, ND 2560 Fayetteville, NC 0.8933 Cumberland, NC 2580 Fayetteville-Springdale-Rogers, AR 0.8016 Benton, AR Washington, AR 2620 Flagstaff, AZ-UT 1.1378 Coconino, AZ Kane, UT 2640 Flint, MI 1.0900 Genesee, MI 2650 Florence, AL 0.7751 Colbert, AL Lauderdale, AL 2655 Florence, SC 0.8739 Florence, SC 2670 Fort Collins-Loveland, CO 1.0173 Larimer, CO 2680 Ft. Lauderdale, FL 1.0168 Broward, FL 2700 Fort Myers-Cape Coral, FL 0.9851 Lee, FL 2710 Fort Pierce-Port St. Lucie, FL 1.0028 Martin, FL St. Lucie, FL 2720 Fort Smith, AR-OK 0.7741 Crawford, AR Sebastian, AR Sequoyah, OK 2750 Fort Walton Beach, FL 0.8905 Okaloosa, FL 2760 Fort Wayne, IN 0.9649 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800 Forth Worth-Arlington, TX 0.9243 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840 Fresno, CA 1.0130 Fresno, CA Madera, CA 2880 Gadsden, AL 0.8254 Etowah, AL 2900 Gainesville, FL 0.8846 Alachua, FL 2920 Galveston-Texas City, TX 0.9335 Galveston, TX 2960 Gary, IN 0.9437 Lake, IN Porter, IN 2975 Glens Falls, NY 0.8546 Warren, NY Washington, NY 2980 Goldsboro, NC 0.8656 Wayne, NC 2985 Grand Forks, ND-MN 0.8670 Polk, MN Grand Forks, ND 2995 Grand Junction, CO 0.9661 Mesa, CO 3000 Grand Rapids-Muskegon-Holland, MI 0.9372 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040 Great Falls, MT 0.8843 Cascade, MT 3060 Greeley, CO 0.9409 Weld, CO 3080 Green Bay, WI 0.9498 Brown, WI 3120 Greensboro-Winston-Salem-High Point, NC 0.8506 Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150 Greenville, NC 0.9595 Pitt, NC 3160 Greenville-Spartanburg-Anderson, SC 0.9264 Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180 Hagerstown, MD 0.9208 Washington, MD 3200 Hamilton-Middletown, OH 0.9211 Butler, OH 3240 Harrisburg-Lebanon-Carlisle, PA 0.9153 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283 Hartford, CT 1.2166 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285 Hattiesburg, MS 0.7812 Forrest, MS Lamar, MS 3290 Hickory-Morganton-Lenoir, NC 0.9065 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320 Honolulu, HI 1.1142 Honolulu, HI 3350 Houma, LA 0.7743 Lafourche, LA Terrebonne, LA 3360 Houston, TX 0.9572 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400 Huntington-Ashland, WV-KY-OH 0.9594 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440 Huntsville, AL 0.9213 Limestone, AL Madison, AL 3480 Indianapolis, IN 0.9921 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500 Iowa City, IA 0.9579 Johnson, IA 3520 Jackson, MI 0.9019 Jackson, MI 3560 Jackson, MS 0.8388 Hinds, MS Madison, MS Rankin, MS 3580 Jackson, TN 0.8579 Madison, TN Chester, TN 3600 Jacksonville, FL 0.9342 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605 Jacksonville, NC 0.8566 Onslow, NC 3610 Jamestown, NY 0.8546 Chautauqua, NY 3620 Janesville-Beloit, WI 0.9318 Rock, WI 3640 Jersey City, NJ 1.1173 Hudson, NJ 3660 Johnson City-Kingsport-Bristol, TN-VA 0.8348 Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680 Johnstown, PA 0.8415 Cambria, PA Somerset, PA 3700 Jonesboro, AR 0.7741 Craighead, AR 3710 Joplin, MO 0.8715 Jasper, MO Newton, MO 3720 Kalamazoo-Battlecreek, MI 1.0526 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740 Kankakee, IL 1.1044 Kankakee, IL 3760 Kansas City, KS-MO 0.9525 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 0.9799 Kenosha, WI 3810 Killeen-Temple, TX 0.9197 Bell, TX Coryell, TX 3840 Knoxville, TN 0.8963 Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850 Kokomo, IN 0.9080 Howard, IN Tipton, IN 3870 La Crosse, WI-MN 0.9234 Houston, MN La Crosse, WI 3880 Lafayette, LA 0.8250 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920 Lafayette, IN 0.9027 Clinton, IN Tippecanoe, IN 3960 Lake Charles, LA 0.8453 Calcasieu, LA 3980 Lakeland-Winter Haven, FL 0.8846 Polk, FL 4000 Lancaster, PA 0.9300 Lancaster, PA 4040 Lansing-East Lansing, MI 0.9245 Clinton, MI Eaton, MI Ingham, MI 4080 Laredo, TX 0.8123 Webb, TX 4100 Las Cruces, NM 0.8509 Dona Ana, NM 4120 Las Vegas, NV-AZ 1.1426 Mohave, AZ Clark, NV Nye, NV 4150 Lawrence, KS 0.8712 Douglas, KS 4200 Lawton, OK 0.8300 Comanche, OK 4243 Lewiston-Auburn, ME 0.9364 Androscoggin, ME 4280 Lexington, KY 0.8599 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320 Lima, OH 0.9432 Allen, OH Auglaize, OH 4360 Lincoln, NE 1.0074 Lancaster, NE 4400 Little Rock-North Little Rock, AR 0.8882 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420 Longview-Marshall, TX 0.9116 Gregg, TX Harrison, TX Upshur, TX 4480 Los Angeles-Long Beach, CA 1.1607 Los Angeles, CA 4520 Louisville, KY-IN 0.9149 Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600 Lubbock, TX 0.8308 Lubbock, TX 4640 Lynchburg, VA 0.9177 Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA 4680 Macon, GA 0.9005 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720 Madison, WI 1.0208 Dane, WI 4800 Mansfield, OH 0.9034 Crawford, OH Richland, OH 4840 Mayaguez, PR 0.4767 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880 McAllen-Edinburg-Mission, TX 0.9060 Hidalgo, TX 4890 Medford-Ashland, OR 1.0815 Jackson, OR 4900 Melbourne-Titusville-Palm Bay, FL 0.9775 Brevard, Fl 4920 Memphis, TN-AR-MS 0.9300 Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN 4940 Merced, CA 0.9956 Merced, CA 5000 Miami, FL 0.9862 Dade, FL 5015 Middlesex-Somerset-Hunterdon, NJ 1.1407 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080 Milwaukee-Waukesha, WI 0.9862 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120 Minneapolis-St. Paul, MN-WI 1.1034 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 0.8806 Missoula, MT 5160 Mobile, AL 0.7927 Baldwin, AL Mobile, AL 5170 Modesto, CA 1.1313 Stanislaus, CA 5190 Monmouth-Ocean, NJ 1.0934 Monmouth, NJ Ocean, NJ 5200 Monroe, LA 0.7956 Ouachita, LA 5240 Montgomery, AL 0.7835 Autauga, AL Elmore, AL Montgomery, AL 5280 Muncie, IN 0.8782 Delaware, IN 5330 Myrtle Beach, SC 0.8926 Horry, SC 5345 Naples, FL 0.9840 Collier, FL 5360 Nashville, TN 0.9809 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN 5380 Nassau-Suffolk, NY 1.2976 Nassau, NY Suffolk, NY 5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT 1.2452 Fairfield, CT New Haven, CT 5523 New London-Norwich, CT 1.2166 New London, CT 5560 New Orleans, LA 0.9148 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 1.3830 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640 Newark, NJ 1.1386 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660 Newburgh, NY-PA 1.1283 Orange, NY Pike, PA 5720 Norfolk-Virginia Beach-Newport News, VA-NC 0.8636 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 1.5004 Alameda, CA Contra Costa, CA 5790 Ocala, FL 0.9761 Marion, FL 5800 Odessa-Midland, TX 0.9422 Ector, TX Midland, TX 5880 Oklahoma City, OK 0.9010 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910 Olympia, WA 1.1001 Thurston, WA 5920 Omaha, NE-IA 0.9718 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945 Orange County, CA 1.1205 Orange, CA 5960 Orlando, FL 0.9586 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990 Owensboro, KY 0.8407 Daviess, KY 6015 Panama City, FL 0.8846 Bay, FL 6020 Parkersburg-Marietta, WV-OH 0.8071 Washington, OH Wood, WV 6080 Pensacola, FL 0.8846 Escambia, FL Santa Rosa, FL 6120 Peoria-Pekin, IL 0.8769 Peoria, IL Tazewell, IL Woodford, IL 6160 Philadelphia, PA-NJ 1.0917 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200 Phoenix-Mesa, AZ 1.0185 Maricopa, AZ Pinal, AZ 6240 Pine Bluff, AR 0.7741 Jefferson, AR 6280 Pittsburgh, PA 0.8764 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323 Pittsfield, MA 1.0832 Berkshire, MA 6340 Pocatello, ID 0.9078 Bannock, ID 6360 Ponce, PR 0.4749 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403 Portland, ME 0.9958 Cumberland, ME Sagadahoc, ME York, ME 6440 Portland-Vancouver, OR-WA 1.1162 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483 Providence-Warwick-Pawtucket, RI 1.0995 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520 Provo-Orem, UT 1.0016 Utah, UT 6560 Pueblo, CO 0.9063 Pueblo, CO 6580 Punta Gorda, FL 0.9493 Charlotte, FL 6600 Racine, WI 0.9204 Racine, WI 6640 Raleigh-Durham-Chapel Hill, NC 1.0073 Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660 Rapid City, SD 0.8841 Pennington, SD 6680 Reading, PA 0.9018 Berks, PA 6690 Redding, CA 1.1389 Shasta, CA 6720 Reno, NV 1.0714 Washoe, NV 6740 Richland-Kennewick-Pasco, WA 1.0599 Benton, WA Franklin, WA 6760 Richmond-Petersburg, VA 0.9377 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 1.1293 Riverside, CA San Bernardino, CA 6800 Roanoke, VA 0.8735 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820 Rochester, MN 1.1770 Olmsted, MN 6840 Rochester, NY 0.9530 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880 Rockford, IL 0.9704 Boone, IL Ogle, IL Winnebago, IL 6895 Rocky Mount, NC 0.9034 Edgecombe, NC Nash, NC 6920 Sacramento, CA 1.1879 El Dorado, CA Placer, CA Sacramento, CA 6960 Saginaw-Bay City-Midland, MI 0.9594 Bay, MI Midland, MI Saginaw, MI 6980 St. Cloud, MN 0.9508 Benton, MN Stearns, MN 7000 St. Joseph, MO 0.9796 Andrew, MO Buchanan, MO 7040 St. Louis, MO-IL 0.9025 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 1.0524 Marion, OR Polk, OR 7120 Salinas, CA 1.4396 Monterey, CA 7160 Salt Lake City-Ogden, UT 0.9872 Davis, UT Salt Lake, UT Weber, UT 7200 San Angelo, TX 0.8266 Tom Green, TX 7240 San Antonio, TX 0.8852 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320 San Diego, CA 1.1176 San Diego, CA 7360 San Francisco, CA 1.4310 Marin, CA San Francisco, CA San Mateo, CA 7400 San Jose, CA 1.4603 Santa Clara, CA 7440 San Juan-Bayamon, PR 0.4890 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 1.1454 San Luis Obispo, CA 7480 Santa Barbara-Santa Maria-Lompoc, CA 1.0483 Santa Barbara, CA 7485 Santa Cruz-Watsonville, CA 1.2977 Santa Cruz, CA 7490 Santa Fe, NM 1.0611 Los Alamos, NM Santa Fe, NM 7500 Santa Rosa, CA 1.2801 Sonoma, CA 7510 Sarasota-Bradenton, FL 0.9793 Manatee, FL Sarasota, FL 7520 Savannah, GA 0.9530 Bryan, GA Chatham, GA Effingham, GA 7560 Scranton—Wilkes-Barre—Hazleton, PA 0.8415 Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600 Seattle-Bellevue-Everett, WA 1.1526 Island, WA King, WA Snohomish, WA 7610 Sharon, PA 0.8415 Mercer, PA 7620 Sheboygan, WI 0.9204 Sheboygan, WI 7640 Sherman-Denison, TX 0.9482 Grayson, TX 7680 Shreveport-Bossier City, LA 0.9119 Bossier, LA Caddo, LA Webster, LA 7720 Sioux City, IA-NE 0.9028 Woodbury, IA Dakota, NE 7760 Sioux Falls, SD 0.9345 Lincoln, SD Minnehaha, SD 7800 South Bend, IN 0.9860 St. Joseph, IN 7840 Spokane, WA 1.0940 Spokane, WA 7880 Springfield, IL 0.8980 Menard, IL Sangamon, IL 7920 Springfield, MO 0.8447 Christian, MO Greene, MO Webster, MO 8003 Springfield, MA 1.0832 Hampden, MA Hampshire, MA 8050 State College, PA 0.8775 Centre, PA 8080 Steubenville-Weirton, OH-WV (WV Hospitals) 0.8431 Jefferson, OH Brooke, WV Hancock, WV 8120 Stockton-Lodi, CA 1.0549 San Joaquin, CA 8140 Sumter, SC 0.8478 Sumter, SC 8160 Syracuse, NY 0.9457 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200 Tacoma, WA 1.0526 Pierce, WA 8240 Tallahassee, FL 0.8846 Gadsden, FL Leon, FL 8280 Tampa-St. Petersburg-Clearwater, FL 0.9087 Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320 Terre Haute, IN 0.8782 Clay, IN Vermillion, IN Vigo, IN 8360 Texarkana,AR-Texarkana, TX 0.8176 Miller, AR Bowie, TX 8400 Toledo, OH 0.9525 Fulton, OH Lucas, OH Wood, OH 8440 Topeka, KS 0.8997 Shawnee, KS 8480 Trenton, NJ 1.0528 Mercer, NJ 8520 Tucson, AZ 0.9017 Pima, AZ 8560 Tulsa, OK 0.9113 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600 Tuscaloosa, AL 0.8217 Tuscaloosa, AL 8640 Tyler, TX 0.8766 Smith, TX 8680 Utica-Rome, NY 0.8546 Herkimer, NY Oneida, NY 8720 Vallejo-Fairfield-Napa, CA 1.3410 Napa, CA Solano, CA 8735 Ventura, CA 1.0444 Ventura, CA 8750 Victoria, TX 0.8084 Victoria, TX 8760 Vineland-Millville-Bridgeton, NJ 1.0447 Cumberland, NJ 8780 Visalia-Tulare-Porterville, CA 0.9956 Tulare, CA 8800 Waco, TX 0.8427 McLennan, TX 8840 Washington, DC-MD-VA-WV 1.0678 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 0.8431 Black Hawk, IA 8940 Wausau, WI 0.9731 Marathon, WI 8960 West Palm Beach-Boca Raton, FL 0.9758 Palm Beach, FL 9000 Wheeling, WV-OH 0.8027 Belmont, OH Marshall, WV Ohio, WV 9040 Wichita, KS 0.9275 Butler, KS Harvey, KS Sedgwick, KS 9080 Wichita Falls, TX 0.8385 Archer, TX Wichita, TX 9140 Williamsport, PA 0.8415 Lycoming, PA 9160 Wilmington-Newark, DE-MD 1.0925 New Castle, DE Cecil, MD 9200 Wilmington, NC 0.9579 New Hanover, NC Brunswick, NC 9260 Yakima, WA 1.0526 Yakima, WA 9270 Yolo, CA 0.9956 Yolo, CA 9280 York, PA 0.9098 York, PA 9320 Youngstown-Warren, OH 0.9248 Columbiana, OH Mahoning, OH Trumbull, OH 9340 Yuba City, CA 1.0236 Sutter, CA Yuba, CA 9360 Yuma, AZ 0.9017 Yuma, AZ Table 4H.—Pre-reclassified Wage Index for Rural Areas Nonurban area Wage index Alabama 0.7470 Alaska 1.1958 Arizona 0.8906 Arkansas 0.7746 California 0.9907 Colorado 0.8897 Connecticut 1.2199 Delaware 0.9280 Florida 0.8782 Georgia 0.8365 Hawaii 0.9896 Idaho 0.8907 Illinois 0.8282 Indiana 0.8770 Iowa 0.8278 Kansas 0.7860 Kentucky 0.7922 Louisiana 0.7478 Maine 0.8995 Maryland 0.9175 Massachusetts 1.1234 Michigan 0.8807 Minnesota 0.9223 Mississippi 0.7795 Missouri 0.7793 Montana 0.8530 Nebraska 0.8326 Nevada 0.9758 New Hampshire 0.9944 1 New Jersey New Mexico 0.8314 New York 0.8530 North Carolina 0.8355 North Dakota 0.7536 Ohio 0.8756 Oklahoma 0.7577 Oregon 0.9939 Pennsylvania 0.8429 Puerto Rico 0.4037 1 Rhode Island South Carolina 0.8489 South Dakota 0.8093 Tennessee 0.7945 Texas 0.7673 Utah 0.9034 Vermont 0.9278 Virginia 0.8542 Washington 1.0242 West Virginia 0.8008 Wisconsin 0.9130 Wyoming 0.9137 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 that could not be assigned to valid DRGs. Note 1: Geometric mean is used only to determine payment for transfer cases. Note 2: Arithmetic mean is presented for informational purposes only. Note 3: 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, and Geographic and Arithmetic Mean Length of Stay
(LOS)DRG MDC Type DRG title Relative weights Geometric mean LOS Arithmetic mean LOS 1 1 SURG CRANIOTOMY AGE >17 W CC 3.5287 7.9 10.6 2 1 SURG CRANIOTOMY AGE >17 W/O CC 2.0797 4.1 5.3 3 1 SURG *CRANIOTOMY AGE 0-17 1.9545 12.7 12.7 4 1 SURG *NO LONGER VALID 0.0000 0.0 0.0 5 1 SURG *NO LONGER VALID 0.0000 0.0 0.0 6 1 SURG CARPAL TUNNEL RELEASE 0.7987 2.1 3.0 7 1 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC 2.6451 6.7 9.9 8 1 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC 1.5337 1.9 2.8 9 1 MED SPINAL DISORDERS & INJURIES 1.3323 4.7 6.4 10 1 MED NERVOUS SYSTEM NEOPLASMS W CC 1.2348 4.8 6.5 11 1 MED NERVOUS SYSTEM NEOPLASMS W/O CC 0.8498 3.0 4.1 12 1 MED DEGENERATIVE NERVOUS SYSTEM DISORDERS 0.9170 4.5 5.9 13 1 MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA 0.8129 4.0 5.0 14 1 MED INTRACRANIAL HEMORRHAGE & STROKE W INFARCT 1.2589 4.7 6.1 15 1 MED NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT 0.9588 3.9 4.9 16 1 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 1.2518 4.8 6.4 17 1 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC 0.6939 2.5 3.2 18 1 MED CRANIAL & PERIPHERAL NERVE DISORDERS W CC 0.9970 4.2 5.5 19 1 MED CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC 0.6971 2.8 3.5 20 1 MED NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS 2.7213 8.0 10.5 21 1 MED VIRAL MENINGITIS 1.5069 5.0 6.6 22 1 MED HYPERTENSIVE ENCEPHALOPATHY 1.0671 3.9 5.1 23 1 MED NONTRAUMATIC STUPOR & COMA 0.8187 3.2 4.3 24 1 MED SEIZURE & HEADACHE AGE >17 W CC 1.0021 3.7 5.0 25 1 MED SEIZURE & HEADACHE AGE >17 W/O CC 0.6060 2.5 3.2 26 1 MED SEIZURE & HEADACHE AGE 0-17 1.4637 2.3 4.3 27 1 MED TRAUMATIC STUPOR & COMA, COMA >1 HR 1.3235 3.2 5.2 28 1 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC 1.3285 4.4 6.1 29 1 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC 0.7042 2.7 3.5 30 1 MED *TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 0.3306 2.0 2.0 31 1 MED *CONCUSSION AGE >17 W CC 0.8940 3.1 4.0 32 1 MED CONCUSSION AGE >17 W/O CC 0.5571 2.0 2.5 33 1 MED CONCUSSION AGE 0-17 0.2076 1.6 1.6 34 1 MED OTHER DISORDERS OF NERVOUS SYSTEM W CC 0.9863 3.7 5.0 35 1 MED OTHER DISORDERS OF NERVOUS SYSTEM W/O CC 0.6293 2.5 3.1 36 2 SURG RETINAL PROCEDURES 0.6302 1.2 1.5 37 2 SURG ORBITAL PROCEDURES 1.0539 2.5 3.8 38 2 SURG PRIMARY IRIS PROCEDURES 0.4676 1.9 2.8 39 2 SURG LENS PROCEDURES WITH OR WITHOUT VITRECTOMY 0.6263 1.5 2.1 40 2 SURG EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 0.8867 2.6 3.8 41 2 SURG *EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 0.3365 1.6 1.6 42 2 SURG INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS 0.7032 1.9 2.7 43 2 MED HYPHEMA 0.5402 2.4 3.4 44 2 MED ACUTE MAJOR EYE INFECTIONS 0.6631 4.0 5.1 45 2 MED NEUROLOGICAL EYE DISORDERS 0.7191 2.5 3.1 46 2 MED OTHER DISORDERS OF THE EYE AGE >17 W CC 0.7876 3.4 4.5 47 2 MED OTHER DISORDERS OF THE EYE AGE >17 W/O CC 0.5275 2.4 3.1 48 2 MED *OTHER DISORDERS OF THE EYE AGE 0-17 0.2964 2.9 2.9 49 3 SURG MAJOR HEAD & NECK PROCEDURES 1.7194 3.2 4.5 50 3 SURG SIALOADENECTOMY 0.8279 1.5 1.9 51 3 SURG SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY 0.8429 1.9 2.8 52 3 SURG CLEFT LIP & PALATE REPAIR 0.7986 1.5 1.8 53 3 SURG SINUS & MASTOID PROCEDURES AGE >17 1.2474 2.2 3.6 54 3 SURG *SINUS & MASTOID PROCEDURES AGE 0-17 0.4805 3.2 3.2 55 3 SURG MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES 0.9181 2.0 2.9 56 3 SURG RHINOPLASTY 0.9174 1.9 2.9 57 3 SURG T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 1.0980 2.4 3.7 58 3 SURG T&A PROC, EXCEPT TONSILLECTOMY &/OR *ADENOIDECTOMY ONLY, AGE 0-17 0.2728 1.5 1.5 59 3 SURG TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 0.9629 1.9 2.7 60 3 SURG *TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 0.2077 1.5 1.5 61 3 SURG MYRINGOTOMY W TUBE INSERTION AGE >17 1.2166 3.0 5.1 62 3 SURG *MYRINGOTOMY W TUBE INSERTION AGE 0-17 0.2942 1.3 1.3 63 3 SURG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES 1.3651 3.0 4.4 64 3 MED EAR, NOSE, MOUTH & THROAT MALIGNANCY 1.3020 4.3 6.5 65 3 MED DYSEQUILIBRIUM 0.5691 2.3 2.8 66 3 MED EPISTAXIS 0.5755 2.4 3.1 67 3 MED EPIGLOTTITIS 0.7751 2.9 3.7 68 3 MED OTITIS MEDIA & URI AGE &gt;17 W CC 0.6481 3.1 3.9 69 3 MED OTITIS MEDIA & URI AGE &gt;17 W/O CC 0.4951 2.5 3.0 70 3 MED OTITIS MEDIA & URI AGE 0-17 0.3243 1.9 2.3 71 3 MED LARYNGOTRACHEITIS 0.6908 2.4 3.4 72 3 MED NASAL TRAUMA & DEFORMITY 0.6909 2.6 3.4 73 3 MED OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 0.8128 3.3 4.5 74 3 MED *OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 0.3344 2.1 2.1 75 4 SURG MAJOR CHEST PROCEDURES 3.0248 7.7 10.0 76 4 SURG OTHER RESP SYSTEM O.R. PROCEDURES W CC 2.7935 8.4 11.1 77 4 SURG OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 1.2268 3.5 4.8 78 4 MED PULMONARY EMBOLISM 1.2641 5.6 6.6 79 4 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC 1.5867 6.7 8.5 80 4 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC 0.8340 4.3 5.4 81 4 MED *RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 1.5139 6.1 6.1 82 4 MED RESPIRATORY NEOPLASMS 1.3626 5.1 6.9 83 4 MED MAJOR CHEST TRAUMA W CC 0.9511 4.3 5.4 84 4 MED MAJOR CHEST TRAUMA W/O CC 0.5304 2.6 3.3 85 4 MED PLEURAL EFFUSION W CC 1.1847 4.8 6.3 86 4 MED PLEURAL EFFUSION W/O CC 0.6805 2.8 3.6 87 4 MED PULMONARY EDEMA & RESPIRATORY FAILURE 1.3301 4.8 6.3 88 4 MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.8869 4.1 5.1 89 4 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC 1.0374 4.9 5.9 90 4 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC 0.6097 3.4 4.0 91 4 MED SIMPLE PNEUMONIA & PLEURISY AGE 0-17 0.7390 3.1 5.1 92 4 MED INTERSTITIAL LUNG DISEASE W CC 1.1938 5.0 6.3 93 4 MED INTERSTITIAL LUNG DISEASE W/O CC 0.7123 3.3 4.0 94 4 MED PNEUMOTHORAX W CC 1.1256 4.7 6.3 95 4 MED PNEUMOTHORAX W/O CC 0.6112 3.0 3.8 96 4 MED BRONCHITIS & ASTHMA AGE >17 W CC 0.7403 3.7 4.6 97 4 MED BRONCHITIS & ASTHMA AGE >17 W/O CC 0.5464 2.9 3.5 98 4 MED *BRONCHITIS & ASTHMA AGE 0-17 0.9560 3.7 3.7 99 4 MED RESPIRATORY SIGNS & SYMPTOMS W CC 0.6974 2.4 3.2 100 4 MED RESPIRATORY SIGNS & SYMPTOMS W/O CC 0.5185 1.7 2.1 101 4 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W CC 0.8582 3.3 4.4 102 4 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC 0.5363 2.1 2.6 103 PRE SURG HEART TRANSPLANT 18.5203 25.9 42.1 104 5 SURG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W CARD CATH 7.9220 12.2 14.4 105 5 SURG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH 5.7134 8.2 9.9 106 5 SURG CORONARY BYPASS W PTCA 7.2710 9.6 11.4 107 5 SURG CORONARY BYPASS W CARDIAC CATH 5.3525 9.2 10.5 108 5 SURG OTHER CARDIOTHORACIC PROCEDURES 5.3651 7.3 9.8 109 5 SURG CORONARY BYPASS W/O PTCA OR CARDIAC CATH 3.9294 6.7 7.7 110 5 SURG MAJOR CARDIOVASCULAR PROCEDURES W CC 4.0328 6.3 8.9 111 5 SURG MAJOR CARDIOVASCULAR PROCEDURES W/O CC 2.4669 3.2 4.1 112 5 SURG NO LONGER VALID 0.0000 0.0 0.0 113 5 SURG AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE 2.9875 10.4 13.3 114 5 SURG UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS 1.6337 6.4 8.7 115 5 SURG PRM CARD PACEM IMPL W AMI/HR/SHOCK OR AICD LEAD OR GNRTR 3.5189 5.0 7.5 116 5 SURG OTHER PERMANENT CARDIAC PACEMAKER IMPLANT 2.3407 3.1 4.4 117 5 SURG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT 1.3838 2.6 4.3 118 5 SURG CARDIAC PACEMAKER DEVICE REPLACEMENT 1.5967 2.0 2.9 119 5 SURG VEIN LIGATION & STRIPPING 1.3679 3.2 5.4 120 5 SURG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 2.3033 5.6 9.0 121 5 MED CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE 1.6033 5.3 6.6 122 5 MED CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE 1.0202 2.9 3.7 123 5 MED CIRCULATORY DISORDERS W AMI, EXPIRED 1.5486 2.9 4.8 124 5 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG 1.4273 3.3 4.4 125 5 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG 1.0885 2.2 2.8 126 5 MED ACUTE & SUBACUTE ENDOCARDITIS 2.5295 9.3 11.8 127 5 MED HEART FAILURE & SHOCK 1.0072 4.1 5.3 128 5 MED DEEP VEIN THROMBOPHLEBITIS 0.7226 4.6 5.5 129 5 MED CARDIAC ARREST, UNEXPLAINED 1.0089 1.7 2.6 130 5 MED PERIPHERAL VASCULAR DISORDERS W CC 0.9430 4.5 5.7 131 5 MED PERIPHERAL VASCULAR DISORDERS W/O CC 0.5634 3.4 4.1 132 5 MED ATHEROSCLEROSIS W CC 0.6364 2.3 2.9 133 5 MED ATHEROSCLEROSIS W/O CC 0.5502 1.8 2.3 134 5 MED HYPERTENSION 0.5905 2.5 3.2 135 5 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC 0.9196 3.4 4.5 136 5 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC 0.5698 2.2 2.7 137 5 MED *CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 0.8156 3.3 3.3 138 5 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 0.8289 3.1 4.0 139 5 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC 0.5120 2.0 2.5 140 5 MED ANGINA PECTORIS 0.5240 2.0 2.5 141 5 MED SYNCOPE & COLLAPSE W CC 0.7408 2.8 3.6 142 5 MED SYNCOPE & COLLAPSE W/O CC 0.5706 2.1 2.6 143 5 MED CHEST PAIN 0.5435 1.7 2.1 144 5 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W CC 1.2176 3.9 5.6 145 5 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC 0.5742 2.0 2.6 146 6 SURG RECTAL RESECTION W CC 2.7198 8.8 10.3 147 6 SURG RECTAL RESECTION W/O CC 1.5267 5.6 6.2 148 6 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 3.3748 10.1 12.3 149 6 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC 1.4487 5.8 6.3 150 6 SURG PERITONEAL ADHESIOLYSIS W CC 2.8525 9.2 11.3 151 6 SURG PERITONEAL ADHESIOLYSIS W/O CC 1.2952 4.4 5.6 152 6 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W CC 1.8931 6.9 8.4 153 6 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC 1.1262 4.7 5.3 154 6 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC 3.9961 9.9 13.3 155 6 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC 1.2946 3.0 4.1 156 6 SURG *STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 0.8400 6.0 6.0 157 6 SURG ANAL & STOMAL PROCEDURES W CC 1.3070 4.0 5.8 158 6 SURG ANAL & STOMAL PROCEDURES W/O CC 0.6472 2.0 2.6 159 6 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC 1.3654 3.8 5.1 160 6 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC 0.8170 2.2 2.7 161 6 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC 1.1598 3.0 4.3 162 6 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC 0.6396 1.6 1.9 163 6 SURG *HERNIA PROCEDURES AGE 0-17 0.6892 2.1 2.1 164 6 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 2.3154 7.0 8.4 165 6 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC 1.2218 3.8 4.5 166 6 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 1.4244 3.6 4.7 167 6 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC 0.8841 2.0 2.4 168 3 SURG MOUTH PROCEDURES W CC 1.3135 3.3 4.9 169 3 SURG MOUTH PROCEDURES W/O CC 0.7487 1.8 2.4 170 6 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 2.8023 7.5 10.9 171 6 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC 1.1816 3.3 4.3 172 6 MED DIGESTIVE MALIGNANCY W CC 1.3576 5.2 7.0 173 6 MED DIGESTIVE MALIGNANCY W/O CC 0.7524 2.8 3.8 174 6 MED G.I. HEMORRHAGE W CC 0.9942 3.9 4.8 175 6 MED G.I. HEMORRHAGE W/O CC 0.5541 2.5 2.9 176 6 MED COMPLICATED PEPTIC ULCER 1.0918 4.1 5.2 177 6 MED UNCOMPLICATED PEPTIC ULCER W CC 0.9182 3.7 4.6 178 6 MED UNCOMPLICATED PEPTIC ULCER W/O CC 0.6879 2.6 3.1 179 6 MED INFLAMMATORY BOWEL DISEASE 1.0800 4.6 6.0 180 6 MED G.I. OBSTRUCTION W CC 0.9562 4.2 5.5 181 6 MED G.I. OBSTRUCTION W/O CC 0.5332 2.8 3.4 182 6 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC 0.8153 3.4 4.4 183 6 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC 0.5710 2.3 2.9 184 6 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 0.4874 2.3 3.2 185 3 MED DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17 0.8680 3.3 4.7 186 3 MED *DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17 0.3202 2.9 2.9 187 3 MED DENTAL EXTRACTIONS & RESTORATIONS 0.7731 3.0 4.0 188 6 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC 1.1000 4.1 5.6 189 6 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC 0.5936 2.4 3.1 190 6 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 0.8080 3.7 5.2 191 7 SURG PANCREAS, LIVER & SHUNT PROCEDURES W CC 4.2734 9.8 13.9 192 7 SURG PANCREAS, LIVER & SHUNT PROCEDURES W/O CC 1.7906 4.7 6.2 193 7 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC 3.4000 10.4 12.8 194 7 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC 1.5934 5.7 6.8 195 7 SURG CHOLECYSTECTOMY W C.D.E. W CC 3.0458 8.7 10.6 196 7 SURG CHOLECYSTECTOMY W C.D.E. W/O CC 1.6025 4.8 5.6 197 7 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 2.5296 7.5 9.2 198 7 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC 1.1732 3.8 4.4 199 7 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY 2.3704 6.9 9.8 200 7 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY 3.0260 6.7 10.6 201 7 SURG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES 3.6753 10.2 14.2 202 7 MED CIRRHOSIS & ALCOHOLIC HEPATITIS 1.3013 4.8 6.4 203 7 MED MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS 1.3407 5.0 6.7 204 7 MED DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1.1582 4.4 5.8 205 7 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC 1.1970 4.6 6.2 206 7 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC 0.7045 2.9 3.8 207 7 MED DISORDERS OF THE BILIARY TRACT W CC 1.1443 4.0 5.3 208 7 MED DISORDERS OF THE BILIARY TRACT W/O CC 0.6540 2.3 2.9 209 8 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF LOWER EXTREMITY 2.0199 4.4 4.9 210 8 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 1.8335 6.1 7.0 211 8 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC 1.2446 4.5 4.9 212 8 SURG *HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 0.8436 11.1 11.1 213 8 SURG AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS 1.8736 6.7 9.2 214 8 SURG NO LONGER VALID 0.0000 0.0 0.0 215 8 SURG NO LONGER VALID 0.0000 0.0 0.0 216 8 SURG BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 2.0981 5.0 8.0 217 8 SURG WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS 2.9860 9.1 13.5 218 8 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC 1.5612 4.3 5.5 219 8 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC 1.0187 2.7 3.2 220 8 SURG *LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17 0.5819 5.3 5.3 221 8 SURG NO LONGER VALID 0.0000 0.0 0.0 222 8 SURG NO LONGER VALID 0.0000 0.0 0.0 223 8 SURG MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC 1.0493 2.2 3.0 224 8 SURG SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC 0.7841 1.6 1.9 225 8 SURG FOOT PROCEDURES 1.1638 3.6 5.3 226 8 SURG SOFT TISSUE PROCEDURES W CC 1.5413 4.5 6.5 227 8 SURG SOFT TISSUE PROCEDURES W/O CC 0.8139 2.1 2.6 228 8 SURG MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC 1.1547 2.7 4.2 229 8 SURG HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC 0.6975 1.8 2.3 230 8 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR 1.3026 3.6 5.6 231 8 SURG *NO LONGER VALID 0.0000 0.0 0.0 232 8 SURG ARTHROSCOPY 0.9638 1.8 2.7 233 8 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC 1.9896 5.0 7.4 234 8 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC 1.1937 2.2 3.1 235 8 MED FRACTURES OF FEMUR 0.7516 3.8 5.0 236 8 MED FRACTURES OF HIP & PELVIS 0.7299 3.9 4.8 237 8 MED SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH 0.5948 2.9 3.7 238 8 MED OSTEOMYELITIS 1.3446 6.5 8.7 239 8 MED PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY 1.0524 5.1 6.4 240 8 MED CONNECTIVE TISSUE DISORDERS W CC 1.3065 4.9 6.7 241 8 MED CONNECTIVE TISSUE DISORDERS W/O CC 0.6297 3.0 3.8 242 8 MED SEPTIC ARTHRITIS 1.1573 5.3 7.0 243 8 MED MEDICAL BACK PROBLEMS 0.7535 3.7 4.7 244 8 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W CC 0.7092 3.7 4.7 245 8 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC 0.4741 2.6 3.3 246 8 MED NON-SPECIFIC ARTHROPATHIES 0.5937 2.9 3.7 247 8 MED SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE 0.5672 2.6 3.3 248 8 MED TENDONITIS, MYOSITIS & BURSITIS 0.8503 3.8 4.9 249 8 MED AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 0.6710 2.5 3.6 250 8 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC 0.7034 3.2 4.1 251 8 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC 0.4539 2.3 2.8 252 8 MED *FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 0.2526 1.8 1.8 253 8 MED FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC 0.7512 3.7 4.7 254 8 MED FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/O CC 0.4417 2.6 3.2 255 8 MED *FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 0.2943 2.9 2.9 256 8 MED OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.8116 3.8 5.1 257 9 SURG TOTAL MASTECTOMY FOR MALIGNANCY W CC 0.8851 2.1 2.6 258 9 SURG TOTAL MASTECTOMY FOR MALIGNANCY W/O CC 0.6978 1.6 1.8 259 9 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC 0.9337 1.8 2.7 260 9 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC 0.6794 1.2 1.4 261 9 SURG BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION 0.8947 1.6 2.1 262 9 SURG BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY 0.9466 2.9 4.3 263 9 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC 2.1904 9.0 12.2 264 9 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC 1.0940 5.2 6.8 265 9 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC 1.5921 4.2 6.6 266 9 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC 0.8719 2.3 3.2 267 9 SURG PERIANAL & PILONIDAL PROCEDURES 0.9515 2.9 4.5 268 9 SURG SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES 1.1516 2.5 3.9 269 9 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W CC 1.7647 6.0 8.6 270 9 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC 0.8085 2.5 3.6 271 9 MED SKIN ULCERS 1.0219 5.6 7.2 272 9 MED MAJOR SKIN DISORDERS W CC 1.0084 4.6 6.0 273 9 MED MAJOR SKIN DISORDERS W/O CC 0.6167 3.0 3.9 274 9 MED MALIGNANT BREAST DISORDERS W CC 1.1449 4.7 6.5 275 9 MED MALIGNANT BREAST DISORDERS W/O CC 0.5738 2.4 3.5 276 9 MED NON-MALIGANT BREAST DISORDERS 0.6410 3.5 4.5 277 9 MED CELLULITIS AGE >17 W CC 0.8738 4.7 5.8 278 9 MED CELLULITIS AGE >17 W/O CC 0.5391 3.5 4.2 279 9 MED CELLULITIS AGE 0-17 0.7687 4.0 5.3 280 9 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC 0.7035 3.2 4.1 281 9 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC 0.4810 2.3 2.9 282 9 MED *TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 0.2558 2.2 2.2 283 9 MED MINOR SKIN DISORDERS W CC 0.7271 3.5 4.7 284 9 MED MINOR SKIN DISORDERS W/O CC 0.4172 2.3 2.9 285 10 SURG AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DISORDERS 2.0611 7.9 10.6 286 10 SURG ADRENAL & PITUITARY PROCEDURES 2.0223 4.4 5.9 287 10 SURG SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS 1.8651 7.7 10.3 288 10 SURG O.R. PROCEDURES FOR OBESITY 2.1578 3.9 5.0 289 10 SURG PARATHYROID PROCEDURES 0.9427 1.8 2.7 290 10 SURG THYROID PROCEDURES 0.8874 1.7 2.2 291 10 SURG THYROGLOSSAL PROCEDURES 0.6425 1.4 1.6 292 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC 2.7077 7.2 10.5 293 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC 1.3678 3.2 4.7 294 10 MED DIABETES AGE >35 0.7632 3.4 4.5 295 10 MED DIABETES AGE 0-35 0.7959 3.0 4.0 296 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC 0.8572 4.0 5.1 297 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC 0.5041 2.7 3.3 298 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 0.4610 2.4 3.2 299 10 MED INBORN ERRORS OF METABOLISM 0.9381 3.7 5.5 300 10 MED ENDOCRINE DISORDERS W CC 1.0938 4.8 6.2 301 10 MED ENDOCRINE DISORDERS W/O CC 0.6113 2.8 3.6 302 11 SURG KIDNEY TRANSPLANT 3.2328 7.2 8.5 303 11 SURG KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM 2.3540 6.4 8.1 304 11 SURG KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC 2.3813 6.2 8.9 305 11 SURG KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC 1.1767 2.8 3.6 306 11 SURG PROSTATECTOMY W CC 1.2134 3.5 5.4 307 11 SURG PROSTATECTOMY W/O CC 0.6094 1.7 2.1 308 11 SURG MINOR BLADDER PROCEDURES W CC 1.5867 4.0 6.2 309 11 SURG MINOR BLADDER PROCEDURES W/O CC 0.8931 1.7 2.1 310 11 SURG TRANSURETHRAL PROCEDURES W CC 1.1402 2.9 4.4 311 11 SURG TRANSURETHRAL PROCEDURES W/O CC 0.6203 1.5 1.8 312 11 SURG URETHRAL PROCEDURES, AGE >17 W CC 1.0784 3.0 4.6 313 11 SURG URETHRAL PROCEDURES, AGE >17 W/O CC 0.6747 1.7 2.3 314 11 SURG *URETHRAL PROCEDURES, AGE 0-17 0.4931 2.3 2.3 315 11 SURG OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES 2.0680 3.8 7.0 316 11 MED RENAL FAILURE 1.2907 4.9 6.6 317 11 MED ADMIT FOR RENAL DIALYSIS 0.8488 2.4 3.6 318 11 MED KIDNEY & URINARY TRACT NEOPLASMS W CC 1.1797 4.5 6.1 319 11 MED KIDNEY & URINARY TRACT NEOPLASMS W/O CC 0.6754 2.2 2.9 320 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC 0.8785 4.3 5.4 321 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC 0.5640 3.1 3.7 322 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 0.4571 2.7 3.2 323 11 MED URINARY STONES W CC, &/OR ESW LITHOTRIPSY 0.8026 2.4 3.2 324 11 MED URINARY STONES W/O CC 0.4752 1.6 1.9 325 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC 0.6497 2.9 3.8 326 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC 0.4181 2.1 2.6 327 11 MED *KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0-17 0.3688 3.1 3.1 328 11 MED URETHRAL STRICTURE AGE >17 W CC 0.7474 2.7 3.7 329 11 MED URETHRAL STRICTURE AGE >17 W/O CC 0.5254 1.7 2.1 330 11 MED *URETHRAL STRICTURE AGE 0-17 0.3177 1.6 1.6 331 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC 1.0546 4.2 5.6 332 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC 0.5949 2.4 3.2 333 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 0.9552 3.7 5.8 334 12 SURG MAJOR MALE PELVIC PROCEDURES W CC 1.4738 3.9 4.6 335 12 SURG MAJOR MALE PELVIC PROCEDURES W/O CC 1.0778 2.8 3.0 336 12 SURG TRANSURETHRAL PROSTATECTOMY W CC 0.8539 2.6 3.4 337 12 SURG TRANSURETHRAL PROSTATECTOMY W/O CC 0.5832 1.8 2.0 338 12 SURG TESTES PROCEDURES, FOR MALIGNANCY 1.2100 3.5 5.5 339 12 SURG TESTES PROCEDURES, NON-MALIGNANCY AGE >17 1.1314 2.9 4.8 340 12 SURG *TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 0.2823 2.4 2.4 341 12 SURG PENIS PROCEDURES 1.2651 2.0 3.2 342 12 SURG CIRCUMCISION AGE >17 0.7717 2.4 3.2 343 12 SURG *CIRCUMCISION AGE 0-17 0.1534 1.7 1.7 344 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY 1.3244 1.6 2.5 345 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY 1.1523 3.0 4.9 346 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC 1.0133 4.5 5.9 347 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC 0.5436 2.2 3.0 348 12 MED BENIGN PROSTATIC HYPERTROPHY W CC 0.7423 3.3 4.4 349 12 MED BENIGN PROSTATIC HYPERTROPHY W/O CC 0.4562 2.0 2.5 350 12 MED INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM 0.7298 3.6 4.5 351 12 MED *STERILIZATION, MALE 0.2354 1.3 1.3 352 12 MED OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES 0.7076 2.9 4.0 353 13 SURG PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY 1.8469 5.0 6.6 354 13 SURG UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC 1.4796 4.7 5.7 355 13 SURG UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC 0.8855 3.0 3.2 356 13 SURG FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 0.7516 1.8 2.1 357 13 SURG UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY 2.2673 6.7 8.4 358 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 1.1754 3.4 4.2 359 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC 0.8055 2.3 2.6 360 13 SURG VAGINA, CERVIX & VULVA PROCEDURES 0.8613 2.2 2.8 361 13 SURG LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 1.0865 2.2 3.2 362 13 SURG *ENDOSCOPIC TUBAL INTERRUPTION 0.3009 1.4 1.4 363 13 SURG D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY 0.9275 2.6 3.6 364 13 SURG D&C, CONIZATION EXCEPT FOR MALIGNANCY 0.8939 2.9 4.1 365 13 SURG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES 2.1194 5.3 8.2 366 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC 1.2567 4.8 6.7 367 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC 0.5496 2.2 3.0 368 13 MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM 1.1619 5.2 6.7 369 13 MED MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.5997 2.4 3.3 370 14 SURG CESAREAN SECTION W CC 0.9992 4.2 5.7 371 14 SURG CESAREAN SECTION W/O CC 0.6267 3.2 3.5 372 14 MED VAGINAL DELIVERY W COMPLICATING DIAGNOSES 0.5457 2.7 3.5 373 14 MED VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 0.3831 2.0 2.3 374 14 SURG VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.7410 2.5 3.0 375 14 SURG *VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C 0.5745 4.4 4.4 376 14 MED POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE 0.5499 2.6 3.4 377 14 SURG POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE 1.0123 3.2 4.1 378 14 MED ECTOPIC PREGNANCY 0.7893 2.0 2.6 379 14 MED THREATENED ABORTION 0.3647 2.0 3.0 380 14 MED ABORTION W/O D&C 0.4261 1.6 2.0 381 14 SURG ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.5247 1.5 1.9 382 14 MED FALSE LABOR 0.2113 1.3 1.7 383 14 MED OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS 0.5103 2.7 3.8 384 14 MED OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS 0.3463 1.9 2.6 385 15 MED *NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 1.3709 1.8 1.8 386 15 MED *EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE 4.5207 17.9 17.9 387 15 MED *PREMATURITY W MAJOR PROBLEMS 3.0876 13.3 1 3.3 388 15 MED *PREMATURITY W/O MAJOR PROBLEMS 1.8630 8.6 8.6 389 15 MED FULL TERM NEONATE W MAJOR PROBLEMS 1.2020 5.2 6.3 390 15 MED *NEONATE W OTHER SIGNIFICANT PROBLEMS 1.1225 3.4 3.4 391 15 MED *NORMAL NEWBORN 0.1520 3.1 3.1 392 16 SURG SPLENECTOMY AGE >17 3.2999 7.1 9.7 393 16 SURG *SPLENECTOMY AGE 0-17 1.3429 9.1 9.1 394 16 SURG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS 1.9216 4.7 7.6 395 16 MED RED BLOOD CELL DISORDERS AGE >17 0.8159 3.2 4.3 396 16 MED RED BLOOD CELL DISORDERS AGE 0-17 0.7409 3.0 4.4 397 16 MED COAGULATION DISORDERS 1.2575 3.7 5.2 398 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC 1.2266 4.5 5.9 399 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC 0.6630 2.8 3.5 400 17 SURG *NO LONGER VALID 0.0000 0.0 0.0 401 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 2.8817 8.1 11.6 402 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC 1.1371 2.7 4.0 403 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W CC 1.8018 5.8 8.1 404 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC 0.8609 3.0 4.1 405 17 MED *ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 1.9038 4.9 4.9 406 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC 2.6845 6.9 9.7 407 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC 1.2347 3.2 4.1 408 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC 2.1935 4.8 8.3 409 17 MED RADIOTHERAPY 1.2333 4.6 6.2 410 17 MED CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 1.0780 3.2 4.1 411 17 MED *HISTORY OF MALIGNANCY W/O ENDOSCOPY 0.3906 4.7 4.7 412 17 MED HISTORY OF MALIGNANCY W ENDOSCOPY 0.5721 2.5 3.7 413 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC 1.3143 5.3 7.1 414 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC 0.7332 3.2 4.2 415 18 SURG O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES 3.5998 10.4 14.4 416 18 MED SEPTICEMIA AGE >17 1.5763 5.6 7.5 417 18 MED SEPTICEMIA AGE 0-17 0.9864 4.4 5.8 418 18 MED POSTOPERATIVE & POST-TRAUMATIC INFECTIONS 1.0605 4.9 6.3 419 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W CC 0.8404 3.6 4.6 420 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC 0.6052 2.8 3.4 421 18 MED VIRAL ILLNESS AGE >17 0.7395 3.1 4.1 422 18 MED VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 0.7271 2.5 3.7 423 18 MED OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES 1.8074 5.9 8.4 424 19 SURG O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS 2.3708 8.0 12.9 425 19 MED ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION 0.6723 2.8 3.8 426 19 MED DEPRESSIVE NEUROSES 0.5051 3.2 4.5 427 19 MED NEUROSES EXCEPT DEPRESSIVE 0.5029 3.1 4.4 428 19 MED DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.7222 4.5 7.1 429 19 MED ORGANIC DISTURBANCES & MENTAL RETARDATION 0.8235 4.5 6.1 430 19 MED PSYCHOSES 0.6750 5.6 7.9 431 19 MED CHILDHOOD MENTAL DISORDERS 0.6551 4.4 6.9 432 19 MED OTHER MENTAL DISORDER DIAGNOSES 0.6453 2.8 4.0 433 20 MED ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA 0.2876 2.2 3.1 434 20 MED NO LONGER VALID 0.0000 0.0 0.0 435 20 MED NO LONGER VALID 0.0000 0.0 0.0 436 20 MED NO LONGER VALID 0.0000 0.0 0.0 437 20 MED NO LONGER VALID 0.0000 0.0 0.0 438 20 NO LONGER VALID 0.0000 0.0 0.0 439 21 SURG SKIN GRAFTS FOR INJURIES 1.7409 5.1 8.1 440 21 SURG WOUND DEBRIDEMENTS FOR INJURIES 1.8767 5.8 9.1 441 21 SURG HAND PROCEDURES FOR INJURIES 0.9595 2.1 3.1 442 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W CC 2.4020 5.6 8.6 443 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W/O CC 0.9737 2.5 3.4 444 21 MED TRAUMATIC INJURY AGE >17 W CC 0.7414 3.2 4.2 445 21 MED TRAUMATIC INJURY AGE >17 W/O CC 0.4945 2.3 2.9 446 21 MED *TRAUMATIC INJURY AGE 0-17 0.2951 2.4 2.4 447 21 MED ALLERGIC REACTIONS AGE >17 0.5156 1.9 2.5 448 21 MED *ALLERGIC REACTIONS AGE 0-17 0.0971 2.9 2.9 449 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC 0.8275 2.6 3.7 450 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC 0.4224 1.6 2.0 451 21 MED *POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 0.2621 2.1 2.1 452 21 MED COMPLICATIONS OF TREATMENT W CC 1.0373 3.5 4.9 453 21 MED COMPLICATIONS OF TREATMENT W/O CC 0.5086 2.1 2.8 454 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC 0.8121 3.0 4.2 455 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC 0.4690 1.8 2.4 456 22 NO LONGER VALID 0.0000 0.0 0.0 457 22 MED NO LONGER VALID 0.0000 0.0 0.0 458 22 SURG NO LONGER VALID 0.0000 0.0 0.0 459 22 SURG NO LONGER VALID 0.0000 0.0 0.0 460 22 MED NO LONGER VALID 0.0000 0.0 0.0 461 23 SURG O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES 1.1855 2.1 3.6 462 23 MED REHABILITATION 1.0073 9.4 11.3 463 23 MED SIGNS & SYMPTOMS W CC 0.6795 3.1 4.1 464 23 MED SIGNS & SYMPTOMS W/O CC 0.4940 2.4 3.0 465 23 MED AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS 0.9078 2.0 4.0 466 23 MED AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS 0.7967 2.2 3.9 467 23 MED OTHER FACTORS INFLUENCING HEALTH STATUS 0.4916 1.9 3.0 468 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 3.7934 9.4 13.1 469 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE **DIAGNOSIS 0.0000 0.0 0.0 470 **UNGROUPABLE 0.0000 0.0 0.0 471 8 SURG BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY 3.0380 4.7 5.4 472 22 SURG NO LONGER VALID 0.0000 0.0 0.0 473 17 MED ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 3.4644 7.4 12.7 474 4 SURG NO LONGER VALID 0.0000 0.0 0.0 475 4 MED RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT 3.5767 8.0 11.3 476 SURG PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.2299 8.0 11.1 477 SURG NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.8593 5.4 8.2 478 5 SURG OTHER VASCULAR PROCEDURES W CC 2.3639 4.9 7.4 479 5 SURG OTHER VASCULAR PROCEDURES W/O CC 1.4223 2.4 3.2 480 PRE SURG LIVER TRANSPLANT 9.6510 14.0 21.1 481 PRE SURG BONE MARROW TRANSPLANT 5.9571 19.1 21.7 482 PRE SURG TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES 3.4598 9.6 12.5 483 PRE SURG TRAC W MECH VENT 96+HRS OR PDX EXCEPT FACE,MOUTH & NECK DX OSES 16.5997 34.1 41.3 484 24 SURG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 5.3969 9.9 14.7 485 24 SURG LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRA 3.1535 7.9 9.9 486 24 SURG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 4.8552 8.8 12.9 487 24 MED OTHER MULTIPLE SIGNIFICANT TRAUMA 1.9609 5.3 7.3 488 25 SURG HIV W EXTENSIVE O.R. PROCEDURE 4.7597 11.7 17.0 489 25 MED HIV W MAJOR RELATED CONDITION 1.8340 6.0 8.6 490 25 MED HIV W OR W/O OTHER RELATED CONDITION 1.0397 3.9 5.5 491 8 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY 1.7059 2.8 3.4 492 17 MED CHEMOTHERAPY W ACUTE LEUKEMIA OR W USE OF HIGH DOSE CHEMOAGENT 3.8083 9.3 14.9 493 7 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 1.8169 4.4 6.0 494 7 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC 0.9950 2.0 2.5 495 PRE SURG LUNG TRANSPLANT 8.3919 13.5 16.4 496 8 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 5.6730 6.8 8.9 497 8 SURG SPINAL FUSION EXCEPT CERVICAL W CC 3.3896 5.2 6.3 498 8 SURG SPINAL FUSION EXCEPT CERVICAL W/O CC 2.5213 3.6 4.0 499 8 SURG BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 1.4186 3.3 4.5 500 8 SURG BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC 0.9344 2.0 2.4 501 8 SURG KNEE PROCEDURES W PDX OF INFECTION W CC 2.6174 8.3 10.7 502 8 SURG KNEE PROCEDURES W PDX OF INFECTION W/O CC 1.4062 5.2 6.2 503 8 SURG KNEE PROCEDURES W/O PDX OF INFECTION 1.2152 3.0 3.9 504 22 SURG EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 11.8123 20.1 27.7 505 22 MED EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT 2.0106 2.3 5.7 506 22 SURG FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA 4.0998 12.1 16.9 507 22 SURG FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 1.8145 6.5 9.1 508 22 MED FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA 1.3754 5.7 8.0 509 22 MED FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA 0.6404 3.0 4.3 510 22 MED NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA 1.1762 4.6 6.8 511 22 MED NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA 0.6654 3.1 4.6 512 PRE SURG SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT 5.3384 11.1 13.1 513 PRE SURG PANCREAS TRANSPLANT 6.0851 8.5 9.8 514 5 SURG NO LONGER VALID 0.0000 0.0 0.0 515 5 SURG CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH 5.3127 3.0 5.2 516 5 SURG PERCUTANEOUS CARDIOVASC PROC W AMI 2.6723 3.7 4.7 517 5 SURG PERC CARDIO PROC W NON-DRUG ELUTING STENT W/O AMI 2.1245 1.8 2.6 518 5 SURG PERC CARDIO PROC W/O CORONARY ARTERY STENT OR AMI 1.8210 2.2 3.3 519 8 SURG CERVICAL SPINAL FUSION W CC 2.4228 3.2 5.1 520 8 SURG CERVICAL SPINAL FUSION W/O CC 1.5749 1.7 2.1 521 20 MED ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC 0.7054 4.3 5.8 522 20 MED ALC/DRUG ABUSE OR DEPEND W REHABILITATION THERAPY W/O CC 0.5151 7.7 9.6 523 20 MED ALC/DRUG ABUSE OR DEPEND W/O REHABILITATION THERAPY W/O CC 0.3929 3.3 4.1 524 1 MED TRANSIENT ISCHEMIA 0.7252 2.7 3.4 525 5 SURG HEART ASSIST SYSTEM IMPLANT 11.4482 9.0 17.6 526 5 SURG PERCUTNEOUS CARDIOVASULAR PROC W DRUG ELUTING STENT W AMI 2.9729 3.6 4.5 527 5 SURG PERCUTNEOUS CARDIOVASULAR PROC W DRUG ELUTING STENT W/O AMI 2.4342 1.8 2.6 528 1 SURG INTRACRANIAL VASCULAR PROC W PDX HEMORRHAGE 7.0434 14.1 17.2 529 1 SURG VENTRICULAR SHUNT PROCEDURES W CC 3.1094 6.6 10.6 530 1 SURG VENTRICULAR SHUNT PROCEDURES W/O CC 1.2664 2.9 3.9 531 1 SURG SPINAL PROCEDURES W CC 3.0474 6.8 10.0 532 1 SURG SPINAL PROCEDURES W/O CC 1.4487 2.9 4.0 533 1 SURG EXTRACRANIAL PROCEDURES W CC 1.6578 2.7 4.1 534 1 SURG EXTRACRANIAL PROCEDURES W/O CC 1.0689 1.6 2.0 535 5 SURG CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK 8.1344 8.1 11.0 536 5 SURG CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK 6.2536 3.9 5.8 537 8 SURG LOCAL EXCIS & REMOV OF INT FIX DEV EXCEPT HIP & FEMUR W CC 1.8090 4.7 7.0 538 8 SURG LOCAL EXCIS & REMOV OF INT FIX DEV EXCEPT HIP & FEMUR W/O CC 0.9874 2.1 2.9 539 17 SURG LYMPHOMA & LEUKEMIA W MAJOR OR PROCEDURE W CC 3.3744 7.5 11.2 540 17 SURG LYMPHOMA & LEUKEMIA W MAJOR OR PROCEDURE W/O CC 1.2851 2.9 4.1 *Medicare data have been supplemented by data from 19 States for low volume DRGs. **DRGs 469 and 470 contain cases that could not be assigned to valid DRGs. Table 6A.—New Diagnosis Codes Diagnosis code Description CC MDC DRG 255.10 Primary aldosteronism N 10 300, 301 255.11 Glucocorticoid-remediable aldosteronism N 10 300, 301 255.12 Conn's syndrome N 10 300, 301 255.13 Bartter's syndrome N 10 300, 301 255.14 Other secondary aldosteronism N 10 300, 301 277.81 Primary carnitine deficiency N 10 299 277.82 Carnitine deficiency due to inborn errors of metabolism N 10 299 277.83 Iatrogenic carnitine deficiency N 10 299 277.84 Other secondary carnitine deficiency N 10 299 277.89 Other specified disorders of metabolism N 10 299 282.41 Sickle-cell thalassemia without crisis Y 15 16 1 387, 1 389 395, 396 282.42 Sickle-cell thalassemia with crisis Y 15 16 1 387, 1 389 395, 396 282.49 Other thalassemia Y 15 16 1 387, 1 389 395, 396 282.64 Sickle-cell/Hb-C disease with crisis Y 16 395, 396 282.68 Other sickle-cell disease without crisis Y 16 395, 396 289.52 Splenic sequestration N 16 398, 399 289.81 Primary hypercoagulable state Y 16 398, 399 289.82 Secondary hypercoagulable state Y 16 398, 399 289.89 Other specified diseases of blood and blood-forming organs N 16 398, 399 331.11 Pick's disease N 1 12 331.19 Other frontotemporal dementia N 1 12 331.82 Dementia with Lewy bodies N 1 12 348.30 Encephalopathy, unspecified N 1 25 16, 17 2 489 348.31 Metabolic encephalopathy N 1 25 16, 17 2 489 348.39 Other encephalopathy N 1 25 16, 17 2 489 358.00 Myasthenia gravis without (acute) exacerbation Y 1 12 358.01 Myasthenia gravis with (acute) exacerbation Y 1 12 414.07 Coronary atherosclerosis, Of bypass graft (artery)
(vein)of transplanted heart N 5 132,133 458.21 Hypotension of hemodialysis N 5 141, 142 458.29 Other iatrogenic hypotension N 5 141,142 493.81 Exercise induced bronchospasm N 4 96, 97, 98 493.82 Cough variant asthma N 4 96, 97, 98 517.3 Acute chest syndrome N 4 92, 93 530.20 Ulcer of esophagus without bleeding N 6 176 530.21 Ulcer of esophagus with bleeding Y 6 176 530.85 Barrett's esophagus N 6 176 600.00 Hypertrophy (benign) of prostate without urinary obstruction N 12 348, 349 600.01 Hypertrophy (benign) of prostate with urinary obstruction N 12 348, 349 600.10 Nodular prostate without urinary obstruction N 12 348, 349 600.11 Nodular prostate with urinary obstruction N 12 348, 349 600.20 Benign localized hyperplasia of prostate without urinary obstruction N 12 348, 349 600.21 Benign localized hyperplasia of prostate with urinary obstruction N 12 348, 349 600.90 Hyperplasia of prostate, unspecified, without urinary obstruction N 12 348, 349 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction N 12 348, 349 607.85 Peyronie's disease N 12 352 674.50 Peripartum cardiomyopathy, unspecified as to episode of care or not applicable Y 14 469 674.51 Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition Y 14 370, 371, 372, 374, 375 674.52 Peripartum cardiomyopathy, delivered, with mention of postpartum condition Y 14 370, 371, 372, 374, 375 674.53 Peripartum cardiomyopathy, antepartum condition or complication Y 14 383, 384 674.54 Peripartum cardiomyopathy, postpartum condition or complication Y 14 376, 377 719.7 Difficulty in walking N 8 247 728.87 Muscle weakness N 8 247 728.88 Rhabdomyolysis Y 8 248 752.81 Scrotal transposition N 12 352 752.89 Other specified anomalies of genital organs N 12 352 766.21 Post-term infant N 15 391 766.22 Prolonged gestation of infant N 15 391 767.11 Epicranial subaponeurotic hemorrhage (massive) Y 15 389 767.19 Other injuries to scalp N 15 391 779.83 Delayed separation of umbilical cord N 15 391 780.93 Memory loss N 23 463, 464 780.94 Early satiety N 23 463, 464 781.94 Facial weakness N 1 34, 35 785.52 Septic shock Y 18 416, 417 788.63 Urgency of urination N 11 325, 326, 327 790.21 Impaired fasting glucose N 10 296, 297, 298 790.22 Impaired glucose tolerance test
(oral)N 10 296, 297, 298 790.29 Other abnormal glucose N 10 296, 297, 298 799.81 Decreased libido N 23 467 799.89 Other ill-defined conditions N 23 467 850.11 Concussion, with loss of consciousness of 30 minutes or less Y 1 24 31, 32, 33 487 850.12 Concussion, with loss of consciousness from 31 to 59 minutes Y 1 24 31, 32, 33 487 959.11 Other injury of chest wall N 21 24 444, 445, 446 487 959.12 Other injury of abdomen N 21 24 444, 445, 446 487 959.13 Fracture of corpus cavernosum penis N 21 24 444, 445, 446 487 959.14 Other injury of external genitals N 21 24 444, 445, 446 487 959.19 Other injury of other sites of trunk N 21 24 444, 445, 446 487 996.57 Complication, Due to insulin pump Y 21 452, 453 V04.81 Need for prophylactic vaccination and inoculation, Influenza N 23 467 V04.82 Need for prophylactic vaccination and inoculation, Respiratory synctial virus
(RSV)N 23 467 V04.89 Need for prophylactic vaccination and inoculation, Other viral diseases N 23 467 V15.87 History of Extracorporeal Membrance Oxygenation
(ECMO)N 23 467 V25.03 Encounter for emergency contraceptive counseling and prescription N 23 467 V43.21 Organ or tissue replaced by other means, Heart assist device Y 5 144, 145 V43.22 Organ or tissue replaced by other means, Fully implantable artificial heart Y 5 144, 145 V45.85 Insulin pump status N 23 467 V53.90 Fitting and adjustment, Unspecified device N 23 467 V53.91 Fitting and adjustment of insulin pump N 23 467 V53.99 Fitting and adjustment, Other device N 23 467 V54.01 Encounter for removal of internal fixation device N 8 249 V54.02 Encounter for lengthening/adjustment of growth rod N 8 249 V54.09 Other aftercare involving internal fixation device N 8 249 V58.63 Long-term (current) use of antiplatelet/antithrombotic N 23 465, 466 V58.64 Long-term (current) use of nonsteriodal anti-inflammatories N 23 465, 466 V58.65 Long-term (current) use of steroids N 23 465, 466 V64.41 Laparoscopic surgical procedure coverted to open procedure N 23 467 V64.42 Thoracoscopic surgical procedure converted to open procedure N 23 467 V64.43 Arthroscopic surgical procedure converted to open procedure N 23 467 V65.11 Pediatric pre-birth visit for expectant mother N 23 467 V65.19 Other person consulting on behalf of another person N 23 467 V65.46 Encounter for insulin pump training N 23 467 1 Classified as a Major Problem. 2 Classified as a Major Related Condition. Table 6B.—New Procedure Codes Procedure Code Description OR MDC DRG 00.15 High-dose infusion interleukin-2 (IL-2) N* 17 492 37.51 Heart transplantation Y PRE 103 37.52 Implantation of total replacement heart system Y 5 525 37.53 Replacement or repair of thoracic unit of total replacement heart system Y 5 525 37.54 Replacement or repair of other implantable component of total replacement heart system Y 5 525 68.31 Laparoscopic supracervical hysterectomy
(LSH)Y 13 354, 355,357, 358, 359 14 375 68.39 Other subtotal abdominal hysterectomy, NOS Y 13 354, 355, 357, 358, 359 14 375 81.62 Fusion or refusion of 2-3 vertebrae 1 N 81.63 Fusion or refusion of 4-8 vertebrae 1 N 81.64 Fusion or refusion of 9 or more vertebrae 1 N *Nonoperating room procedure, but affects DRG. 1 Nonoperating room procedure code. The DRG assignment is made based on the specific fusion or refusion (81.00-81.08, 81.30-81.39, 81.61). Table 6C.—Invalid Diagnosis Codes Diagnosis code Description CC MDC DRG 255.1 Hyperaldosteronism N 10 300, 301 277.8 Other specified disorders of metabolism N 10 299 282.4 Thalassemias Y 15 16 1 1381, 1 389 395, 396 289.8 Other specified diseases of blood and blood-forming organs N 16 398, 399 331.1 Pick's disease N 1 12 348.3 Encephalopathy, unspecified N 1 25 16, 17 2 489 358.0 Myasthenia gravis Y 1 12 458.2 Iatrogenic hypotension N 5 141, 142 530.2 Ulcer of esophagus N 6 176 600.0 Hypertrophy (benign) of prostate N 12 348, 349 600.1 Nodular prostate N 12 348, 349 600.2 Benign localized hyperplasia of prostate N 12 348, 349 600.9 Hyperplasia of prostate, unspecified N 12 348, 349 719.70 Difficulty in walking, site unspecified N 8 247 719.75 Difficulty in walking, pelvic region and thigh N 8 247 719.76 Difficulty in walking, lower leg N 8 247 719.77 Difficulty in walking, ankle and foot N 8 247 719.78 Difficulty in walking, other specified sites N 8 247 719.79 Difficulty in walking, multiple sites N 8 247 752.8 Other specified anomalies of genital organs N 12 13 352 358, 359, 369 766.2 Post term infant, not “heavy for dates” N 15 391 767.1 Injuries to scalp N 15 391 790.2 Abnormal glucose tolerance test N 10 296, 297, 298 799.8 Other ill-defined conditions N 23 467 850.1 Concussion, with brief loss of consciousness Y 1 24 31, 32, 33 487 959.1 Injury, trunk N 21 24 444, 445, 446 487 V04.8 Need for prophylactic vaccination and inoculation against certain viral disease, Influenza N 23 467 V43.2 Organ or tissue replaced by other means, Heart Y 5 144, 145 V53.9 Fitting and adjustment of other device, Other and unspecified device N 23 467 V54.0 Aftercare involving removal of fracture plate or other internal fixation device N 8 249 V64.4 Laparoscopic surgical procedure converted to open procedure N 23 467 V65.1 Person consulting on behalf of another person N 23 467 1 Classified as a “Major Problem.” 2 Classified as a “Major Related Condition.” TABLE 6D.—Invalid Procedure Codes Procedure code Description OR MDC DRG 37.5 Heart transplantation Y PRE 103 68.3 Subtotal abdominal hysterectomy Y 13 354, 355, 357, 358, 359 14 375 Table 6E.—Revised Diagnosis Code Titles Diagnosis code Description CC MDC DRG 282.60 Sickle-cell disease, unspecified Y 16 395, 396 282.61 Hb-SS disease without crisis Y 16 395, 396 282.62 Hb-SS disease with crisis Y 16 395, 396 282.63 Sickle-cell/Hb-C disease without crisis Y 16 395, 396 282.69 Other sickle-cell disease with crisis Y 16 395, 396 414.06 Of native coronary artery of transplanted heart N 5 132, 133 491.20 Obstructive chronic bronchitis, without exacerbation Y 4 88 491.21 Obstructive chronic bronchitis, with (acute) exacerbation Y 4 88 493.00 Extrinsic asthma, unspecified N 4 96, 97, 98 493.02 Extrinsic asthma, with (acute) exacerbation Y 4 96, 97, 98 493.10 Intrinsic asthma, unspecified N 4 96, 97, 98 493.12 Intrinsic asthma, with (acute) exacerbation Y 4 96, 97, 98 493.20 Chronic obstructive asthma, unspecified Y 4 88 493.22 Chronic obstructive asthma, with (acute) exacerbation Y 4 88 493.90 Asthma, unspecified, unspecified N 4 96, 97, 98 493.92 Asthma, unspecified, with (acute) exacerbation Y 4 96, 97, 98 V06.1 Diphtheria-tetanus-pertussis, combined [DTP] [DtaP] N 23 467 V06.5 Tetanus-diphtheria [Td][DT] N 23 467 Table 6F.—Revised Procedure Code Titles Procedure code Description OR MDC DRG 37.33 Excision or destruction of other lesion or tissue of heart, open approach Y 5 108 37.34 Excision or destruction of other lesion or tissue of heart, other approach Y 5 516, 517, 518 39.79 Other endovascular repair (of aneurysm) of other vessels Y 1 5 11 21 24 1, 2, 3 110, 111 315 442, 443 486 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.] *25060 *2800 28242 2848 28262 28249 28268 2860 35800 28241 28249 2849 28263 28264 *28522 2861 35801 28242 28264 2850 28264 28268 28241 2862 *25061 28249 28268 2851 28268 *28310 28242 2863 35800 28264 *2821 *28249 28269 28241 28249 2864 35801 28268 28241 2800 2830 28242 28264 2865 *25062 *2801 28242 2814 28310 28249 28268 2866 35800 28241 28249 2818 28311 28264 *28529 2867 35801 28242 28264 28241 28319 28268 28241 2869 *25063 28249 28268 28242 2832 *28311 28242 2870 35800 28264 *2822 28249 2839 28241 28249 2871 35801 28268 28241 28260 2840 28242 28264 2872 *25080 *2808 28242 28261 2848 28249 28268 2873 35800 28241 28249 28262 2849 28264 *2858 2874 35801 28242 28264 28263 2850 28268 28241 2875 *25081 28249 28268 28264 2851 *28319 28242 2878 35800 28264 *2823 28268 *28268 28241 28249 2879 35801 28268 28241 28269 2800 28242 28264 2880 *25082 *2809 28242 2830 2814 28249 28268 2881 35800 28241 28249 28310 2818 28264 *2859 28981 35801 28242 28264 28311 28241 28268 28241 28982 *25083 28249 28268 28319 28242 *2832 28242 *28982 35800 28264 *28241 2832 28249 28241 28249 2800 35801 28268 2800 2839 28260 28242 28264 2814 *25090 *2810 2814 2840 28261 28249 28268 2818 35800 28241 2818 2848 28262 28264 *2880 28241 35801 28242 28241 2849 28263 28268 28981 28242 *25091 28249 28242 2850 28264 *2839 28982 28249 35800 28264 28249 2851 28268 28241 *2881 28260 35801 28268 28260 *2825 28269 28242 28981 28261 *25092 *2811 28261 28241 2830 28249 28982 28262 35800 28241 28262 28242 28310 28264 *2882 28263 35801 28242 28263 28249 28311 28268 28981 28264 *25093 28249 28264 28264 28319 *2840 28982 28268 35800 28264 28268 28268 2832 28241 *2883 28269 35801 28268 28269 *28260 2839 28242 28981 2830 *2515 *2812 2830 28241 2840 28249 28982 28310 53021 28241 28310 28242 2848 28264 *2888 28311 *25510 28242 28311 28249 2849 28268 28981 28319 2550 28249 28319 28264 2850 *2848 28982 2832 2580 28264 2832 28268 2851 28241 *2889 2839 2581 28268 2839 *28261 *28269 28242 28981 2840 2588 *2813 2840 28241 28241 28249 28982 2848 2589 28241 2848 28242 28242 28264 *28981 2849 *25511 28242 2849 28249 28249 28268 2800 2850 2550 28249 2850 28264 28264 *2849 2814 2851 2580 28264 2851 28268 28268 28241 2818 2860 2581 28268 *28242 *28262 *2827 28242 28241 2861 2588 *2814 2800 28241 28241 28249 28242 2862 2589 28241 2814 28242 28242 28264 28249 2863 *25512 28242 2818 28249 28249 28268 28260 2864 2550 28249 28241 28264 28264 *2850 28261 2865 2580 28264 28242 28268 28268 28241 28262 2866 2581 28268 28249 *28263 *2828 28242 28263 2867 2588 *2818 28260 28241 28241 28249 28264 2869 2589 28241 28261 28242 28242 28264 28268 2870 *25513 28242 28262 28249 28249 28268 28269 2871 2550 28249 28263 28264 28264 *2851 2830 2872 2580 28264 28264 28268 28268 28241 28310 2873 2581 28268 28268 *28264 *2829 28242 28311 2874 2588 *2819 28269 2800 28241 28249 28319 2875 2589 28241 2830 2814 28242 28264 2832 2878 *25514 28242 28310 2818 28249 28268 2839 2879 2550 28249 28311 28241 28264 *28521 2840 2880 2580 28264 28319 28242 28268 28241 2848 2881 2581 28268 2832 28249 *2830 28242 2849 28981 2588 *2820 2839 28260 28241 28249 2850 28982 2589 28241 2840 28261 28242 28264 2851 *28989 2800 35801 53201 53121 5789 53531 53021 *53451 2814 3581 53210 53131 *5307 53541 *53251 53021 2818 *3581 53211 53140 53021 53551 53021 *53460 28241 35800 53220 53141 *53082 53561 *53260 53021 28242 35801 53221 53150 53021 53783 53021 *53461 28249 *4560 53231 53151 *53085 53784 *53261 53021 28260 53021 53240 53160 4560 56202 53021 *53470 28261 *49381 53241 53161 53021 56203 *53270 53021 28262 49301 53250 53171 5307 56212 53021 *53471 28263 49302 53251 53191 53082 56213 *53271 53021 28264 49311 53260 53200 53100 5693 53021 *53490 28268 49312 53261 53201 53101 56985 *53290 53021 28269 49320 53271 53210 53110 56986 53021 *53491 2830 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80603 9529 80669 80614 80510 85011 85012 *85416 80604 *95912 80670 80615 80511 85012 *85306 85011 80605 80500 80671 80616 80512 *85236 85011 85012 80606 80501 80672 80617 80513 85011 85012 *85419 80607 80502 80679 80618 80514 85012 *85309 85011 80608 80503 8068 80619 80515 *85239 85011 85012 80609 80504 8069 80620 80516 85011 85012 *8738 80610 80505 95200 80621 80517 85012 *85310 85011 80611 80506 95201 80622 80518 *85240 85011 85012 80612 80507 95202 80623 8052 85011 85012 *8739 80613 80508 95203 80624 8053 85012 *85311 85011 80614 80510 95204 80625 8054 *85241 85011 85012 80615 80511 95205 80626 8055 85011 85012 *8798 80616 80512 95206 80627 8056 85012 *85312 85011 80617 80513 95207 80628 8057 *85242 85011 85012 80618 80514 95208 80629 8058 85011 85012 *8799 80619 80515 95209 80630 8059 85012 *85313 85011 80620 80516 95210 80631 80600 *85243 85011 85012 80621 80517 95211 80632 80601 85011 85012 *9050 80622 80518 95212 80633 80602 85012 *85314 85011 80623 8052 95213 80634 80603 *85244 85011 85012 80624 8053 95214 80635 80604 85011 85012 *9251 80625 8054 95215 80636 80605 85012 *85315 85011 80626 8055 95216 80637 80606 *85245 85011 85012 80627 8056 95217 80638 80607 85011 85012 *9252 80628 8057 95218 80639 80608 85012 *85316 85011 80629 8058 95219 8064 80609 *85246 85011 85012 80630 8059 9522 8065 80610 85011 85012 *9290 80631 80600 9523 80660 80611 85012 *85319 85011 80632 80601 9524 80661 80612 *85249 85011 85012 80633 80602 9528 80662 80613 85011 85012 *9299 80634 80603 9529 80669 80614 85012 *85400 85011 80635 80604 *95913 80670 80615 *85250 85011 85012 80636 80605 80500 80671 80616 85011 85012 *9588 80637 80606 80501 80672 80617 85012 *85401 85011 80638 80607 80502 80679 80618 *85251 85011 85012 80639 80608 80503 8068 80619 85011 85012 *95901 8064 80609 80504 8069 80620 85012 *85402 85011 8065 80610 80505 95200 80621 *85252 85011 85012 80660 80611 80506 95201 80622 85011 85012 *95909 80661 80612 80507 95202 80623 85012 *85403 85011 80662 80613 80508 95203 80624 *85253 85011 85012 80669 80614 80510 95204 80625 85011 85012 *95911 80670 80615 80511 95205 80626 85012 *85404 80500 80671 80616 80512 95206 80627 *85254 85011 80501 80672 80617 80513 95207 80628 85011 85012 80502 80679 80618 80514 95208 80629 85012 *85405 80503 8068 80619 80515 95209 80630 *85255 85011 80504 8069 80620 80516 95210 80631 85011 85012 80505 95200 80621 80517 95211 80632 85012 *85406 80506 95201 80622 80518 95212 80633 *85256 85011 80507 95202 80623 8052 95213 80634 85011 85012 80508 95203 80624 8053 95214 80635 85012 *85409 80510 95204 80625 8054 95215 80636 *85259 85011 80511 95205 80626 8055 95216 80637 85011 85012 80512 95206 80627 8056 95217 80638 85012 *85410 80513 95207 80628 8057 95218 80639 *85300 85011 80514 95208 80629 8058 95219 8064 85011 85012 80515 95209 80630 8059 9522 8065 85012 *85411 80516 95210 80631 80600 9523 80660 *85301 85011 80517 95211 80632 80601 9524 80661 85011 85012 80518 95212 80633 80602 9528 80662 5012 *85412 8052 95213 80634 80603 9529 80669 *85302 85011 8053 95214 80635 80604 *95914 80670 85011 85012 8054 95215 80636 80605 80500 80671 85012 *85413 8055 95216 80637 80606 80501 80672 *85303 85011 8056 95217 80638 80607 80502 80679 85011 85012 8057 95218 80639 80608 80503 8068 8069 80620 *99609 *99671 95200 80621 99657 99657 95201 80622 *9961 *99672 95202 80623 99657 99657 95203 80624 *9962 *99673 95204 80625 99657 99657 95205 80626 *99630 *99674 95206 80627 99657 99657 95207 80628 *99639 *99675 95208 80629 99657 99657 95209 80630 *9964 *99676 95210 80631 99657 99657 95211 80632 *99651 *99677 95212 80633 99657 99657 95213 80634 *99652 *99678 95214 80635 99657 99657 95215 80636 *99653 *99679 95216 80637 99657 99657 95217 80638 *99654 *99680 95218 80639 99657 V4321 95219 8064 *99655 V4322 9522 8065 99657 *99683 9523 80660 *99656 V4321 9524 80661 99657 V4322 9528 80662 *99657 *99687 9529 80669 99655 V4321 *95919 80670 99656 V4322 80500 80671 99657 *99791 80501 80672 99659 99657 80502 80679 99660 *99799 80503 8068 99661 99657 80504 8069 99662 *99881 80505 95200 99663 99657 80506 95201 99664 *99883 80507 95202 99665 99657 80508 95203 99666 *99889 80510 95204 99667 99657 80511 95205 99668 *9989 80512 95206 99669 99657 80513 95207 99670 *V421 80514 95208 99671 V4321 80515 95209 99672 V4322 80516 95210 99673 *V4321 80517 95211 99674 V4321 80518 95212 99675 V4322 8052 95213 99676 *V4322 8053 95214 99677 V4321 8054 95215 99678 V4322 8055 95216 99679 8056 95217 *99659 8057 95218 99657 8058 95219 *99660 8059 9522 99657 80600 9523 *99661 80601 9524 99657 80602 9528 *99662 80603 9529 99657 80604 *9598 *99663 80605 85011 99657 80606 85012 *99664 80607 *9599 99657 80608 85011 *99665 80609 85012 99657 80610 *99600 *99666 80611 99657 99657 80612 *99601 *99667 80613 99657 99657 80614 *99602 *99668 80615 99657 99657 80616 *99603 *99669 80617 99657 99657 80618 *99604 *99670 80619 99657 99657 Table 6H.—Deletions From 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.] *25060 28263 28260 53201 6013 71169 6960 8501 3580 28269 28261 53210 6021 7141 71100 *80005 *25061 2830 28262 53211 78820 7142 71101 8501 3580 28310 28263 53220 78829 71430 71102 *80006 *25062 28311 28269 53221 *6001 71431 71103 8501 3580 28319 2830 53231 5960 71432 71104 *80009 *25063 2832 28310 53240 5996 71433 71105 8501 3580 2839 28311 53241 6010 *71976 71106 *80010 *25080 2840 28319 53250 6012 6960 71107 8501 3580 2848 2832 53251 6013 71100 71108 *80011 *25081 2849 2839 53260 6021 71106 71109 8501 3580 2850 2840 53261 78820 71108 71160 *80012 *25082 2851 2848 53271 78829 71109 71161 8501 3580 *2825 2849 53291 *6002 71160 71162 *80013 *25083 2824 2850 53300 5960 71166 71163 8501 3580 *28260 2851 53301 5996 71168 71164 *80014 *25090 2824 2860 53310 6010 71169 71165 8501 3580 *28261 2861 53311 6012 7141 71166 *80015 *25091 2824 2862 53320 6013 7142 71167 8501 3580 *28262 2863 53321 6021 71430 71168 *80016 *25092 2824 2864 53331 78820 71431 71169 8501 3580 *28263 2865 53340 78829 71432 7141 *80019 *25093 2824 2866 53341 *6009 71433 7142 8501 3580 *28269 2867 53350 5960 *71977 71430 *80020 *2551 2824 2869 53351 5996 6960 71431 8501 2550 *2827 2870 53360 6010 71100 71432 *80021 2580 2824 2871 53361 6012 71107 71433 8501 2581 *2828 2872 53371 6013 71108 *7528 *80022 2588 2824 2873 53391 6021 71109 5970 8501 2589 *2829 2874 53400 78820 71160 5994 *80023 *2800 2824 2875 53401 78829 71167 6140 8501 2824 *2830 2878 53410 *71970 71168 6143 *80024 *2801 2824 2879 53411 6960 71169 6145 8501 2824 *28310 2880 53420 71100 7141 6150 *80025 *2808 2824 2881 53421 71101 7142 6163 8501 2824 *28311 *2899 53431 71102 71430 6164 *80026 *2809 2824 2824 53440 71103 71431 6207 8501 2824 *28319 *3483 53441 71104 71432 *7998 *80029 *2810 2824 34982 53450 71105 71433 04082 8501 2824 *2832 *34989 53451 71106 *71978 44024 *80030 *2811 2824 3580 53460 71107 6960 78001 8501 2824 *2839 *3499 53461 71108 71100 78003 *80031 *2812 2824 3580 53471 71109 71101 7801 8501 2824 *2840 *3580 53491 71160 71102 78031 *80032 *2813 2824 3580 53501 71161 71103 78039 8501 2824 *2848 3581 53511 71162 71104 7817 *80033 *2814 2824 *3581 53521 71163 71105 7854 8501 2824 *2849 3580 53531 71164 71106 78550 *80034 *2818 2824 *5302 53541 71165 71107 78551 8501 2824 *2850 4560 53551 71166 71108 78559 *80035 *2819 2824 5307 53561 71167 71109 7863 8501 2824 *2851 53082 53783 71168 71160 78820 *80036 *2820 2824 53100 53784 71169 71161 78829 8501 2824 *28521 53101 56202 7141 71162 7895 *80039 *2821 2824 53110 56203 7142 71163 7907 8501 2824 *28522 53111 56212 71430 71164 7911 *80040 *2822 2824 53120 56213 71431 71165 7913 8501 2824 *28529 53121 5693 71432 71166 7991 *80041 *2823 2824 53131 56985 71433 71167 7994 8501 2824 *2858 53140 56986 *71975 71168 *80000 *80042 *2824 2824 53141 5780 6960 71169 8501 8501 2800 *2859 53150 5781 71100 7141 *80001 *80043 2814 2824 53151 5789 71105 7142 8501 8501 2818 *2898 53160 *6000 71108 71430 *80002 *80044 2824 2800 53161 5960 71109 71431 8501 8501 28260 2814 53171 5996 71160 71432 *80003 *80045 28261 2818 53191 6010 71165 71433 8501 8501 28262 2824 53200 6012 71168 *71979 *80004 *80046 8501 *80093 8501 *80184 8501 *80375 8501 *80466 *80049 8501 *80140 8501 *80331 8501 *80422 8501 8501 *80094 8501 *80185 8501 *80376 8501 *80469 *80050 8501 *80141 8501 *80332 8501 *80423 8501 8501 *80095 8501 *80186 8501 *80379 8501 *80470 *80051 8501 *80142 8501 *80333 8501 *80424 8501 8501 *80096 8501 *80189 8501 *80380 8501 *80471 *80052 8501 *80143 8501 *80334 8501 *80425 8501 8501 *80099 8501 *80190 8501 *80381 8501 *80472 *80053 8501 *80144 8501 *80335 8501 *80426 8501 8501 *80100 8501 *80191 8501 *80382 8501 *80473 *80054 8501 *80145 8501 *80336 8501 *80429 8501 8501 *80101 8501 *80192 8501 *80383 8501 *80474 *80055 8501 *80146 8501 *80339 8501 *80430 8501 8501 *80102 8501 *80193 8501 *80384 8501 *80475 *80056 8501 *80149 8501 *80340 8501 *80431 8501 8501 *80103 8501 *80194 8501 *80385 8501 *80476 *80059 8501 *80150 8501 *80341 8501 *80432 8501 8501 *80104 8501 *80195 8501 *80386 8501 *80479 *80060 8501 *80151 8501 *80342 8501 *80433 8501 8501 *80105 8501 *80196 8501 *80389 8501 *80480 *80061 8501 *80152 8501 *80343 8501 *80434 8501 8501 *80106 8501 *80199 8501 *80390 8501 *80481 *80062 8501 *80153 8501 *80344 8501 *80435 8501 8501 *80109 8501 *80300 8501 *80391 8501 *80482 *80063 8501 *80154 8501 *80345 8501 *80436 8501 8501 *80110 8501 *80301 8501 *80392 8501 *80483 *80064 8501 *80155 8501 *80346 8501 *80439 8501 8501 *80111 8501 *80302 8501 *80393 8501 *80484 *80065 8501 *80156 8501 *80349 8501 *80440 8501 8501 *80112 8501 *80303 8501 *80394 8501 *80485 *80066 8501 *80159 8501 *80350 8501 *80441 8501 8501 *80113 8501 *80304 8501 *80395 8501 *80486 *80069 8501 *80160 8501 *80351 8501 *80442 8501 8501 *80114 8501 *80305 8501 *80396 8501 *80489 *80070 8501 *80161 8501 *80352 8501 *80443 8501 8501 *80115 8501 *80306 8501 *80399 8501 *80490 *80071 8501 *80162 8501 *80353 8501 *80444 8501 8501 *80116 8501 *80309 8501 *80400 8501 *80491 *80072 8501 *80163 8501 *80354 8501 *80445 8501 8501 *80119 8501 *80310 8501 *80401 8501 *80492 *80073 8501 *80164 8501 *80355 8501 *80446 8501 8501 *80120 8501 *80311 8501 *80402 8501 *80493 *80074 8501 *80165 8501 *80356 8501 *80449 8501 8501 *80121 8501 *80312 8501 *80403 8501 *80494 *80075 8501 *80166 8501 *80359 8501 *80450 8501 8501 *80122 8501 *80313 8501 *80404 8501 *80495 *80076 8501 *80169 8501 *80360 8501 *80451 8501 8501 *80123 8501 *80314 8501 *80405 8501 *80496 *80079 8501 *80170 8501 *80361 8501 *80452 8501 8501 *80124 8501 *80315 8501 *80406 8501 *80499 *80080 8501 *80171 8501 *80362 8501 *80453 8501 8501 *80125 8501 *80316 8501 *80409 8501 *8500 *80081 8501 *80172 8501 *80363 8501 *80454 8501 8501 *80126 8501 *80319 8501 *80410 8501 *8501 *80082 8501 *80173 8501 *80364 8501 *80455 430 8501 *80129 8501 *80320 8501 *80411 8501 431 *80083 8501 *80174 8501 *80365 8501 *80456 4320 8501 *80130 8501 *80321 8501 *80412 8501 4321 *80084 8501 *80175 8501 *80366 8501 *80459 436 8501 *80131 8501 *80322 8501 *80413 8501 78001 *80085 8501 *80176 8501 *80369 8501 *80460 78003 8501 *80132 8501 *80323 8501 *80414 8501 80000 *80086 8501 *80179 8501 *80370 8501 *80461 80001 8501 *80133 8501 *80324 8501 *80415 8501 80002 *80089 8501 *80180 8501 *80371 8501 *80462 80003 8501 *80134 8501 *80325 8501 *80416 8501 80004 *80090 8501 *80181 8501 *80372 8501 *80463 80005 8501 *80135 8501 *80326 8501 *80419 8501 80006 *80091 8501 *80182 8501 *80373 8501 *80464 80009 8501 *80136 8501 *80329 8501 *80420 8501 80010 *80092 8501 *80183 8501 *80374 8501 *80465 80011 8501 *80139 8501 *80330 8501 *80421 8501 80012 80013 80104 80195 80353 80444 85126 85219 *8509 80014 80105 80196 80354 80445 85129 85220 8501 80015 80106 80199 80355 80446 85130 85221 *85100 80016 80109 8021 80356 80449 85131 85222 8501 80019 80110 80220 80359 80450 85132 85223 *85101 80020 80111 80221 80360 80451 85133 85224 8501 80021 80112 80222 80361 80452 85134 85225 *85102 80022 80113 80223 80362 80453 85135 85226 8501 80023 80114 80224 80363 80454 85136 85229 *85103 80024 80115 80225 80364 80455 85139 85230 8501 80025 80116 80226 80365 80456 85140 85231 *85104 80026 80119 80227 80366 80459 85141 85232 8501 80029 80120 80228 80369 80460 85142 85233 *85105 80030 80121 80229 80370 80461 85143 85234 8501 80031 80122 80230 80371 80462 85144 85235 *85106 80032 80123 80231 80372 80463 85145 85236 8501 80033 80124 80232 80373 80464 85146 85239 *85109 80034 80125 80233 80374 80465 85149 85240 8501 80035 80126 80234 80375 80466 85150 85241 *85110 80036 80129 80235 80376 80469 85151 85242 8501 80039 80130 80236 80379 80470 85152 85243 *85111 80040 80131 80237 80380 80471 85153 85244 8501 80041 80132 80238 80381 80472 85154 85245 *85112 80042 80133 80239 80382 80473 85155 85246 8501 80043 80134 8024 80383 80474 85156 85249 *85113 80044 80135 8025 80384 80475 85159 85250 8501 80045 80136 8026 80385 80476 85160 85251 *85114 80046 80139 8027 80386 80479 85161 85252 8501 80049 80140 8028 80389 80480 85162 85253 *85115 80050 80141 8029 80390 80481 85163 85254 8501 80051 80142 80300 80391 80482 85164 85255 *85116 80052 80143 80301 80392 80483 85165 85256 8501 80053 80144 80302 80393 80484 85166 85259 *85119 80054 80145 80303 80394 80485 85169 85300 8501 80055 80146 80304 80395 80486 85170 85301 *85120 80056 80149 80305 80396 80489 85171 85302 8501 80059 80150 80306 80399 80490 85172 85303 *85121 80060 80151 80309 80400 80491 85173 85304 8501 80061 80152 80310 80401 80492 85174 85305 *85122 80062 80153 80311 80402 80493 85175 85306 8501 80063 80154 80312 80403 80494 85176 85309 *85123 80064 80155 80313 80404 80495 85179 85310 8501 80065 80156 80314 80405 80496 85180 85311 *85124 80066 80159 80315 80406 80499 85181 85312 8501 80069 80160 80316 80409 8500 85182 85313 *85125 80070 80161 80319 80410 8501 85183 85314 8501 80071 80162 80320 80411 8502 85184 85315 *85126 80072 80163 80321 80412 8503 85185 85316 8501 80073 80164 80322 80413 8504 85186 85319 *85129 80074 80165 80323 80414 8505 85189 85400 8501 80075 80166 80324 80415 8509 85190 85401 *85130 80076 80169 80325 80416 85100 85191 85402 8501 80079 80170 80326 80419 85101 85192 85403 *85131 80080 80171 80329 80420 85102 85193 85404 8501 80081 80172 80330 80421 85103 85194 85405 *85132 80082 80173 80331 80422 85104 85195 85406 8501 80083 80174 80332 80423 85105 85196 85409 *85133 80084 80175 80333 80424 85106 85199 85410 8501 80085 80176 80334 80425 85109 85200 85411 *85134 80086 80179 80335 80426 85110 85201 85412 8501 80089 80180 80336 80429 85111 85202 85413 *85135 80090 80181 80339 80430 85112 85203 85414 8501 80091 80182 80340 80431 85113 85204 85415 *85136 80092 80183 80341 80432 85114 85205 85416 8501 80093 80184 80342 80433 85115 85206 85419 *85139 80094 80185 80343 80434 85116 85209 *8502 8501 80095 80186 80344 80435 85119 85210 8501 *85140 80096 80189 80345 80436 85120 85211 *8503 8501 80099 80190 80346 80439 85121 85212 8501 *85141 80100 80191 80349 80440 85122 85213 *8504 8501 80101 80192 80350 80441 85123 85214 8501 *85142 80102 80193 80351 80442 85124 85215 *8505 8501 80103 80194 80352 80443 85125 85216 8501 *85143 8501 *85190 8501 *85402 8054 95215 *85144 8501 *85236 8501 8055 95216 8501 *85191 8501 *85403 8056 95217 *85145 8501 *85239 8501 8057 95218 8501 *85192 8501 *85404 8058 95219 *85146 8501 *85240 8501 8059 9522 8501 *85193 8501 *85405 80600 9523 *85149 8501 *85241 8501 80601 9524 8501 *85194 8501 *85406 80602 9528 *85150 8501 *85242 8501 80603 9529 8501 *85195 8501 *85409 80604 *9598 *85151 8501 *85243 8501 80605 8501 8501 *85196 8501 *85410 80606 *9599 *85152 8501 *85244 8501 80607 8501 8501 *85199 8501 *85411 80608 *99680 *85153 8501 *85245 8501 80609 V432 8501 *85200 8501 *85412 80610 *99683 *85154 8501 *85246 8501 80611 V432 8501 *85201 8501 *85413 80612 *99687 *85155 8501 *85249 8501 80613 V432 8501 *85202 8501 *85414 80614 *V421 *85156 8501 *85250 8501 80615 V432 8501 *85203 8501 *85415 80616 *V432 *85159 8501 *85251 8501 80617 V432 8501 *85204 8501 *85416 80618 *85160 8501 *85252 8501 80619 8501 *85205 8501 *85419 80620 *85161 8501 *85253 8501 80621 8501 *85206 8501 *8738 80622 *85162 8501 *85254 8501 80623 8501 *85209 8501 *8739 80624 *85163 8501 *85255 8501 80625 8501 *85210 8501 *8798 80626 *85164 8501 *85256 8501 80627 8501 *85211 8501 *8799 80628 *85165 8501 *85259 8501 80629 8501 *85212 8501 *9050 80630 *85166 8501 *85300 8501 80631 8501 *85213 8501 *9251 80632 *85169 8501 *85301 8501 80633 8501 *85214 8501 *9252 80634 *85170 8501 *85302 8501 80635 8501 *85215 8501 *9290 80636 *85171 8501 *85303 8501 80637 8501 *85216 8501 *9299 80638 *85172 8501 *85304 8501 80639 8501 *85219 8501 *9588 8064 *85173 8501 *85305 8501 8065 8501 *85221 8501 *95901 80660 *85174 8501 *85306 8501 80661 8501 *85222 8501 *95909 80662 *85175 8501 *85309 8501 80669 8501 *85223 8501 *9591 80670 *85176 8501 *85310 80500 80671 8501 *85224 8501 80501 80672 *85179 8501 *85311 80502 80679 8501 *85225 8501 80503 8068 *85180 8501 *85312 80504 8069 8501 *85226 8501 80505 95200 *85181 8501 *85313 80506 95201 8501 *85229 8501 80507 95202 *85182 8501 *85314 80508 95203 8501 *85230 8501 80510 95204 *85183 8501 *85315 80511 95205 8501 *85231 8501 80512 95206 *85184 8501 *85316 80513 95207 8501 *85232 8501 80514 95208 *85185 8501 *85319 80515 95209 8501 *85233 8501 80516 95210 *85186 8501 *85400 80517 95211 8501 *85234 8501 80518 95212 *85189 8501 *85401 8052 95213 8501 *85235 8501 8053 95214 Table 7A.—Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2002 MEDPAR Update December 2002 Grouper V20.0] DRG Number of discharges Arithmetic mean length of stay 10th Percentile 25th Percentile 50th Percentile 75th Percentile 90th Percentile 1 29,262 10.8505 3 5 8 14 22 2 14,769 5.0718 1 2 4 7 10 3 3 6.0000 1 1 4 13 13 4 6,712 7.3524 1 2 5 9 16 5 95,618 2.9596 1 1 2 3 7 6 356 3.0197 1 1 2 4 7 7 14,683 9.8438 2 4 7 12 20 8 4,106 2.8015 1 1 1 3 7 9 1,711 6.2402 1 3 5 8 12 10 18,655 6.3850 2 3 5 8 13 11 3,291 4.0413 1 2 3 5 8 12 52,512 5.7513 2 3 4 7 11 13 7,068 5.0035 2 3 4 6 9 14 237,027 5.9456 2 3 5 7 11 15 94,223 4.8529 2 3 4 6 9 16 9,938 6.3106 2 3 5 8 12 17 2,744 3.2172 1 2 2 4 6 18 29,701 5.4868 2 3 4 7 10 19 8,519 3.5184 1 2 3 5 7 20 6,207 10.1927 3 5 8 13 20 21 1,885 6.5963 2 3 5 9 13 22 2,785 5.1178 2 2 4 6 10 23 12,583 4.1677 1 2 3 5 8 24 59,102 4.8803 1 2 4 6 10 25 27,433 3.1776 1 2 3 4 6 26 18 4.2778 1 1 2 3 4 27 4,398 5.1719 1 1 3 7 11 28 13,919 6.0265 1 3 5 8 12 29 5,282 3.4924 1 2 3 5 7 30 2 6.5000 2 2 11 11 11 31 3,897 4.0429 1 2 3 5 8 32 1,895 2.4776 1 1 2 3 5 34 23,811 4.9368 1 2 4 6 9 35 7,451 3.1094 1 1 3 4 6 36 2,117 1.5328 1 1 1 1 2 37 1,382 3.7685 1 1 2 5 8 38 ,97 2.8041 1 1 1 4 5 39 559 2.1163 1 1 1 2 4 40 1,549 3.8070 1 1 3 5 7 42 1,581 2.7381 1 1 1 3 6 43 94 3.3936 1 1 3 4 6 44 1,227 4.9935 2 3 4 6 9 45 2,668 3.1267 1 2 3 4 6 46 3,482 4.4730 1 2 3 6 8 47 1,402 3.0927 1 1 2 4 6 49 2,391 4.4676 1 2 3 6 9 50 2,429 1.8506 1 1 1 2 3 51 243 2.8354 1 1 1 3 8 52 223 1.8161 1 1 1 2 3 53 2,478 3.6186 1 1 2 4 8 55 1,481 2.9338 1 1 1 3 7 56 469 2.8955 1 1 1 3 6 57 711 3.6709 1 1 2 4 8 58 1 2.0000 2 2 2 2 2 59 116 2.6724 1 1 1 3 6 60 1 3.0000 3 3 3 3 3 61 254 5.1535 1 1 3 7 11 62 2 7.0000 1 1 13 13 13 63 3,000 4.3860 1 2 3 5 9 64 3,126 6.4997 1 2 4 8 14 65 40,407 2.8127 1 1 2 4 5 66 7,841 3.0778 1 1 2 4 6 67 385 3.6442 1 2 3 5 7 68 11,658 3.8813 1 2 3 5 7 69 3,769 3.0186 1 2 3 4 5 70 30 2.3333 1 1 2 3 4 71 80 3.4000 1 1 2 4 6 72 964 3.4035 1 1 3 4 6 73 7,697 4.4433 1 2 3 6 9 75 43,504 9.9907 3 5 7 12 20 76 44,508 11.1024 3 5 9 14 21 77 2,458 4.8031 1 2 4 7 10 78 39,504 6.5709 3 4 6 8 11 79 169,239 8.4557 3 4 7 11 16 80 8,077 5.3480 2 3 4 7 10 81 5 4.4000 1 1 3 8 8 82 64,299 6.8753 2 3 5 9 14 83 6,665 5.3655 2 3 4 7 10 84 1,575 3.2565 1 2 3 4 6 85 22,398 6.2473 2 3 5 8 12 86 2,250 3.5364 1 2 3 4 7 87 61,129 6.3127 1 3 5 8 12 88 404,045 5.0463 2 3 4 6 9 89 535,162 5.8340 2 3 5 7 11 90 48,843 3.9563 2 2 3 5 7 91 45 5.0444 1 2 3 5 13 92 15,809 6.2907 2 3 5 8 12 93 1,778 4.0079 1 2 3 5 7 94 12,813 6.2387 2 3 5 8 12 95 1,655 3.8127 1 2 3 5 7 96 56,893 4.5613 2 2 4 6 8 97 28,776 3.5275 1 2 3 4 6 98 9 3.6667 1 1 2 2 5 99 21,400 3.1554 1 1 2 4 6 100 8,324 2.1371 1 1 2 3 4 101 22,329 4.3853 1 2 3 6 9 102 5,644 2.6487 1 1 2 3 5 103 484 42.1240 9 12 23 53 92 104 20,637 14.3306 6 8 12 17 25 105 29,223 9.8741 4 6 8 11 18 106 3,498 11.4019 5 7 10 14 20 107 83,307 10.4339 5 7 9 12 17 108 6,508 9.7617 2 5 8 12 18 109 57,450 7.7160 4 5 6 9 13 110 54,835 8.7534 2 4 7 11 17 111 9,568 4.0565 1 2 4 6 7 113 39,734 12.4805 4 6 9 15 24 114 8,315 8.6592 2 4 7 11 17 115 19,805 7.4228 1 3 6 10 15 116 116,294 4.3974 1 2 3 6 9 117 4,731 4.3075 1 1 2 5 10 118 8,299 2.8976 1 1 1 4 7 119 1,237 5.2967 1 1 3 7 13 120 38,109 9.0051 1 3 6 12 20 121 164,425 6.2836 2 3 5 8 12 122 77,231 3.5159 1 2 3 5 7 123 38,627 4.7915 1 1 3 6 11 124 135,291 4.3838 1 2 3 6 9 125 91,946 2.7616 1 1 2 4 5 126 5,395 11.5218 3 6 9 15 22 127 676,101 5.2357 2 3 4 7 10 128 7,187 5.4446 2 3 5 7 9 129 3,853 2.5951 1 1 1 3 6 130 88,911 5.5991 2 3 5 7 10 131 27,124 4.0330 1 2 4 5 7 132 142,443 2.8904 1 1 2 4 5 133 8,694 2.2843 1 1 2 3 4 134 41,542 3.1609 1 2 2 4 6 135 7,810 4.4540 1 2 3 5 8 136 1,185 2.6641 1 1 2 3 5 138 208,716 3.9930 1 2 3 5 8 139 87,938 2.4733 1 1 2 3 5 140 55,735 2.5252 1 1 2 3 5 141 108,834 3.5704 1 2 3 4 7 142 52,684 2.5530 1 1 2 3 5 143 250,177 2.0911 1 1 2 3 4 144 94,588 5.5436 1 2 4 7 11 145 7,370 2.5700 1 1 2 3 5 146 10,785 10.2338 5 6 8 12 17 147 2,644 6.2266 3 5 6 8 9 148 134,125 12.2751 5 7 10 15 22 149 20,205 6.3062 4 5 6 7 9 150 21,184 11.3235 4 6 9 14 20 151 5,140 5.5586 2 3 5 7 10 152 4,578 8.3724 3 5 7 10 15 153 2,058 5.2546 3 4 5 7 8 154 28,368 13.2140 3 7 10 17 26 155 6,618 4.0801 1 2 3 6 8 156 4 2.5000 1 1 1 3 5 157 8,301 5.7459 1 2 4 7 12 158 4,362 2.6016 1 1 2 3 5 159 18,136 5.1194 1 2 4 7 10 160 12,203 2.6826 1 1 2 3 5 161 10,803 4.3270 1 2 3 6 9 162 6,421 1.9305 1 1 1 2 4 163 8 3.2500 1 1 2 3 6 164 5,400 8.3580 3 5 7 10 15 165 2,335 4.4882 2 3 4 6 7 166 4,206 4.7263 1 2 4 6 9 167 4,091 2.4133 1 1 2 3 4 168 1,425 4.8386 1 2 3 6 10 169 814 2.4005 1 1 2 3 5 170 15,682 10.8241 2 4 8 14 22 171 1,530 4.3333 1 2 4 6 9 172 31,435 6.9669 2 3 5 9 14 173 2,482 3.7808 1 2 3 5 8 174 252,303 4.7834 2 3 4 6 9 175 34,977 2.9157 1 2 3 4 5 176 13,498 5.2318 2 3 4 6 10 177 9,080 4.5719 2 3 4 6 8 178 3,382 3.1227 1 2 3 4 6 179 13,193 5.9431 2 3 5 7 11 180 90,752 5.4251 2 3 4 7 10 181 27,280 3.3710 1 2 3 4 6 182 273,118 4.4204 1 2 3 5 8 183 91,272 2.8962 1 1 2 4 5 184 69 3.2319 1 1 2 4 6 185 5,350 4.6680 1 2 3 6 10 186 6 6.6667 2 3 3 10 10 187 619 4.0307 1 2 3 6 8 188 84,099 5.5620 1 2 4 7 11 189 13,098 3.1005 1 1 2 4 6 190 75 5.1733 1 2 4 6 11 191 9,537 13.7975 3 6 10 17 28 192 1,322 6.2201 1 3 6 8 11 193 4,822 12.7242 5 7 10 16 23 194 650 6.7323 2 4 6 8 12 195 4,019 10.5175 4 6 9 13 19 196 998 5.6092 2 3 5 7 10 197 18,313 9.1566 3 5 7 11 17 198 5,418 4.4118 2 3 4 6 7 199 1,636 9.7353 2 4 7 13 21 200 1,076 10.4898 2 3 7 14 23 201 2,130 14.1469 3 6 11 18 29 202 26,756 6.3872 2 3 5 8 13 203 30,055 6.6816 2 3 5 9 13 204 65,585 5.7470 2 3 4 7 11 205 27,481 6.1736 2 3 5 8 12 206 2,057 3.7832 1 2 3 5 8 207 32,881 5.1924 1 2 4 7 10 208 10,188 2.8924 1 1 2 4 5 209 399,893 4.8600 3 3 4 5 7 210 122,843 6.8859 3 4 6 8 11 211 30,096 4.8394 3 4 4 6 7 212 9 7.0000 1 1 4 5 7 213 9,950 9.2035 2 4 7 12 18 216 8,770 7.9789 1 2 6 11 17 217 17,292 13.3846 3 5 9 16 28 218 23,796 5.5121 2 3 4 7 10 219 19,891 3.1961 1 2 3 4 6 220 1 1.0000 1 1 1 1 1 223 13,308 3.0326 1 1 2 4 6 224 11,738 1.9052 1 1 1 2 3 225 6,481 5.2626 1 2 4 7 11 226 5,874 6.5259 1 2 4 8 14 227 4,854 2.6360 1 1 2 3 5 228 2,534 4.1492 1 1 3 5 9 229 1,263 2.3286 1 1 2 3 5 230 2,456 5.5668 1 2 3 7 12 231 13,312 5.0159 1 1 3 6 11 232 816 2.7132 1 1 1 2 6 233 9,940 7.3671 1 3 6 10 15 234 5,364 3.0626 1 1 2 4 7 235 5,107 4.8659 1 2 4 6 9 236 40,182 4.6505 1 3 4 6 8 237 1,782 3.6599 1 2 3 5 7 238 8,956 8.6382 3 4 7 10 17 239 46,252 6.2694 2 3 5 8 12 240 12,062 6.6231 2 3 5 8 13 241 3,173 3.7690 1 2 3 5 7 242 2,597 6.8814 2 3 5 9 14 243 96,552 4.6506 1 2 4 6 9 244 14,695 4.6521 1 2 4 6 9 245 5,861 3.2950 1 2 3 4 6 246 1,498 3.7216 1 2 3 5 7 247 20,507 3.3340 1 1 3 4 7 248 13,931 4.9200 1 3 4 6 9 249 12,932 3.6170 1 1 2 4 7 250 3,802 4.1302 1 2 3 5 8 251 2,375 2.7651 1 1 3 3 5 253 22,095 4.6939 2 3 4 6 8 254 10,763 3.1601 1 2 3 4 5 256 6,698 5.1020 1 2 4 6 10 257 15,758 2.6395 1 1 2 3 5 258 15,317 1.8212 1 1 2 2 3 259 3,517 2.6747 1 1 1 3 6 260 4,236 1.3973 1 1 1 1 2 261 1,776 2.0884 1 1 1 2 4 262 668 4.3204 1 1 3 6 9 263 23,192 11.4687 3 5 8 14 22 264 3,869 6.5585 2 3 5 8 13 265 4,103 6.6074 1 2 4 8 14 266 2,555 3.2337 1 1 2 4 7 267 241 4.4606 1 1 3 6 10 268 920 3.7978 1 1 2 4 8 269 9,852 8.5323 2 3 7 11 17 270 2,798 3.5615 1 1 2 5 7 271 19,436 7.2481 2 4 6 9 14 272 5,752 6.0176 2 3 5 7 12 273 1,343 3.9598 1 2 3 5 8 274 2,305 6.4586 1 3 5 8 13 275 230 3.6217 1 1 2 4 7 276 1,327 4.4574 1 2 4 6 8 277 100,811 5.7271 2 3 5 7 10 278 32,531 4.1962 2 2 4 5 7 279 10 5.3000 2 2 3 7 7 280 17,882 4.1159 1 2 3 5 8 281 7,536 2.8879 1 1 2 4 5 283 6,093 4.6606 1 2 4 6 9 284 2,029 2.9359 1 1 2 4 6 285 6,962 10.5315 3 5 8 13 20 286 2,502 5.8981 2 3 4 7 12 287 6,287 10.2537 3 5 8 13 20 288 5,524 4.9716 2 3 4 5 8 289 6,938 2.7257 1 1 1 2 6 290 9,964 2.1995 1 1 1 2 4 291 58 1.6379 1 1 1 2 3 292 6,534 10.4645 2 4 8 14 21 293 364 4.7033 1 1 3 6 9 294 98,755 4.5121 1 2 3 6 9 295 3,550 3.9721 1 2 3 5 7 296 280,547 5.0716 1 2 4 6 10 297 48,715 3.2855 1 2 3 4 6 298 111 3.1802 1 1 2 4 7 299 1,276 5.4412 1 2 4 7 11 300 18,798 6.1364 2 3 5 8 12 301 3,636 3.5954 1 2 3 4 7 302 8,722 8.5255 4 5 6 9 15 303 21,880 8.0372 3 4 6 9 15 304 12,572 8.8705 2 4 6 11 18 305 3,047 3.5510 1 2 3 4 7 306 7,077 5.3740 1 2 3 7 12 307 2,035 2.0708 1 1 2 2 3 308 7,299 6.2077 1 2 4 8 14 309 4,183 2.0995 1 1 1 2 4 310 24,884 4.3725 1 1 3 6 10 311 7,495 1.8220 1 1 1 2 3 312 1,524 4.5623 1 1 3 6 10 313 555 2.2559 1 1 1 3 5 314 2 40.5000 1 1 80 80 80 315 34,134 6.9586 1 1 4 9 16 316 119,645 6.5348 2 3 5 8 13 317 2,018 3.6051 1 1 2 4 7 318 5,782 6.0930 1 3 5 8 12 319 412 2.9320 1 1 2 4 6 320 188,165 5.2818 2 3 4 6 10 321 31,355 3.7221 1 2 3 5 7 322 50 3.2200 1 2 3 4 5 323 19,957 3.1681 1 1 2 4 6 324 7,040 1.9006 1 1 1 2 4 325 9,310 3.8056 1 2 3 5 7 326 2,732 2.6190 1 1 2 3 5 327 7 2.5714 1 1 2 3 4 328 742 3.7251 1 1 3 5 8 329 94 2.0851 1 1 1 3 5 331 51,439 5.5878 1 3 4 7 11 332 5,006 3.1596 1 1 2 4 6 333 255 5.7843 1 2 3 7 11 334 10,536 4.5813 2 3 4 5 8 335 12,727 3.0264 2 2 3 4 5 336 35,950 3.3945 1 2 2 4 7 337 29,532 2.0157 1 1 2 2 3 338 940 5.4851 1 2 3 7 13 339 1,481 4.7968 1 1 3 6 11 340 1 2.0000 2 2 2 2 2 341 3,580 3.2031 1 1 2 3 7 342 693 3.1977 1 1 2 4 7 344 3,580 2.5232 1 1 1 2 5 345 1,370 4.9051 1 1 3 6 11 346 4,890 5.8937 2 3 5 8 12 347 315 3.0762 1 1 2 4 7 348 3,401 4.3355 1 2 3 5 8 349 616 2.5049 1 1 2 3 5 350 6,748 4.4884 2 2 4 6 8 352 960 3.9740 1 2 3 5 7 353 2,600 6.4942 2 3 5 7 12 354 7,444 5.7016 3 3 4 6 10 355 5,590 3.1971 2 2 3 4 5 356 25,990 2.0785 1 1 2 3 3 357 5,663 8.3744 3 4 6 10 16 358 21,660 4.1750 2 2 3 5 7 359 32,036 2.5609 1 2 2 3 4 360 15,871 2.7521 1 1 2 3 4 361 346 3.2052 1 1 2 3 8 362 5 1.4000 1 1 1 2 2 363 2,527 3.6312 1 2 2 4 8 364 1,637 4.1307 1 1 3 5 8 365 1,843 8.1872 1 3 5 10 17 366 4,581 6.6619 1 3 5 8 14 367 487 3.0678 1 1 2 4 7 368 3,572 6.6551 2 3 5 8 13 369 3,482 3.3090 1 1 2 4 7 370 1,350 5.7911 2 3 4 5 9 371 1,691 3.4826 2 3 3 4 5 372 947 3.4805 2 2 2 3 5 373 4,145 2.2955 1 2 2 3 3 374 91 2.9341 1 2 2 3 6 376 325 3.4123 1 2 2 4 7 377 48 4.0833 1 2 3 5 8 378 175 2.5943 1 1 2 3 5 379 355 3.0028 1 1 2 3 5 380 99 1.9697 1 1 1 2 3 381 190 1.9053 1 1 1 2 4 382 49 1.6939 1 1 1 2 3 383 2,003 3.7913 1 1 3 4 7 384 129 2.6279 1 1 2 3 5 385 3 2.0000 1 1 2 3 3 387 1 55.0000 55 55 55 55 55 389 12 6.2500 2 3 5 9 10 390 20 4.3000 1 2 3 5 7 392 2,271 9.6874 3 4 7 12 21 393 1 4.0000 4 4 4 4 4 394 2,605 7.5965 1 2 5 9 17 395 108,024 4.3238 1 2 3 5 9 396 17 4.4118 1 1 3 7 9 397 19,035 5.1743 1 2 4 6 10 398 18,162 5.8655 2 3 5 7 11 399 1,693 3.4826 1 2 3 4 6 400 6,371 9.0333 1 3 6 12 21 401 5,845 11.5341 2 5 9 15 23 402 1,478 3.9831 1 1 3 5 9 403 31,947 8.1013 2 3 6 10 17 404 4,350 4.1069 1 2 3 5 8 405 1 31.0000 31 31 31 31 31 406 2,444 9.6579 2 4 7 12 20 407 643 4.0560 1 2 3 5 7 408 2,134 8.2291 1 2 5 10 20 409 2,154 6.1565 2 3 4 6 12 410 28,484 4.0951 1 2 4 5 6 411 7 2.2857 1 1 2 2 4 412 16 3.8125 1 1 3 6 7 413 5,349 7.0501 2 3 5 9 14 414 633 4.2354 1 2 3 5 8 415 43,349 14.3233 4 6 11 18 28 416 192,908 7.4362 2 4 6 9 14 417 38 5.8421 2 3 5 7 12 418 25,920 6.2986 2 3 5 8 12 419 16,446 4.5517 1 2 4 6 9 420 3,220 3.4202 1 2 3 4 6 421 10,745 4.0624 1 2 3 5 8 422 66 3.6970 1 2 2 4 6 423 8,116 8.3228 2 3 6 10 17 424 1,236 12.7929 2 4 9 15 26 425 16,189 3.7961 1 2 3 5 8 426 4,589 4.4655 1 2 3 6 9 427 1,596 4.3784 1 2 3 5 9 428 796 7.1382 1 2 5 8 14 429 25,933 6.0111 2 3 4 7 11 430 65,276 7.8291 2 3 6 10 16 431 314 6.8248 1 2 4 7 12 432 451 4.0111 1 2 3 4 7 433 5,554 3.1300 1 1 2 4 6 439 1,520 8.1855 1 3 5 9 17 440 5,771 9.0806 2 3 6 11 19 441 677 3.1374 1 1 2 4 6 442 17,571 8.5218 1 3 6 10 18 443 3,920 3.3663 1 1 3 4 7 444 5,754 4.2011 1 2 3 5 8 445 2,546 2.8610 1 1 2 4 5 447 6,514 2.5091 1 1 2 3 5 448 1 1.0000 1 1 1 1 1 449 33,181 3.7059 1 1 3 4 7 450 7,441 1.9790 1 1 1 2 4 451 1 1.0000 1 1 1 1 1 452 25,679 4.9178 1 2 3 6 10 453 5,687 2.7579 1 1 2 3 5 454 4,792 4.2398 1 2 3 5 8 455 1,070 2.4140 1 1 2 3 5 461 5,216 3.5861 1 1 2 4 8 462 9,650 10.8636 4 6 9 14 20 463 27,061 4.0439 1 2 3 5 8 464 7,232 2.9887 1 1 2 4 6 465 200 3.9100 1 1 1 3 6 466 1,737 4.0219 1 1 2 4 7 467 1,140 3.0035 1 1 2 3 6 468 52,318 12.7674 3 6 10 16 25 471 13,363 5.3722 3 3 4 6 8 473 8,095 12.4119 2 3 7 17 32 475 109,726 11.1546 2 5 9 15 22 476 3,657 11.0941 2 5 10 15 21 477 25,400 8.1660 1 3 6 11 17 478 108,133 7.3130 1 3 5 9 15 479 24,052 3.1910 1 1 2 4 7 480 611 21.0638 6 8 12 22 47 481 865 21.7584 13 17 20 25 33 482 5,296 12.5015 4 6 9 15 24 483 45,427 39.2033 15 22 33 48 70 484 336 14.5744 2 6 11 21 28 485 3,220 9.8264 4 5 7 11 19 486 2,094 12.7612 1 6 10 17 26 487 3,731 7.1702 1 3 6 9 15 488 769 16.9129 4 7 13 22 36 489 13,373 8.5374 2 3 6 10 17 490 5,462 5.4888 1 2 4 7 11 491 15,370 3.3853 1 2 3 4 6 492 3,140 14.9239 3 5 7 25 33 493 59,615 5.9843 1 3 5 8 11 494 28,880 2.5293 1 1 2 3 5 495 192 16.4167 7 9 12 19 31 496 2,479 8.8709 3 4 6 11 18 497 22,473 6.3553 3 4 5 7 11 498 16,070 4.0191 2 3 4 5 6 499 34,688 4.5204 1 2 3 6 9 500 49,936 2.4069 1 1 2 3 4 501 2,608 10.6031 4 5 8 13 20 502 771 6.1647 3 4 5 7 11 503 5,970 3.9084 1 2 3 5 7 504 125 27.6560 7 13 21 37 55 505 134 5.6567 1 1 1 5 11 506 919 16.8836 4 7 13 21 35 507 341 9.0411 2 4 7 13 19 508 631 7.8051 2 3 5 10 17 509 160 4.2688 1 2 3 5 9 510 1,651 6.7274 1 3 5 8 15 511 581 4.6076 1 1 3 6 10 512 481 13.1185 6 8 10 15 23 513 207 9.7585 5 6 8 10 15 514 26,570 6.9035 1 2 5 9 15 515 8,131 5.1646 1 1 3 7 12 516 84,846 4.6338 2 2 4 5 9 517 198,743 2.5406 1 1 1 3 5 518 56,613 3.2508 1 1 2 4 7 519 8,486 4.8547 1 1 3 6 11 520 12,687 2.0548 1 1 1 2 4 521 30,898 5.7395 2 3 4 7 11 522 6,069 9.5670 4 5 8 12 20 523 15,456 4.0538 1 2 3 5 7 524 132,651 3.3690 1 2 3 4 6 525 571 17.2907 1 4 9 18 37 11,713,347 Table 7B.—Medicare Prospective Payment System Selected Percentile Lengths of Stay—FY 2002 MEDPAR Update December 2002 Grouper V21.0 DRG Number of discharges Arithmetic mean length of stay 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile 1 23,433 10.5551 3 5 8 14 21 2 11,715 5.2534 1 3 4 7 10 3 3 6.0000 1 1 4 13 13 6 356 3.0197 1 1 2 4 7 7 14,683 9.8438 2 4 7 12 20 8 4,106 2.8015 1 1 1 3 7 9 1,711 6.2402 1 3 5 8 12 10 18,655 6.3850 2 3 5 8 13 11 3,291 4.0413 1 2 3 5 8 12 52,512 5.7513 2 3 4 7 11 13 7,068 5.0035 2 3 4 6 9 14 237,027 5.9456 2 3 5 7 11 15 94,223 4.8529 2 3 4 6 9 16 9,938 6.3106 2 3 5 8 12 17 2,744 3.2172 1 2 2 4 6 18 29,701 5.4868 2 3 4 7 10 19 8,519 3.5184 1 2 3 5 7 20 6,207 10.1927 3 5 8 13 20 21 1,885 6.5963 2 3 5 9 13 22 2,785 5.1178 2 2 4 6 10 23 11,270 4.2627 1 2 3 5 8 24 59,102 4.8803 1 2 4 6 10 25 27,433 3.1776 1 2 3 4 6 26 18 4.2778 1 1 2 3 4 27 4,398 5.1719 1 1 3 7 11 28 13,919 6.0265 1 3 5 8 12 29 5,282 3.4924 1 2 3 5 7 30 2 6.5000 2 2 11 11 11 31 3,897 4.0429 1 2 3 5 8 32 1,895 2.4776 1 1 2 3 5 34 23,811 4.9368 1 2 4 6 9 35 7,451 3.1094 1 1 3 4 6 36 2,117 1.5328 1 1 1 1 2 37 1,382 3.7685 1 1 2 5 8 38 97 2.8041 1 1 1 4 5 39 559 2.1163 1 1 1 2 4 40 1,549 3.8070 1 1 3 5 7 42 1,581 2.7381 1 1 1 3 6 43 94 3.3936 1 1 3 4 6 44 1,227 4.9935 2 3 4 6 9 45 2,668 3.1267 1 2 3 4 6 46 3,482 4.4730 1 2 3 6 8 47 1,402 3.0927 1 1 2 4 6 49 2,391 4.4676 1 2 3 6 9 50 2,429 1.8506 1 1 1 2 3 51 243 2.8354 1 1 1 3 8 52 223 1.8161 1 1 1 2 3 53 2,478 3.6186 1 1 2 4 8 55 1,481 2.9338 1 1 1 3 7 56 469 2.8955 1 1 1 3 6 57 711 3.6709 1 1 2 4 8 58 1 2.0000 2 2 2 2 2 59 116 2.6724 1 1 1 3 6 60 1 3.0000 3 3 3 3 3 61 254 5.1535 1 1 3 7 11 62 2 7.0000 1 1 13 13 13 63 3,000 4.3860 1 2 3 5 9 64 3,126 6.4997 1 2 4 8 14 65 40,407 2.8127 1 1 2 4 5 66 7,841 3.0778 1 1 2 4 6 67 385 3.6442 1 2 3 5 7 68 11,658 3.8813 1 2 3 5 7 69 3,769 3.0186 1 2 3 4 5 70 30 2.3333 1 1 2 3 4 71 80 3.4000 1 1 2 4 6 72 964 3.4035 1 1 3 4 6 73 7,697 4.4433 1 2 3 6 9 75 43,504 9.9907 3 5 7 12 20 76 44,508 11.1024 3 5 9 14 21 77 2,458 4.8031 1 2 4 7 10 78 39,504 6.5709 3 4 6 8 11 79 169,239 8.4557 3 4 7 11 16 80 8,077 5.3480 2 3 4 7 10 81 5 4.4000 1 1 3 8 8 82 64,299 6.8753 2 3 5 9 14 83 6,665 5.3655 2 3 4 7 10 84 1,575 3.2565 1 2 3 4 6 85 22,398 6.2473 2 3 5 8 12 86 2,250 3.5364 1 2 3 4 7 87 61,129 6.3127 1 3 5 8 12 88 404,045 5.0463 2 3 4 6 9 89 535,162 5.8340 2 3 5 7 11 90 48,843 3.9563 2 2 3 5 7 91 45 5.0444 1 2 3 5 13 92 15,809 6.2907 2 3 5 8 12 93 1,778 4.0079 1 2 3 5 7 94 12,813 6.2387 2 3 5 8 12 95 1,655 3.8127 1 2 3 5 7 96 56,893 4.5613 2 2 4 6 8 97 28,776 3.5275 1 2 3 4 6 98 9 3.6667 1 1 2 2 5 99 21,400 3.1554 1 1 2 4 6 100 8,324 2.1371 1 1 2 3 4 101 22,329 4.3853 1 2 3 6 9 102 5,644 2.6487 1 1 2 3 5 103 484 42.1240 9 12 23 53 92 104 20,637 14.3306 6 8 12 17 25 105 29,223 9.8741 4 6 8 11 18 106 3,498 11.4019 5 7 10 14 20 107 83,307 10.4339 5 7 9 12 17 108 6,508 9.7617 2 5 8 12 18 109 57,450 7.7160 4 5 6 9 13 110 54,856 8.7568 2 4 7 11 17 111 9,569 4.0574 1 2 4 6 7 113 39,734 12.4805 4 6 9 15 24 114 8,315 8.6592 2 4 7 11 17 115 19,805 7.4228 1 3 6 10 15 116 116,294 4.3974 1 2 3 6 9 117 4,731 4.3075 1 1 2 5 10 118 8,299 2.8976 1 1 1 4 7 119 1,237 5.2967 1 1 3 7 13 120 38,109 9.0051 1 3 6 12 20 121 164,425 6.2836 2 3 5 8 12 122 77,231 3.5159 1 2 3 5 7 123 38,627 4.7915 1 1 3 6 11 124 135,291 4.3838 1 2 3 6 9 125 91,946 2.7616 1 1 2 4 5 126 5,395 11.5218 3 6 9 15 22 127 676,101 5.2357 2 3 4 7 10 128 7,187 5.4446 2 3 5 7 9 129 3,853 2.5951 1 1 1 3 6 130 88,911 5.5991 2 3 5 7 10 131 27,124 4.0330 1 2 4 5 7 132 142,443 2.8904 1 1 2 4 5 133 8,694 2.2843 1 1 2 3 4 134 41,542 3.1609 1 2 2 4 6 135 7,810 4.4540 1 2 3 5 8 136 1,185 2.6641 1 1 2 3 5 138 208,716 3.9930 1 2 3 5 8 139 87,938 2.4733 1 1 2 3 5 140 55,735 2.5252 1 1 2 3 5 141 108,834 3.5704 1 2 3 4 7 142 52,684 2.5530 1 1 2 3 5 143 250,177 2.0911 1 1 2 3 4 144 94,588 5.5436 1 2 4 7 11 145 7,370 2.5700 1 1 2 3 5 146 10,785 10.2338 5 6 8 12 17 147 2,644 6.2266 3 5 6 8 9 148 134,125 12.2751 5 7 10 15 22 149 20,205 6.3062 4 5 6 7 9 150 21,184 11.3235 4 6 9 14 20 151 5,140 5.5586 2 3 5 7 10 152 4,578 8.3724 3 5 7 10 15 153 2,058 5.2546 3 4 5 7 8 154 28,368 13.2140 3 7 10 17 26 155 6,618 4.0801 1 2 3 6 8 156 4 2.5000 1 1 1 3 5 157 8,301 5.7459 1 2 4 7 12 158 4,362 2.6016 1 1 2 3 5 159 18,136 5.1194 1 2 4 7 10 160 12,203 2.6826 1 1 2 3 5 161 10,803 4.3270 1 2 3 6 9 162 6,421 1.9305 1 1 1 2 4 163 8 3.2500 1 1 2 3 6 164 5,400 8.3580 3 5 7 10 15 165 2,335 4.4882 2 3 4 6 7 166 4,206 4.7263 1 2 4 6 9 167 4,091 2.4133 1 1 2 3 4 168 1,425 4.8386 1 2 3 6 10 169 814 2.4005 1 1 2 3 5 170 15,682 10.8241 2 4 8 14 22 171 1,530 4.3333 1 2 4 6 9 172 31,435 6.9669 2 3 5 9 14 173 2,482 3.7808 1 2 3 5 8 174 252,303 4.7834 2 3 4 6 9 175 34,977 2.9157 1 2 3 4 5 176 13,498 5.2318 2 3 4 6 10 177 9,080 4.5719 2 3 4 6 8 178 3,382 3.1227 1 2 3 4 6 179 13,193 5.9431 2 3 5 7 11 180 90,752 5.4251 2 3 4 7 10 181 27,280 3.3710 1 2 3 4 6 182 273,118 4.4204 1 2 3 5 8 183 91,272 2.8962 1 1 2 4 5 184 69 3.2319 1 1 2 4 6 185 5,350 4.6680 1 2 3 6 10 186 6 6.6667 2 3 3 10 10 187 619 4.0307 1 2 3 6 8 188 84,099 5.5620 1 2 4 7 11 189 13,098 3.1005 1 1 2 4 6 190 75 5.1733 1 2 4 6 11 191 9,537 13.7975 3 6 10 17 28 192 1,322 6.2201 1 3 6 8 11 193 4,822 12.7242 5 7 10 16 23 194 650 6.7323 2 4 6 8 12 195 4,019 10.5175 4 6 9 13 19 196 998 5.6092 2 3 5 7 10 197 18,313 9.1566 3 5 7 11 17 198 5,418 4.4118 2 3 4 6 7 199 1,636 9.7353 2 4 7 13 21 200 1,076 10.4898 2 3 7 14 23 201 2,130 14.1469 3 6 11 18 29 202 26,756 6.3872 2 3 5 8 13 203 30,055 6.6816 2 3 5 9 13 204 65,585 5.7470 2 3 4 7 11 205 27,481 6.1736 2 3 5 8 12 206 2,057 3.7832 1 2 3 5 8 207 32,881 5.1924 1 2 4 7 10 208 10,188 2.8924 1 1 2 4 5 209 399,893 4.8600 3 3 4 5 7 210 122,843 6.8859 3 4 6 8 11 211 30,096 4.8394 3 4 4 6 7 212 9 7.0000 1 1 4 5 7 213 9,950 9.2035 2 4 7 12 18 216 8,770 7.9789 1 2 6 11 17 217 17,292 13.3846 3 5 9 16 28 218 23,796 5.5121 2 3 4 7 10 219 19,891 3.1961 1 2 3 4 6 220 1 1.0000 1 1 1 1 1 223 13,308 3.0326 1 1 2 4 6 224 11,738 1.9052 1 1 1 2 3 225 6,481 5.2626 1 2 4 7 11 226 5,874 6.5259 1 2 4 8 14 227 4,854 2.6360 1 1 2 3 5 228 2,534 4.1492 1 1 3 5 9 229 1,263 2.3286 1 1 2 3 5 230 2,456 5.5668 1 2 3 7 12 232 816 2.7132 1 1 1 2 6 233 9,940 7.3671 1 3 6 10 15 234 5,364 3.0626 1 1 2 4 7 235 5,107 4.8659 1 2 4 6 9 236 40,182 4.6505 1 3 4 6 8 237 1,782 3.6599 1 2 3 5 7 238 8,956 8.6382 3 4 7 10 17 239 46,252 6.2694 2 3 5 8 12 240 12,062 6.6231 2 3 5 8 13 241 3,173 3.7690 1 2 3 5 7 242 2,597 6.8814 2 3 5 9 14 243 96,552 4.6506 1 2 4 6 9 244 14,695 4.6521 1 2 4 6 9 245 5,861 3.2950 1 2 3 4 6 246 1,498 3.7216 1 2 3 5 7 247 20,507 3.3340 1 1 3 4 7 248 13,931 4.9200 1 3 4 6 9 249 12,932 3.6170 1 1 2 4 7 250 3,802 4.1302 1 2 3 5 8 251 2,375 2.7651 1 1 3 3 5 253 22,095 4.6939 2 3 4 6 8 254 10,763 3.1601 1 2 3 4 5 256 6,714 5.1008 1 2 4 6 10 257 15,758 2.6395 1 1 2 3 5 258 15,317 1.8212 1 1 2 2 3 259 3,517 2.6747 1 1 1 3 6 260 4,236 1.3973 1 1 1 1 2 261 1,776 2.0884 1 1 1 2 4 262 668 4.3204 1 1 3 6 9 263 23,192 11.4687 3 5 8 14 22 264 3,869 6.5585 2 3 5 8 13 265 4,103 6.6074 1 2 4 8 14 266 2,555 3.2337 1 1 2 4 7 267 241 4.4606 1 1 3 6 10 268 920 3.7978 1 1 2 4 8 269 9,852 8.5323 2 3 7 11 17 270 2,798 3.5615 1 1 2 5 7 271 19,436 7.2481 2 4 6 9 14 272 5,752 6.0176 2 3 5 7 12 273 1,343 3.9598 1 2 3 5 8 274 2,305 6.4586 1 3 5 8 13 275 230 3.6217 1 1 2 4 7 276 1,327 4.4574 1 2 4 6 8 277 100,811 5.7271 2 3 5 7 10 278 32,531 4.1962 2 2 4 5 7 279 10 5.3000 2 2 3 7 7 280 17,882 4.1159 1 2 3 5 8 281 7,536 2.8879 1 1 2 4 5 283 6,093 4.6606 1 2 4 6 9 284 2,029 2.9359 1 1 2 4 6 285 6,962 10.5315 3 5 8 13 20 286 2,502 5.8981 2 3 4 7 12 287 6,287 10.2537 3 5 8 13 20 288 5,524 4.9716 2 3 4 5 8 289 6,938 2.7257 1 1 1 2 6 290 9,964 2.1995 1 1 1 2 4 291 58 1.6379 1 1 1 2 3 292 6,534 10.4645 2 4 8 14 21 293 364 4.7033 1 1 3 6 9 294 98,755 4.5121 1 2 3 6 9 295 3,550 3.9721 1 2 3 5 7 296 280,547 5.0716 1 2 4 6 10 297 48,715 3.2855 1 2 3 4 6 298 111 3.1802 1 1 2 4 7 299 1,276 5.4412 1 2 4 7 11 300 18,798 6.1364 2 3 5 8 12 301 3,636 3.5954 1 2 3 4 7 302 8,722 8.5255 4 5 6 9 15 303 21,880 8.0372 3 4 6 9 15 304 12,572 8.8705 2 4 6 11 18 305 3,047 3.5510 1 2 3 4 7 306 7,077 5.3740 1 2 3 7 12 307 2,035 2.0708 1 1 2 2 3 308 7,299 6.2077 1 2 4 8 14 309 4,183 2.0995 1 1 1 2 4 310 24,884 4.3725 1 1 3 6 10 311 7,495 1.8220 1 1 1 2 3 312 1,524 4.5623 1 1 3 6 10 313 555 2.2559 1 1 1 3 5 314 2 40.5000 1 1 80 80 80 315 34,134 6.9586 1 1 4 9 16 316 119,645 6.5348 2 3 5 8 13 317 2,018 3.6051 1 1 2 4 7 318 5,782 6.0930 1 3 5 8 12 319 412 2.9320 1 1 2 4 6 320 188,165 5.2818 2 3 4 6 10 321 31,355 3.7221 1 2 3 5 7 322 50 3.2200 1 2 3 4 5 323 19,957 3.1681 1 1 2 4 6 324 7,040 1.9006 1 1 1 2 4 325 9,310 3.8056 1 2 3 5 7 326 2,732 2.6190 1 1 2 3 5 327 7 2.5714 1 1 2 3 4 328 742 3.7251 1 1 3 5 8 329 94 2.0851 1 1 1 3 5 331 51,439 5.5878 1 3 4 7 11 332 5,006 3.1596 1 1 2 4 6 333 255 5.7843 1 2 3 7 11 334 10,536 4.5813 2 3 4 5 8 335 12,727 3.0264 2 2 3 4 5 336 35,950 3.3945 1 2 2 4 7 337 29,532 2.0157 1 1 2 2 3 338 940 5.4851 1 2 3 7 13 339 1,481 4.7968 1 1 3 6 11 340 1 2.0000 2 2 2 2 2 341 3,580 3.2031 1 1 2 3 7 342 693 3.1977 1 1 2 4 7 344 3,580 2.5232 1 1 1 2 5 345 1,370 4.9051 1 1 3 6 11 346 4,890 5.8937 2 3 5 8 12 347 315 3.0762 1 1 2 4 7 348 3,401 4.3355 1 2 3 5 8 349 616 2.5049 1 1 2 3 5 350 6,748 4.4884 2 2 4 6 8 352 960 3.9740 1 2 3 5 7 353 2,600 6.4942 2 3 5 7 12 354 7,444 5.7016 3 3 4 6 10 355 5,590 3.1971 2 2 3 4 5 356 25,990 2.0785 1 1 2 3 3 357 5,663 8.3744 3 4 6 10 16 358 21,660 4.1750 2 2 3 5 7 359 32,036 2.5609 1 2 2 3 4 360 15,871 2.7521 1 1 2 3 4 361 346 3.2052 1 1 2 3 8 362 5 1.4000 1 1 1 2 2 363 2,527 3.6312 1 2 2 4 8 364 1,637 4.1307 1 1 3 5 8 365 1,843 8.1872 1 3 5 10 17 366 4,581 6.6619 1 3 5 8 14 367 487 3.0678 1 1 2 4 7 368 3,572 6.6551 2 3 5 8 13 369 3,482 3.3090 1 1 2 4 7 370 1,350 5.7911 2 3 4 5 9 371 1,691 3.4826 2 3 3 4 5 372 947 3.4805 2 2 2 3 5 373 4,145 2.2955 1 2 2 3 3 374 91 2.9341 1 2 2 3 6 376 325 3.4123 1 2 2 4 7 377 48 4.0833 1 2 3 5 8 378 175 2.5943 1 1 2 3 5 379 355 3.0028 1 1 2 3 5 380 99 1.9697 1 1 1 2 3 381 190 1.9053 1 1 1 2 4 382 49 1.6939 1 1 1 2 3 383 2,003 3.7913 1 1 3 4 7 384 129 2.6279 1 1 2 3 5 385 3 2.0000 1 1 2 3 3 387 1 55.0000 55 55 55 55 55 389 12 6.2500 2 3 5 9 10 392 2,271 9.6874 3 4 7 12 21 393 1 4.0000 4 4 4 4 4 394 2,605 7.5965 1 2 5 9 17 395 108,024 4.3238 1 2 3 5 9 396 17 4.4118 1 1 3 7 9 397 19,035 5.1743 1 2 4 6 10 398 18,162 5.8655 2 3 5 7 11 399 1,693 3.4826 1 2 3 4 6 401 5,845 11.5341 2 5 9 15 23 402 1,478 3.9831 1 1 3 5 9 403 31,947 8.1013 2 3 6 10 17 404 4,350 4.1069 1 2 3 5 8 405 1 31.0000 31 31 31 31 31 406 2,444 9.6579 2 4 7 12 20 407 643 4.0560 1 2 3 5 7 408 2,134 8.2291 1 2 5 10 20 409 2,154 6.1565 2 3 4 6 12 410 28,484 4.0951 1 2 4 5 6 411 7 2.2857 1 1 2 2 4 412 16 3.8125 1 1 3 6 7 413 5,349 7.0501 2 3 5 9 14 414 633 4.2354 1 2 3 5 8 415 43,349 14.3233 4 6 11 18 28 416 192,908 7.4362 2 4 6 9 14 417 38 5.8421 2 3 5 7 12 418 25,920 6.2986 2 3 5 8 12 419 16,446 4.5517 1 2 4 6 9 420 3,220 3.4202 1 2 3 4 6 421 10,745 4.0624 1 2 3 5 8 422 66 3.6970 1 2 2 4 6 423 8,116 8.3228 2 3 6 10 17 424 1,236 12.7929 2 4 9 15 26 425 16,189 3.7961 1 2 3 5 8 426 4,589 4.4655 1 2 3 6 9 427 1,596 4.3784 1 2 3 5 9 428 796 7.1382 1 2 5 8 14 429 27,249 5.8827 2 3 4 7 11 430 65,276 7.8291 2 3 6 10 16 431 314 6.8248 1 2 4 7 12 432 451 4.0111 1 2 3 4 7 433 5,554 3.1300 1 1 2 4 6 439 1,520 8.1855 1 3 5 9 17 440 5,771 9.0806 2 3 6 11 19 441 677 3.1374 1 1 2 4 6 442 17,571 8.5218 1 3 6 10 18 443 3,920 3.3663 1 1 3 4 7 444 5,754 4.2011 1 2 3 5 8 445 2,546 2.8610 1 1 2 4 5 447 6,514 2.5091 1 1 2 3 5 448 1 1.0000 1 1 1 1 1 449 33,181 3.7059 1 1 3 4 7 450 7,441 1.9790 1 1 1 2 4 451 1 1.0000 1 1 1 1 1 452 25,679 4.9178 1 2 3 6 10 453 5,687 2.7579 1 1 2 3 5 454 4,792 4.2398 1 2 3 5 8 455 1,070 2.4140 1 1 2 3 5 461 5,216 3.5861 1 1 2 4 8 462 9,650 10.8636 4 6 9 14 20 463 27,061 4.0439 1 2 3 5 8 464 7,232 2.9887 1 1 2 4 6 465 200 3.9100 1 1 1 3 6 466 1,737 4.0219 1 1 2 4 7 467 1,141 3.0035 1 1 2 3 6 468 52,318 12.7674 3 6 10 16 25 471 13,363 5.3722 3 3 4 6 8 473 8,095 12.4119 2 3 7 17 32 475 109,726 11.1546 2 5 9 15 22 476 3,657 11.0941 2 5 10 15 21 477 25,400 8.1660 1 3 6 11 17 478 108,112 7.3110 1 3 5 9 15 479 24,051 3.1906 1 1 2 4 7 480 611 21.0638 6 8 12 22 47 481 865 21.7584 13 17 20 25 33 482 5,296 12.5015 4 6 9 15 24 483 45,427 39.2033 15 22 33 48 70 484 336 14.5744 2 6 11 21 28 485 3,220 9.8264 4 5 7 11 19 486 2,094 12.7612 1 6 10 17 26 487 3,731 7.1702 1 3 6 9 15 488 769 16.9129 4 7 13 22 36 489 13,373 8.5374 2 3 6 10 17 490 5,462 5.4888 1 2 4 7 11 491 15,370 3.3853 1 2 3 4 6 492 3,140 14.9239 3 5 7 25 33 493 59,615 5.9843 1 3 5 8 11 494 28,880 2.5293 1 1 2 3 5 495 192 16.4167 7 9 12 19 31 496 2,479 8.8709 3 4 6 11 18 497 21,955 6.2773 3 4 5 7 11 498 15,754 4.0072 2 3 4 5 6 499 34,688 4.5204 1 2 3 6 9 500 49,936 2.4069 1 1 2 3 4 501 2,608 10.6031 4 5 8 13 20 502 771 6.1647 3 4 5 7 11 503 5,970 3.9084 1 2 3 5 7 504 125 27.6560 7 13 21 37 55 505 134 5.6567 1 1 1 5 11 506 919 16.8836 4 7 13 21 35 507 341 9.0411 2 4 7 13 19 508 631 7.8051 2 3 5 10 17 509 160 4.2688 1 2 3 5 9 510 1,651 6.7274 1 3 5 8 15 511 581 4.6076 1 1 3 6 10 512 481 13.1185 6 8 10 15 23 513 207 9.7585 5 6 8 10 15 515 8,131 5.1646 1 1 3 7 12 516 84,846 4.6338 2 2 4 5 9 517 198,743 2.5406 1 1 1 3 5 518 56,613 3.2508 1 1 2 4 7 519 9,004 5.1313 1 1 3 6 12 520 13,003 2.1170 1 1 2 2 4 521 30,898 5.7395 2 3 4 7 11 522 6,069 9.5670 4 5 8 12 20 523 15,456 4.0538 1 2 3 5 7 524 132,651 3.3690 1 2 3 4 6 525 571 17.2907 1 4 9 18 37 528 1,354 17.0990 6 10 15 22 31 529 4,687 10.5078 2 3 7 14 24 530 2,842 3.9170 1 2 3 5 8 531 3,802 9.9408 2 4 7 13 21 532 2,910 3.9704 1 1 3 5 8 533 43,264 4.1077 1 1 2 5 9 534 52,354 2.0108 1 1 1 2 4 535 6,005 10.9189 2 5 9 14 21 536 20,565 5.7310 1 2 4 8 12 537 6,870 7.0199 1 3 5 9 14 538 6,442 2.8788 1 1 2 4 6 539 4,472 11.1456 2 4 8 15 24 540 1,899 4.0590 1 1 3 5 8 11,713,347 Table 8A.—Statewide Average Operating Cost-To-Charge Ratios for Urban and Rural Hospitals (Case Weighted)—March 2003 State Urban Rural Alabama 0.326 0.393 Alaska 0.401 0.662 Arizona 0.334 0.453 Arkansas 0.424 0.413 California 0.322 0.411 Colorado 0.408 0.532 Connecticut 0.501 0.538 Delaware 0.592 0.483 District of Columbia 0.382 Florida 0.330 0.344 Georgia 0.449 0.444 Hawaii 0.402 0.447 Idaho 0.541 0.518 Illinois 0.384 0.476 Indiana 0.486 0.523 Iowa 0.456 0.587 Kansas 0.376 0.558 Kentucky 0.458 0.462 Louisiana 0.383 0.459 Maine 0.542 0.499 Maryland 0.760 0.820 Massachusetts 0.499 0.553 Michigan 0.438 0.534 Minnesota 0.460 0.619 Mississippi 0.431 0.419 Missouri 0.389 0.459 Montana 0.510 0.516 Nebraska 0.415 0.525 Nevada 0.284 0.461 New Hampshire 0.523 0.587 New Jersey 0.343 New Mexico 0.473 0.479 New York 0.470 0.579 North Carolina 0.503 0.468 North Dakota 0.640 0.628 Ohio 0.481 0.567 Oklahoma 0.371 0.466 Oregon 0.525 0.568 Pennsylvania 0.367 0.497 Puerto Rico 0.479 0.569 Rhode Island 0.484 South Carolina 0.435 0.452 South Dakota 0.484 0.535 Tennessee 0.411 0.434 Texas 0.373 0.477 Utah 0.481 0.581 Vermont 0.522 0.596 Virginia 0.428 0.499 Washington 0.532 0.581 West Virginia 0.572 0.545 Wisconsin 0.509 0.583 Wyoming 0.442 0.618 Table 8B.—Statewide Average Capital Cost-to-Charge Ratios (Case Weighted)—March 2003 State Ratio Alabama 0.040 Alaska 0.053 Arizona 0.033 Arkansas 0.042 California 0.031 Colorado 0.043 Connecticut 0.036 Delaware 0.050 District of Columbia 0.026 Florida 0.039 Georgia 0.047 Hawaii 0.041 Idaho 0.045 Illinois 0.037 Indiana 0.051 Iowa 0.046 Kansas 0.045 Kentucky 0.045 Louisiana 0.043 Maine 0.035 Maryland 0.013 Massachusetts 0.049 Michigan 0.043 Minnesota 0.042 Mississippi 0.041 Missouri 0.040 Montana 0.049 Nebraska 0.047 Nevada 0.032 New Hampshire 0.059 New Jersey 0.030 New Mexico 0.044 New York 0.047 North Carolina 0.046 North Dakota 0.065 Ohio 0.044 Oklahoma 0.040 Oregon 0.043 Pennsylvania 0.035 Puerto Rico 0.043 Rhode Island 0.033 South Carolina 0.046 South Dakota 0.051 Tennessee 0.046 Texas 0.043 Utah 0.046 Vermont 0.046 Virginia 0.048 Washington 0.052 West Virginia 0.045 Wisconsin 0.050 Wyoming 0.050 Table 9.—Hospital Reclassifications and Redesignations by Individual Hospital—FY 2004 Provider No. 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 010089 01 1000 010101 01 0450 0450 010118 01 5240 010120 01 5160 010121 01 5240 010126 01 2180 010150 01 5240 010158 01 2030 020008 02 0380 030007 03 2620 030012 03 6200 030033 03 2620 030043 03 8520 040014 04 4400 040017 04 26 040019 04 4920 040020 3700 4920 040026 04 4400 040027 04 7920 040041 04 4400 040066 04 4400 040069 04 4920 040072 04 4400 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 050071 7400 5775 050073 8720 5775 050101 8720 5775 050150 05 6920 050174 7500 8720 050228 7360 5775 050230 5945 4480 050236 8735 4480 050236 8735 4480 050251 05 6720 050296 05 7120 050325 05 5170 050335 05 5170 050419 05 6690 050457 7360 5775 050464 5170 8120 050494 05 6920 050510 7360 5775 050541 7360 5775 050549 8735 4480 050569 05 7500 050594 5945 4480 050609 5945 4480 050668 7360 5775 050686 6780 5945 060001 3060 2080 2080 060003 1125 2080 2080 060013 06 0200 060023 2995 6520 060027 1125 2080 2080 060044 06 2080 060049 06 2080 060057 06 2995 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 0560 100022 5000 2680 100023 10 5960 100024 10 5000 100045 2020 5960 100049 10 3980 100098 10 8960 8960 100103 10 3600 3600 100105 10 4900 100109 10 5960 100150 10 5000 100176 8960 2710 100211 8280 3980 100232 10 5790 2900 100239 8280 7510 100249 10 8280 100268 8960 2680 110001 11 0520 110001 11 0520 110002 11 0520 110003 11 3600 110016 11 1800 110023 11 0520 110025 11 3600 110025 11 3600 110029 11 0520 110038 11 10 110040 11 0500 0500 110041 11 0500 110050 11 0520 110054 11 0520 110074 0500 0520 110075 11 7520 110118 11 0120 110122 11 10 110150 11 4680 110168 11 0520 110187 11 0520 110188 11 0520 110189 11 0520 110205 11 0520 120028 12 3320 130002 13 6340 130003 13 50 130011 13 50 130018 13 6340 130026 13 6340 130028 6340 7160 130049 13 7840 130060 13 1080 140014 6120 1040 140015 14 7040 140027 14 1960 140031 14 1400 140032 14 7040 140034 14 7040 7040 140040 14 6120 140043 14 6880 140046 14 7040 140058 14 7880 140064 14 1960 140086 14 7040 7040 140093 14 1400 140102 14 7880 7880 140110 14 6120 140141 14 7040 7040 140143 14 6120 140160 14 6880 140161 14 1600 140164 14 7040 140189 14 1400 140230 14 1400 1400 140234 14 6120 140245 14 7040 140271 14 7800 7800 150002 2960 1600 1600 150004 2960 1600 1600 150006 15 7800 150008 2960 1600 1600 150011 15 3480 3480 150015 15 1600 1600 150027 15 3480 150030 15 3480 3480 150034 2960 1600 1600 150036 15 3850 150048 15 3200 150051 1020 3480 150062 15 3480 3480 150065 15 3480 150067 15 3480 150069 15 1640 1640 150076 15 7800 150090 2960 1600 1600 150096 15 2330 150102 15 7800 150105 15 3480 150112 15 3480 3480 150125 2960 1600 1600 150126 2960 1600 1600 150127 15 3480 150132 2960 1600 1600 150133 15 2330 150146 15 2330 150147 2960 1600 1600 160001 16 2120 160016 16 2120 160026 16 2120 160030 16 2120 160037 16 24 160057 16 3500 160064 16 24 160080 16 6880 160088 16 2120 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 170045 17 8440 170058 17 3710 170060 17 28 170089 17 0320 170094 17 8440 170120 17 3710 170131 17 8440 8440 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 180066 18 5360 180069 18 3400 180078 18 3400 180102 18 1660 180104 18 1660 180116 18 1660 180124 18 5360 180125 18 3400 180127 18 4520 180132 18 4280 180139 18 4280 190001 19 5560 190003 19 3880 190010 19 5560 190015 19 5560 190025 19 3880 190049 19 5560 190054 19 3880 190083 19 5200 190086 19 5200 190099 19 3880 190106 19 3880 190131 19 5560 190218 19 0220 200002 20 6403 200020 6403 1123 1123 200024 4243 6403 200034 4243 6403 200039 20 6403 200040 6403 1123 200050 20 0733 200063 20 6403 220060 1123 0743 220077 8003 3283 220123 22 0743 230022 23 0440 230027 23 3000 3000 230030 23 6960 230036 23 6960 230037 23 0440 230040 23 3720 3000 230054 23 3080 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 240011 24 5120 5120 240013 24 5120 240014 24 5120 240016 24 2520 240018 24 5120 240023 24 5120 240045 24 2240 240052 24 2520 240064 24 2240 240069 24 6820 240071 24 5120 240072 24 2240 240075 24 6980 240088 24 6980 240089 24 5120 240100 24 2985 240119 24 2240 240121 24 2240 240139 24 5120 240142 24 6980 240152 24 5120 240187 24 5120 250002 25 2650 250004 25 4920 250009 25 3580 250025 25 01 250030 25 3560 250031 25 3560 250034 25 4920 250042 25 4920 250058 25 3285 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 260009 26 3760 260011 26 1740 260015 26 3700 260017 26 7040 260022 26 1740 260025 26 7040 260034 26 3760 260047 26 1740 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 260164 26 7040 260183 26 7040 260186 26 1740 270002 27 0880 270003 27 3040 270011 27 3040 270017 27 5140 270051 27 5140 270057 27 0880 270082 27 3040 280009 28 4360 280023 28 4360 280032 28 4360 280054 28 4360 280058 28 4360 280061 28 53 280065 28 3060 280077 28 5920 280111 28 5920 280125 28 7720 290006 29 6720 290008 29 4120 300003 30 1123 300005 30 1123 300019 30 1123 1123 300024 30 1123 310001 0875 5600 310002 5640 5600 310003 3640 5600 310015 5640 0875 310021 8480 5190 310031 6160 5190 310032 8760 6160 6160 310038 5015 5600 310045 0875 5600 310047 0560 6160 310048 5015 5640 310064 0560 6160 310070 5015 5600 310076 5640 5600 310087 8760 6160 310088 0560 6160 310119 5640 5600 320005 32 0200 320006 32 7490 320011 32 7490 320013 32 7490 320063 32 5800 320065 32 5800 330001 5660 0875 0875 330004 33 2281 330023 2281 5660 5600 330027 5380 5600 330084 33 1303 330085 33 8160 330103 33 1280 330106 5380 5600 330126 5660 0875 0875 330135 5660 0875 0875 330136 33 8160 330157 33 8160 330181 5380 5600 330182 5380 5600 330205 5660 0875 0875 330209 5660 0875 0875 330224 33 3283 330235 8160 6840 330239 3610 2360 330250 33 1303 330264 5660 0875 0875 330307 33 8160 330386 33 5660 340003 34 3120 340008 34 2560 340010 2980 6640 340013 34 1520 340017 34 0480 340021 34 1520 340023 34 0480 340027 34 3150 340039 34 1520 340050 34 2560 340051 34 3290 340052 3120 1520 340064 34 3120 340068 34 9200 340071 34 6640 6640 340088 34 0480 340109 34 5720 5720 340115 34 6640 6640 340124 34 6640 6640 340126 34 6640 6640 340131 34 3150 340143 3290 1520 340147 6895 6640 350003 35 1010 350005 35 2985 350006 35 1010 350008 35 1010 350009 35 2520 350038 35 2985 360002 36 1680 360008 36 3400 360010 36 0080 360011 36 1840 1840 360013 36 2000 360014 36 1840 360024 36 1680 1680 360025 36 1680 1680 360036 36 0080 360037 1680 0080 360039 36 1840 1840 360046 3200 1640 360054 36 1480 360056 3200 1640 360063 36 1680 360065 36 1680 1680 360071 36 4320 4320 360076 3200 1640 360078 0080 1680 1680 360081 8400 2160 360084 1320 0080 360088 36 1840 360090 8400 2160 360092 36 1840 1840 360095 36 8400 360107 36 8400 360109 36 1840 1840 360112 8400 0440 360121 36 0440 360132 3200 1640 360142 36 1640 360144 1680 0080 360150 0080 1680 360159 36 1840 360175 36 3200 360186 36 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 380006 38 6440 380022 38 1890 380027 38 2400 380040 38 2400 380047 38 2400 380050 38 4890 380051 7080 6440 380065 38 2400 380070 38 6440 380090 38 2400 390006 39 3240 390008 39 6280 6280 390013 39 3240 390016 39 6280 6280 390017 39 6280 6280 390030 39 6680 6680 390031 39 6680 6680 390048 39 3240 390052 39 0280 390065 39 9280 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 390163 39 6280 390181 39 6680 6680 390183 39 6680 6680 390189 39 3240 390197 0240 6160 390201 39 5640 5640 390263 0240 6160 400018 40 1310 410001 6483 1123 1123 410004 6483 1123 1123 410005 6483 1123 1123 410006 6483 1123 1123 410007 6483 1123 1123 410008 6483 1123 1123 410009 6483 1123 1123 410010 6483 1123 1123 410011 6483 1123 1123 410012 6483 1123 1123 410013 6483 1123 1123 420020 42 1440 420030 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 430004 43 6660 430008 43 24 430012 43 7760 430013 43 7760 430014 43 2520 430015 43 6660 430047 43 28 430048 43 53 430089 43 7720 440008 44 3580 440020 44 3440 440024 44 1560 440050 44 0480 440058 44 1560 440059 44 5360 440060 44 3580 440067 44 3840 440068 44 3840 440072 44 4920 440073 44 5360 440148 44 5360 440175 44 3440 440180 44 3840 440185 44 1560 440186 44 5360 440187 44 18 440192 44 5360 440200 44 5360 440203 44 1560 450007 45 7240 450014 45 8750 450080 45 4420 450085 45 9080 450098 45 4420 450099 45 0320 450140 45 5800 450144 45 5800 450146 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 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 450623 45 1920 450626 45 8750 450653 45 5800 450656 45 8640 450694 45 3360 450747 45 1920 450755 45 4600 450763 45 0320 450770 45 0640 460011 46 6520 460021 46 4120 460027 46 6520 460032 46 6520 460036 46 6520 460039 46 7160 470001 47 30 470011 47 1123 1123 470012 47 6323 470018 47 1123 1123 490001 49 3660 490004 49 1540 490005 49 8840 490013 49 4640 490018 49 4640 490038 49 3660 490047 49 8840 490066 5720 6760 490079 49 3120 3120 490126 49 6800 500002 50 6740 500003 50 7600 500007 50 0860 500016 50 7600 500031 50 5910 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 520032 52 4720 520037 52 8940 520059 6600 5080 5080 520066 3620 4720 520071 52 5080 5080 520076 52 4720 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 530002 53 1350 530008 53 1350 530009 53 1350 530015 53 6340 530025 53 2670 530032 53 7160 Table 10.—Mean and Standard Deviation by Diagnosis-Related Groups (DRGS)—FY 2004 1 DRG Cases Mean + 1 standard deviation 1 23,157 $71,862 2 11,535 $41,916 3 3 $57,168 6 350 $15,743 7 14,489 $55,309 8 4,031 $33,403 9 1,677 $27,210 10 18,339 $25,124 11 3,244 $17,654 12 51,660 $17,776 13 6,919 $16,312 14 233,816 $24,738 15 92,167 $19,059 16 9,810 $25,016 17 2,700 $13,796 18 29,250 $20,071 19 8,385 $14,298 20 6,112 $57,114 21 1,869 $30,726 22 2,746 $21,754 23 11,062 $16,410 24 58,122 $19,963 25 26,945 $12,212 26 18 $22,836 27 4,348 $27,026 28 13,770 $26,999 29 5,226 $14,276 30 2 $19,365 31 3,834 $18,092 32 1,866 $11,256 34 23,474 $19,760 35 7,325 $12,760 36 2,079 $11,821 37 1,351 $21,123 38 94 $9,781 39 547 $12,494 40 1,508 $17,526 42 1,553 $14,008 43 93 $11,353 44 1,185 $13,306 45 2,622 $14,326 46 3,418 $16,038 47 1,373 $10,908 49 2,341 $34,744 50 2,385 $15,810 51 241 $16,991 52 216 $15,789 53 2,435 $23,943 55 1,458 $18,384 56 458 $16,976 57 700 $21,430 59 113 $16,063 61 249 $24,772 62 2 $20,652 63 2,964 $28,015 64 3,064 $27,189 65 39,700 $11,389 66 7,690 $11,535 67 379 $15,758 68 11,373 $12,869 69 3,665 $9,805 70 29 $6,582 71 79 $13,057 72 949 $13,674 73 7,561 $16,376 75 42,731 $60,129 76 43,909 $56,525 77 2,427 $23,987 78 38,870 $24,907 79 165,957 $32,680 80 7,866 $16,846 81 5 $20,229 82 63,317 $28,781 83 6,565 $19,177 84 1,552 $10,644 85 21,981 $24,242 86 2,201 $13,781 87 60,101 $27,456 88 396,200 $17,702 89 523,048 $20,511 90 47,344 $11,871 91 44 $14,737 92 15,549 $24,280 93 1,738 $14,448 94 12,597 $22,970 95 1,622 $12,263 96 55,628 $14,761 97 28,174 $10,803 98 9 $14,090 99 20,984 $13,983 100 8,129 $10,369 101 21,861 $17,290 102 5,503 $10,797 103 484 $378,244 104 20,223 $150,559 105 28,716 $108,046 106 3,432 $136,812 107 81,816 $99,133 108 6,341 $109,106 109 56,282 $73,253 110 53,777 $81,343 111 9,323 $49,746 113 39,244 $56,405 114 8,198 $33,220 115 19,499 $69,161 116 114,338 $44,903 117 4,622 $27,878 118 8,168 $31,457 119 1,211 $27,147 120 37,745 $46,550 121 161,616 $30,683 122 75,737 $19,715 123 38,021 $32,143 124 133,344 $27,371 125 90,371 $20,832 126 5,309 $51,405 127 663,251 $20,085 128 7,042 $14,239 129 3,774 $20,775 130 87,289 $18,660 131 26,583 $11,113 132 140,158 $12,462 133 8,475 $10,723 134 40,649 $11,970 135 7,697 $17,958 136 1,166 $11,432 138 204,872 $16,521 139 86,072 $10,173 140 54,193 $10,288 141 107,180 $14,813 142 51,782 $11,382 143 245,795 $10,741 144 93,108 $24,851 145 7,201 $11,714 146 10,627 $52,920 147 2,602 $29,373 148 132,078 $67,116 149 19,892 $27,061 150 20,888 $57,096 151 5,067 $25,243 152 4,490 $37,305 153 2,025 $21,509 154 27,969 $82,200 155 6,498 $25,001 156 4 $16,997 157 8,150 $25,875 158 4,273 $12,709 159 17,842 $26,972 160 11,973 $15,839 161 10,620 $22,659 162 6,290 $12,519 163 8 $9,397 164 5,322 $45,313 165 2,297 $22,967 166 4,142 $27,527 167 4,013 $16,618 168 1,406 $26,010 169 802 $14,782 170 15,473 $57,315 171 1,495 $23,568 172 30,878 $28,013 173 2,414 $15,971 174 247,933 $19,856 175 34,337 $11,032 176 13,301 $21,548 177 8,939 $18,108 178 3,315 $13,584 179 12,973 $21,773 180 88,999 $19,227 181 26,699 $10,651 182 268,140 $16,395 183 89,558 $11,492 184 69 $9,542 185 5,256 $17,532 186 6 $17,504 187 609 $15,462 188 82,829 $22,197 189 12,856 $12,176 190 75 $16,578 191 9,340 $88,382 192 1,299 $36,558 193 4,733 $68,254 194 638 $31,775 195 3,957 $59,356 196 969 $30,122 197 17,996 $50,435 198 5,289 $23,379 199 1,609 $48,963 200 1,069 $62,346 201 2,100 $75,551 202 26,307 $26,667 203 29,543 $28,095 204 64,510 $22,991 205 27,001 $24,271 206 2,015 $14,280 207 32,214 $22,980 208 9,967 $13,150 209 394,702 $35,979 210 121,348 $33,587 211 29,657 $22,493 212 9 $31,925 213 9,818 $37,689 216 8,691 $41,935 217 17,092 $61,011 218 23,524 $30,313 219 19,672 $19,359 223 13,125 $20,384 224 11,574 $14,926 225 6,390 $22,849 226 5,793 $30,350 227 4,783 $15,628 228 2,495 $22,908 229 1,245 $13,667 230 2,430 $25,765 232 809 $18,306 233 9,829 $40,036 234 5,300 $24,173 235 5,032 $14,695 236 39,468 $13,922 237 1,748 $11,857 238 8,729 $27,480 239 45,525 $20,661 240 11,846 $26,301 241 3,110 $12,646 242 2,542 $23,380 243 94,969 $15,031 244 14,423 $14,330 245 5,746 $9,757 246 1,473 $11,896 247 20,113 $11,410 248 13,674 $17,154 249 12,784 $13,336 250 3,727 $14,018 251 2,332 $9,097 253 21,753 $14,893 254 10,593 $8,759 256 6,586 $16,469 257 15,517 $16,712 258 15,055 $13,056 259 3,486 $17,996 260 4,160 $12,825 261 1,747 $17,565 262 653 $18,615 263 22,868 $41,675 264 3,819 $21,268 265 4,031 $31,156 266 2,516 $17,172 267 238 $20,021 268 895 $23,309 269 9,688 $35,630 270 2,743 $16,079 271 18,989 $20,610 272 5,658 $20,167 273 1,313 $12,601 274 2,264 $24,353 275 223 $12,616 276 1,304 $13,267 277 98,858 $17,235 278 31,750 $10,661 279 10 $15,979 280 17,551 $13,991 281 7,377 $9,589 283 5,976 $14,555 284 1,992 $8,504 285 6,869 $41,732 286 2,477 $39,318 287 6,166 $37,798 288 5,471 $41,746 289 6,830 $18,048 290 9,803 $16,847 291 58 $13,308 292 6,420 $55,995 293 356 $28,741 294 96,631 $15,356 295 3,475 $16,050 296 275,298 $17,000 297 47,552 $9,995 298 109 $9,503 299 1,253 $18,904 300 18,462 $22,372 301 3,554 $12,547 302 8,653 $61,825 303 21,521 $46,383 304 12,430 $47,807 305 3,009 $23,106 306 6,967 $24,014 307 1,983 $11,422 308 7,203 $31,717 309 4,094 $17,613 310 24,593 $22,507 311 7,407 $11,963 312 1,502 $21,429 313 547 $13,534 314 2 $815,660 315 33,535 $41,732 316 117,415 $26,424 317 1,994 $16,978 318 5,685 $24,541 319 403 $14,083 320 184,548 $17,149 321 30,606 $11,011 322 49 $9,127 323 19,641 $16,239 324 6,874 $9,611 325 9,136 $13,204 326 2,696 $8,569 327 7 $7,111 328 732 $15,295 329 93 $10,358 331 50,553 $21,469 332 4,905 $12,274 333 254 $19,142 334 10,300 $27,789 335 12,490 $19,981 336 35,495 $16,280 337 29,140 $10,776 338 929 $23,997 339 1,460 $22,362 341 3,545 $25,849 342 686 $14,916 344 3,549 $26,710 345 1,354 $22,352 346 4,775 $21,343 347 308 $11,845 348 3,361 $15,104 349 604 $9,831 350 6,602 $14,657 352 945 $14,499 353 2,491 $35,744 354 7,324 $28,230 355 5,481 $16,312 356 25,562 $14,230 357 5,570 $44,892 358 21,321 $22,339 359 31,420 $14,957 360 15,538 $16,445 361 339 $21,352 362 5 $16,578 363 2,471 $18,875 364 1,610 $18,054 365 1,815 $42,185 366 4,504 $25,764 367 477 $11,799 368 3,503 $23,599 369 3,419 $12,532 370 1,327 $18,299 371 1,662 $11,458 372 927 $10,237 373 4,076 $6,914 374 89 $13,913 376 316 $11,055 377 47 $21,747 378 171 $14,743 379 349 $7,238 380 98 $8,554 381 188 $10,611 382 48 $4,333 383 1,956 $10,030 384 129 $7,214 385 3 $34,210 389 12 $23,975 392 2,248 $66,268 394 2,567 $38,588 395 105,976 $16,486 396 17 $16,006 397 18,727 $25,519 398 17,860 $24,884 399 1,671 $13,548 401 5,768 $59,903 402 1,454 $22,863 403 31,365 $37,680 404 4,277 $18,437 406 2,391 $53,929 407 634 $24,003 408 2,081 $44,985 409 2,127 $25,574 410 28,001 $21,908 411 7 $7,483 412 15 $11,456 413 5,253 $27,415 414 622 $15,291 415 42,746 $75,112 416 189,451 $32,070 417 38 $22,076 418 25,456 $21,447 419 16,128 $17,016 420 3,139 $12,214 421 10,563 $14,503 422 66 $12,891 423 7,972 $36,726 424 1,224 $49,024 425 15,914 $13,506 426 4,462 $10,410 427 1,557 $10,483 428 782 $14,266 429 26,797 $15,953 430 64,123 $13,703 431 310 $12,670 432 443 $12,980 433 5,479 $5,805 439 1,493 $34,068 440 5,673 $36,892 441 668 $18,081 442 17,291 $48,763 443 3,848 $19,622 444 5,629 $14,813 445 2,485 $9,965 447 6,390 $10,119 449 32,589 $16,465 450 7,304 $8,328 452 25,308 $20,911 453 5,591 $10,522 454 4,691 $16,299 455 1,043 $9,576 461 5,133 $24,128 462 9,531 $19,503 463 26,512 $13,669 464 7,075 $9,864 465 192 $13,169 466 1,684 $14,122 467 1,106 $10,115 468 51,680 $77,692 470 52 $504,684 471 13,167 $54,184 473 7,976 $72,650 475 108,084 $75,747 476 3,608 $46,392 477 25,103 $37,665 478 106,238 $48,149 479 23,387 $27,938 480 610 $193,008 481 819 $122,102 482 5,175 $70,600 483 44,784 $328,441 484 334 $110,056 485 3,178 $61,849 486 2,077 $99,908 487 3,701 $40,225 488 760 $99,624 489 13,168 $37,620 490 5,356 $21,486 491 15,098 $31,213 492 3,052 $82,667 493 58,870 $35,610 494 28,431 $18,981 495 191 $165,379 496 2,444 $112,012 497 21,734 $66,414 498 15,556 $49,426 499 34,350 $27,633 500 49,302 $17,736 501 2,580 $51,260 502 761 $27,677 503 5,883 $24,011 504 125 $257,167 505 134 $36,044 506 916 $87,492 507 337 $37,309 508 612 $27,746 509 155 $13,241 510 1,625 $23,313 511 571 $13,248 512 481 $101,931 513 206 $107,611 515 8,028 $105,722 516 83,464 $45,394 517 194,015 $35,730 518 55,225 $36,574 519 8,892 $47,738 520 12,823 $29,760 521 30,454 $14,130 522 6,008 $10,049 523 15,103 $7,817 524 130,318 $14,293 525 562 $247,370 526 73,724 $42,080 527 194,015 $33,802 528 1,343 $140,528 529 4,633 $63,385 530 2,807 $24,282 531 3,766 $64,237 532 2,888 $30,290 533 42,601 $32,675 534 51,346 $20,340 535 5,896 $156,207 536 20,103 $118,567 537 6,765 $36,526 538 6,350 $19,355 539 4,388 $69,606 540 1,866 $25,633 1 Cases are taken from the FY 2002 MedPAR file; DRGs are from GROUPER V21.0. Table 11.—Proposed LTC-DRGs Relative Weights and Geometric and Five-Sixths of the Average Length of Stay—FY 2004 LTC-DRG Description Relative weight Geo-metric average length of stay 5/6ths of the average length of stay 1 5 CRANIOTOMY AGE >17 W CC 1.9873 41.3 34.4 2 8 CRANIOTOMY AGE > 17 W/O CC 1.9873 41.3 34.4 3 8 CRANIOTOMY AGE 0-17 1.9873 41.3 34.4 6 8 CARPAL TUNNEL RELEASE 0.5711 20.8 17.3 7 PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC 1.5898 42.5 35.4 8 4 PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC 1.4090 34.1 28.4 9 SPINAL DISORDERS & INJURIES 1.5189 34.7 28.9 10 NERVOUS SYSTEM NEOPLASMS W CC 0.7590 23.4 19.5 11 NERVOUS SYSTEM NEOPLASMS W/O CC 0.7322 21.2 17.6 12 DEGENERATIVE NERVOUS SYSTEM DISORDERS 0.7760 26.4 22.0 13 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA 0.8287 28.3 23.5 14 INTERCRANIAL HEMORRHAGE & STROKE W INFARCT 0.9449 27.5 22.9 15 NONSPECIFIC CVA & PRECEREBRAL OCCULUSION W/O INFARCT 0.9058 28.9 24.0 16 NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 0.9158 24.7 20.5 17 NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC 0.5478 20.0 16.6 18 CRANIAL & PERIPHERAL NERVE DISORDERS W CC 0.8845 24.9 20.7 19 CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC 0.6378 22.6 18.8 20 NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS 1.0135 25.1 20.9 21 2 VIRAL MENINGITIS 0.7347 23.1 19.2 22 2 HYPERTENSIVE ENCEPHALOPATHY 0.7347 23.1 19.2 23 NONTRAUMATIC STUPOR & COMA 1.0331 30.8 25.6 24 SEIZURE & HEADACHE AGE >17 W CC 1.0059 28.1 23.4 25 SEIZURE & HEADACHE AGE >17 W/O CC 0.8044 25.6 21.3 26 8 SEIZURE & HEADACHE AGE 0-17 0.7347 23.1 19.2 27 TRAUMATIC STUPOR & COMA, COMA >1 HR 1.1071 28.8 24.0 28 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC 1.0527 29.2 24.3 29 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC 0.9365 26.2 21.8 30 8 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 0.9785 27.4 22.8 31 3 CONCUSSION AGE >17 W CC 0.9785 27.4 22.8 32 3 CONCUSSION AGE >17 W/O CC 0.9785 27.4 22.8 33 8 CONCUSSION AGE 0-17 0.7347 23.1 19.2 34 OTHER DISORDERS OF NERVOUS SYSTEM W CC 0.9885 28.5 23.7 35 OTHER DISORDERS OF NERVOUS SYSTEM W/O CC 0.7817 26.9 22.4 36 8 RETINAL PROCEDURES 0.5711 20.8 17.3 37 8 ORBITAL PROCEDURES 0.5711 20.8 17.3 38 8 PRIMARY IRIS PROCEDURES 0.5711 20.8 17.3 39 8 LENS PROCEDURES WITH OR WITHOUT VITRECTOMY 0.5711 20.8 17.3 40 8 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 0.5711 20.8 17.3 41 8 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 0.5711 20.8 17.3 42 8 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS 0.5711 20.8 17.3 43 8 HYPHEMA 0.5711 20.8 17.3 44 1 ACUTE MAJOR EYE INFECTIONS 0.5711 20.8 17.3 45 8 NEUROLOGICAL EYE DISORDERS 0.7347 23.1 19.2 46 2 OTHER DISORDERS OF THE EYE AGE >17 W CC 0.7347 23.1 19.2 47 1 OTHER DISORDERS OF THE EYE AGE >17 W/O CC 0.5711 20.8 17.3 48 8 OTHER DISORDERS OF THE EYE AGE 0-17 0.5711 20.8 17.3 49 8 MAJOR HEAD & NECK PROCEDURES 1.4090 34.1 28.4 50 8 SIALOADENECTOMY 0.9785 27.4 22.8 51 8 SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY 0.9785 27.4 22.8 52 8 CLEFT LIP & PALATE REPAIR 0.9785 27.4 22.8 53 2 SINUS & MASTOID PROCEDURES AGE >17 0.7347 23.1 19.2 54 8 SINUS & MASTOID PROCEDURES AGE 0-17 0.9785 27.4 22.8 55 5 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES 1.9873 41.3 34.4 56 8 RHINOPLASTY 0.5711 20.8 17.3 57 8 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 0.9785 27.4 22.8 58 8 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 0.9785 27.4 22.8 59 8 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 0.9785 27.4 22.8 60 8 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 0.9785 27.4 22.8 61 8 MYRINGOTOMY W TUBE INSERTION AGE >17 1.4090 34.1 28.4 62 8 MYRINGOTOMY W TUBE INSERTION AGE 0-17 0.9785 27.4 22.8 63 3 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES 0.9785 27.4 22.8 64 EAR, NOSE, MOUTH & THROAT MALIGNANCY 1.2957 27.9 23.2 65 1 DYSEQUILIBRIUM 0.5711 20.8 17.3 66 1 EPISTAXIS 0.5711 20.8 17.3 67 8 EPIGLOTTITIS 0.9785 27.4 22.8 68 OTITIS MEDIA & URI AGE &>17 W CC 0.8396 23.5 19.5 69 1 OTITIS MEDIA & URI AGE &>17 W/O CC 0.5711 20.8 17.3 70 8 OTITIS MEDIA & URI AGE 0-17 0.5711 20.8 17.3 71 8 LARYNGOTRACHEITIS 0.7347 23.1 19.2 72 1 NASAL TRAUMA & DEFORMITY 0.5711 20.8 17.3 73 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 0.9506 23.7 19.7 74 8 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 0.5711 20.8 17.3 75 5 MAJOR CHEST PROCEDURES 1.9873 41.3 34.4 76 OTHER RESP SYSTEM O.R. PROCEDURES W CC 2.3848 42.2 35.1 77 5 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 1.9873 41.3 34.4 78 PULMONARY EMBOLISM 0.9226 24.8 20.6 79 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC 0.9853 23.7 19.7 80 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC 0.8550 22.8 19.0 81 8 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 0.5711 20.8 17.3 82 RESPIRATORY NEOPLASMS 0.7759 20.4 17.0 83 3 MAJOR CHEST TRAUMA W CC 0.9785 27.4 22.8 84 2 MAJOR CHEST TRAUMA W/O CC 0.7347 23.1 19.2 85 PLEURAL EFFUSION W CC 0.9068 23.9 19.9 86 PLEURAL EFFUSION W/O CC 0.7121 24.9 20.7 87 PULMONARY EDEMA & RESPIRATORY FAILURE 1.7382 32.9 27.4 88 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 0.7996 21.0 17.5 89 SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC 0.8676 22.9 19.0 90 SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC 0.7429 21.7 18.0 91 8 SIMPLE PNEUMONIA & PLEURISY AGE 0-17 0.7347 23.1 19.2 92 INTERSTITIAL LUNG DISEASE W CC 0.8403 21.8 18.1 93 INTERSTITIAL LUNG DISEASE W/O CC 0.7332 20.2 16.8 94 7 PNEUMOTHORAX W CC 0.7917 21.1 17.5 95 7 PNEUMOTHORAX W/O CC 0.7917 21.1 17.5 96 BRONCHITIS & ASTHMA AGE >17 W CC 0.7787 20.7 17.2 97 BRONCHITIS & ASTHMA AGE >17 W/O CC 0.6616 22.5 18.7 98 8 BRONCHITIS & ASTHMA AGE 0-17 0.7347 23.1 19.2 99 RESPIRATORY SIGNS & SYMPTOMS W CC 1.0818 26.9 22.4 100 RESPIRATORY SIGNS & SYMPTOMS W/O CC 1.0374 26.0 21.6 101 OTHER RESPIRATORY SYSTEM DIAGNOSES W CC 1.0071 24.5 20.4 102 OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC 0.9460 24.2 20.1 103 6 HEART TRANSPLANT 0.0000 0.0 0.0 104 8 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W CARDIAC CATH 1.9873 41.3 34.4 105 8 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W/O CARDIAC CATH 1.9873 41.3 34.4 106 8 CORONARY BYPASS W PTCA 1.9873 41.3 34.4 107 8 CORONARY BYPASS W CARDIAC CATH 1.9873 41.3 34.4 108 5 OTHER CARDIOTHORACIC PROCEDURES 1.9873 41.3 34.4 109 8 CORONARY BYPASS W/O PTCA OR CARDIAC CATH 1.9873 41.3 34.4 110 5 MAJOR CARDIOVASCULAR PROCEDURES W CC 1.9873 41.3 34.4 111 8 MAJOR CARDIOVASCULAR PROCEDURES W/O CC 1.9873 41.3 34.4 113 AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE 1.5870 40.5 33.7 114 UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS 1.4854 39.9 33.2 115 5 PRM CARD PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GNRTR P 1.9873 41.3 34.4 116 5 OTH PERM CARD PACEMAK IMPL OR PTCA W CORONARY ARTERY STENT IMPLNT 1.9873 41.3 34.4 117 3 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT 0.9785 27.4 22.8 118 5 CARDIAC PACEMAKER DEVICE REPLACEMENT 1.9873 41.3 34.4 119 3 VEIN LIGATION & STRIPPING 0.9785 27.4 22.8 120 OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 1.2476 34.1 28.4 121 CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE 0.7531 21.9 18.2 122 CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE 0.6915 20.0 16.6 123 CIRCULATORY DISORDERS W AMI, EXPIRED 0.8856 19.0 15.8 124 4 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG 1.4090 34.1 28.4 125 4 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG 1.4090 34.1 28.4 126 ACUTE & SUBACUTE ENDOCARDITIS 0.8902 25.7 21.4 127 HEART FAILURE & SHOCK 0.7968 21.9 18.2 128 1 DEEP VEIN THROMBOPHLEBITIS 0.5711 20.8 17.3 129 CARDIAC ARREST, UNEXPLAINED 1.4170 28.5 23.7 130 PERIPHERAL VASCULAR DISORDERS W CC 0.8207 25.0 20.8 131 PERIPHERAL VASCULAR DISORDERS W/O CC 0.6269 22.4 18.6 132 ATHEROSCLEROSIS W CC 0.8211 22.5 18.7 133 ATHEROSCLEROSIS W/O CC 0.7264 22.6 18.8 134 HYPERTENSION 0.8971 28.4 23.6 135 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC 0.9873 23.8 19.8 136 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC 0.7492 22.9 19.0 137 8 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 0.7347 23.1 19.2 138 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 0.9390 25.2 21.0 139 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC 0.6224 21.9 18.2 140 ANGINA PECTORIS 0.6056 19.3 16.0 141 SYNCOPE & COLLAPSE W CC 0.6735 23.3 19.4 142 SYNCOPE & COLLAPSE W/O CC 0.5149 20.5 17.0 143 CHEST PAIN 0.7317 21.9 18.2 144 OTHER CIRCULATORY SYSTEM DIAGNOSES W CC 0.8588 22.9 19.0 145 OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC 0.7001 21.4 17.8 146 8 RECTAL RESECTION W CC 1.9873 41.3 34.4 147 8 RECTAL RESECTION W/O CC 1.9873 41.3 34.4 148 MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 1.9660 36.8 30.6 149 1 MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC 0.5711 20.8 17.3 150 4 PERITONEAL ADHESIOLYSIS W CC 1.4090 34.1 28.4 151 8 PERITONEAL ADHESIOLYSIS W/O CC 1.4090 34.1 28.4 152 4 MINOR SMALL & LARGE BOWEL PROCEDURES W CC 1.4090 34.1 28.4 153 8 MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC 1.4090 34.1 28.4 154 5 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC 1.9873 41.3 34.4 155 8 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC 1.9873 41.3 34.4 156 8 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 1.9873 41.3 34.4 157 8 ANAL & STOMAL PROCEDURES W CC 1.4090 34.1 28.4 158 3 ANAL & STOMAL PROCEDURES W/O CC 0.9785 27.4 22.8 159 8 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC 1.4090 34.1 28.4 160 8 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC 1.4090 34.1 28.4 161 4 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC 1.4090 34.1 28.4 162 8 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC 0.5711 20.8 17.3 163 8 HERNIA PROCEDURES AGE 0-17 0.5711 20.8 17.3 164 8 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 1.9873 41.3 34.4 165 8 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC 0.5711 20.8 17.3 166 8 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 1.9873 41.3 34.4 167 8 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC 0.5711 20.8 17.3 168 5 MOUTH PROCEDURES W CC 1.9873 41.3 34.4 169 8 MOUTH PROCEDURES W/O CC 0.5711 20.8 17.3 170 7 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 1.7827 42.2 35.1 171 7 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC 1.7827 42.2 35.1 172 DIGESTIVE MALIGNANCY W CC 0.8857 22.4 18.6 173 DIGESTIVE MALIGNANCY W/O CC 0.7843 21.9 18.2 174 G.I. HEMORRHAGE W CC 0.8741 24.8 20.6 175 G.I. HEMORRHAGE W/O CC 0.6770 21.8 18.1 176 COMPLICATED PEPTIC ULCER 0.7835 20.6 17.1 177 2 UNCOMPLICATED PEPTIC ULCER W CC 0.7347 23.1 19.2 178 1 UNCOMPLICATED PEPTIC ULCER W/O CC 0.5711 20.8 17.3 179 INFLAMMATORY BOWEL DISEASE 1.0317 26.2 21.8 180 G.I. OBSTRUCTION W CC 0.9491 24.2 20.1 181 G.I. OBSTRUCTION W/O CC 0.7694 21.2 17.6 182 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC 0.9666 25.5 21.2 183 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC 0.7038 22.4 18.6 184 8 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 0.7347 23.1 19.2 185 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17 0.6932 24.6 20.5 186 8 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17 0.7347 23.1 19.2 187 8 DENTAL EXTRACTIONS & RESTORATIONS 0.7347 23.1 19.2 188 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC 1.0481 26.0 21.6 189 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC 0.8501 23.5 19.5 190 8 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 0.7347 23.1 19.2 191 4 PANCREAS, LIVER & SHUNT PROCEDURES W CC 1.4090 34.1 28.4 192 1 PANCREAS, LIVER & SHUNT PROCEDURES W/O CC 0.5711 20.8 17.3 193 2 BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC 0.7347 23.1 19.2 194 2 BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC 0.7347 23.1 19.2 195 4 CHOLECYSTECTOMY W C.D.E. W CC 1.4090 34.1 28.4 196 8 CHOLECYSTECTOMY W C.D.E. W/O CC 0.9785 27.4 22.8 197 3 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 0.9785 27.4 22.8 198 8 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC 0.9785 27.4 22.8 199 8 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY 0.7347 23.1 19.2 200 2 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY 0.7347 23.1 19.2 201 5 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES 1.9873 41.3 34.4 202 CIRRHOSIS & ALCOHOLIC HEPATITIS 0.7529 22.7 18.9 203 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS 0.6801 19.2 16.0 204 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1.0141 23.4 19.5 205 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC 0.7334 22.3 18.5 206 2 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC 0.7347 23.1 19.2 207 DISORDERS OF THE BILIARY TRACT W CC 0.7940 22.1 18.4 208 2 DISORDERS OF THE BILIARY TRACT W/O CC 0.7347 23.1 19.2 209 5 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF LOWER EXTREMITY 1.9873 41.3 34.4 210 4 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 1.4090 34.1 28.4 211 2 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC 0.7347 23.1 19.2 212 8 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 0.7347 23.1 19.2 213 AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS 1.3912 34.9 29.0 216 5 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 1.9873 41.3 34.4 217 WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS 1.4438 39.3 32.7 218 3 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC 0.9785 27.4 22.8 219 8 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC 0.9785 27.4 22.8 220 8 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17 0.9785 27.4 22.8 223 3 MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC 0.9785 27.4 22.8 224 8 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC 0.7347 23.1 19.2 225 FOOT PROCEDURES 0.8912 26.7 22.2 226 4 SOFT TISSUE PROCEDURES W CC 1.4090 34.1 28.4 227 3 SOFT TISSUE PROCEDURES W/O CC 0.9785 27.4 22.8 228 3 MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC 0.9785 27.4 22.8 229 8 HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC 0.7347 23.1 19.2 230 4 LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR 1.4090 34.1 28.4 232 2 ARTHROSCOPY 0.7347 23.1 19.2 233 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC 0.9797 28.5 23.7 234 2 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC 0.7347 23.1 19.2 235 FRACTURES OF FEMUR 0.8715 29.7 24.7 236 FRACTURES OF HIP & PELVIS 0.7598 27.2 22.6 237 2 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH 0.7347 23.1 19.2 238 OSTEOMYELITIS 0.8818 28.5 23.7 239 PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY 0.6892 22.4 18.6 240 CONNECTIVE TISSUE DISORDERS W CC 0.7118 21.4 17.8 241 CONNECTIVE TISSUE DISORDERS W/O CC 0.4744 19.4 16.1 242 SEPTIC ARTHRITIS 0.7814 26.2 21.8 243 MEDICAL BACK PROBLEMS 0.6867 23.5 19.5 244 BONE DISEASES & SPECIFIC ARTHROPATHIES W CC 0.5664 20.1 16.7 245 BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC 0.5134 19.5 16.2 246 NON-SPECIFIC ARTHROPATHIES 0.5556 23.0 19.1 247 SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE 0.5976 21.4 17.8 248 TENDONITIS, MYOSITIS & BURSITIS 0.7623 24.9 20.7 249 AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE 0.8101 27.3 22.7 250 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC 0.8309 30.1 25.0 251 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC 0.6031 26.7 22.2 252 8 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 0.7347 23.1 19.2 253 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC 0.8406 27.1 22.5 254 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/O CC 0.7028 25.8 21.5 255 8 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 0.7347 23.1 19.2 256 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES 0.8577 26.6 22.1 257 3 TOTAL MASTECTOMY FOR MALIGNANCY W CC 0.9785 27.4 22.8 258 8 TOTAL MASTECTOMY FOR MALIGNANCY W/O CC 0.9785 27.4 22.8 259 8 SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC 0.9785 27.4 22.8 260 8 SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC 0.9785 27.4 22.8 261 5 BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION 1.9873 41.3 34.4 262 1 BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY 0.5711 20.8 17.3 263 SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC 1.4696 41.1 34.2 264 SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC 1.2160 39.9 33.2 265 7 SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC 1.2294 34.7 28.9 266 7 SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC 1.2294 34.7 28.9 267 8 PERIANAL & PILONIDAL PROCEDURES 0.5711 20.8 17.3 268 4 SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES 1.4090 34.1 28.4 269 OTHER SKIN, SUBCUT TISS & BREAST PROC W CC 1.5232 45.2 37.6 270 OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC 1.0105 35.9 29.9 271 SKIN ULCERS 0.9795 29.9 24.9 272 MAJOR SKIN DISORDERS W CC 0.7163 22.7 18.9 273 1 MAJOR SKIN DISORDERS W/O CC 0.5711 20.8 17.3 274 MALIGNANT BREAST DISORDERS W CC 0.9469 24.9 20.7 275 2 MALIGNANT BREAST DISORDERS W/O CC 0.7347 23.1 19.2 276 1 NON-MALIGANT BREAST DISORDERS 0.5711 20.8 17.3 277 CELLULITIS AGE >17 W CC 0.7762 24.1 20.0 278 CELLULITIS AGE >17 W/O CC 0.6373 21.6 18.0 279 CELLULITIS AGE 0-178 0.5711 20.8 17.3 280 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC 0.9719 29.3 24.4 281 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC 0.7915 27.8 23.1 282 8 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 0.7347 23.1 19.2 283 MINOR SKIN DISORDERS W CC 0.6998 20.7 17.2 284 MINOR SKIN DISORDERS W/O CC 0.6259 23.0 19.1 285 AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DISORDERS 1.5856 38.6 32.1 286 ADRENAL & PITUITARY PROCEDURES8 1.4090 34.1 28.4 287 SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS 1.4793 41.7 34.7 288 5 O.R. PROCEDURES FOR OBESITY 1.9873 41.3 34.4 289 8 PARATHYROID PROCEDURES 0.9785 27.4 22.8 290 8 THYROID PROCEDURES 0.9785 27.4 22.8 291 8 THYROGLOSSAL PROCEDURES 0.9785 27.4 22.8 292 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC 1.5633 35.8 29.8 293 3 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC 0.9785 27.4 22.8 294 DIABETES AGE >35 0.8729 26.6 22.1 295 3 DIABETES AGE 0-35 0.9785 27.4 22.8 296 NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC 0.9560 26.3 21.9 297 NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC 0.7552 26.4 22.0 298 8 NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 0.7347 23.1 19.2 299 2 INBORN ERRORS OF METABOLISM 0.7347 23.1 19.2 300 ENDOCRINE DISORDERS W CC 0.8175 23.9 19.9 301 ENDOCRINE DISORDERS W/O CC 0.7287 22.9 19.0 302 6 KIDNEY TRANSPLANT 0.0000 0.0 0.0 303 8 KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM 1.9873 41.3 34.4 304 5 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC 1.9873 41.3 34.4 305 1 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC 0.5711 20.8 17.3 306 4 PROSTATECTOMY W CC 1.4090 34.1 28.4 307 8 PROSTATECTOMY W/O CC 1.4090 34.1 28.4 308 4 MINOR BLADDER PROCEDURES W CC 1.4090 34.1 28.4 309 2 MINOR BLADDER PROCEDURES W/O CC 0.7347 23.1 19.2 310 4 TRANSURETHRAL PROCEDURES W CC 1.4090 34.1 28.4 311 1 TRANSURETHRAL PROCEDURES W/O CC 0.5711 20.8 17.3 312 4 URETHRAL PROCEDURES, AGE >17 W CC 1.4090 34.1 28.4 313 8 URETHRAL PROCEDURES, AGE >17 W/O CC 0.5711 20.8 17.3 314 8 URETHRAL PROCEDURES, AGE 0-17 0.5711 20.8 17.3 315 OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES 1.5690 36.4 30.3 316 RENAL FAILURE 0.9869 24.5 20.4 317 3 ADMIT FOR RENAL DIALYSIS 0.9785 27.4 22.8 318 KIDNEY & URINARY TRACT NEOPLASMS W CC 0.7466 21.7 18.0 319 1 KIDNEY & URINARY TRACT NEOPLASMS W/O CC 0.5711 20.8 17.3 320 KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC 0.7744 23.5 19.5 321 KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC 0.6641 23.0 19.1 322 8 KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 0.7347 23.1 19.2 323 2 URINARY STONES W CC, &/OR ESW LITHOTRIPSY 0.7347 23.1 19.2 324 2 URINARY STONES W/O CC 0.7347 23.1 19.2 325 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC 0.8854 27.2 22.6 326 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC 0.7590 24.7 20.5 327 8 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0-17 0.7347 23.1 19.2 328 1 URETHRAL STRICTURE AGE >17 W CC 0.5711 20.8 17.3 329 8 URETHRAL STRICTURE AGE >17 W/O CC 0.5711 20.8 17.3 330 8 URETHRAL STRICTURE AGE 0-17 0.5711 20.8 17.3 331 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC 0.8847 23.8 19.8 332 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC 0.6201 22.1 18.4 333 8 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 0.5711 20.8 17.3 334 8 MAJOR MALE PELVIC PROCEDURES W CC 0.9785 27.4 22.8 335 8 MAJOR MALE PELVIC PROCEDURES W/O CC 0.9785 27.4 22.8 336 8 TRANSURETHRAL PROSTATECTOMY W CC 0.7347 23.1 19.2 337 8 TRANSURETHRAL PROSTATECTOMY W/O CC 0.7347 23.1 19.2 338 8 TESTES PROCEDURES, FOR MALIGNANCY 0.5711 20.8 17.3 339 1 TESTES PROCEDURES, NON-MALIGNANCY AGE >17 0.5711 20.8 17.3 340 8 TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 0.5711 20.8 17.3 341 2 PENIS PROCEDURES 0.7347 23.1 19.2 342 1 CIRCUMCISION AGE >17 0.5711 20.8 17.3 343 8 CIRCUMCISION AGE 0-17 0.5711 20.8 17.3 344 2 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY 0.7347 23.1 19.2 345 3 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY 0.9785 27.4 22.8 346 7 MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC 0.7787 22.3 18.5 347 7 MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC 0.7787 22.3 18.5 348 1 BENIGN PROSTATIC HYPERTROPHY W CC 0.5711 20.8 17.3 349 1 BENIGN PROSTATIC HYPERTROPHY W/O CC 0.5711 20.8 17.3 350 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM 1.1947 25.6 21.3 351 8 STERILIZATION, MALE 0.5711 20.8 17.3 352 3 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES 0.9785 27.4 22.8 353 8 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY 1.9873 41.3 34.4 354 8 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC 1.9873 41.3 34.4 355 8 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC 1.9873 41.3 34.4 356 8 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1.4090 34.1 28.4 357 8 UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY 1.4090 34.1 28.4 358 8 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 1.4090 34.1 28.4 359 8 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC 1.4090 34.1 28.4 360 4 VAGINA, CERVIX & VULVA PROCEDURES 1.4090 34.1 28.4 361 8 LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 0.5711 20.8 17.3 362 8 ENDOSCOPIC TUBAL INTERRUPTION 0.5711 20.8 17.3 363 8 D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY 0.7347 23.1 19.2 364 8 D&C, CONIZATION EXCEPT FOR MALIGNANCY 0.7347 23.1 19.2 365 5 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES 1.9873 41.3 34.4 366 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC 0.8153 23.0 19.1 367 2 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC 0.7347 23.1 19.2 368 INFECTIONS, FEMALE REPRODUCTIVE SYSTEM 0.6911 20.1 16.7 369 3 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 0.9785 27.4 22.8 370 8 CESAREAN SECTION W CC 0.9785 27.4 22.8 371 8 CESAREAN SECTION W/O CC 0.7347 23.1 19.2 372 8 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 0.7347 23.1 19.2 373 8 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 0.7347 23.1 19.2 374 8 VAGINAL DELIVERY W STERILIZATION &/OR D&C 0.7347 23.1 19.2 375 8 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C 0.7347 23.1 19.2 376 1 POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE 0.5711 20.8 17.3 377 8 POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE 0.7347 23.1 19.2 378 8 ECTOPIC PREGNANCY 0.9785 27.4 22.8 379 8 THREATENED ABORTION 0.5711 20.8 17.3 380 8 ABORTION W/O D&C 0.5711 20.8 17.3 381 8 ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 0.5711 20.8 17.3 382 8 FALSE LABOR 0.5711 20.8 17.3 383 8 OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS 0.5711 20.8 17.3 384 8 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS 0.5711 20.8 17.3 385 1 NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 0.5711 20.8 17.3 386 8 EXTREME IMMATURITY 0.7347 23.1 19.2 387 8 PREMATURITY W MAJOR PROBLEMS 0.7347 23.1 19.2 388 8 PREMATURITY W/O MAJOR PROBLEMS 0.7347 23.1 19.2 389 8 FULL TERM NEONATE W MAJOR PROBLEMS 0.7347 23.1 19.2 390 8 NEONATE W OTHER SIGNIFICANT PROBLEMS 0.7347 23.1 19.2 391 8 NORMAL NEWBORN 0.5711 20.8 17.3 392 8 SPLENECTOMY AGE >17 0.7347 23.1 19.2 393 8 SPLENECTOMY AGE 0-17 0.7347 23.1 19.2 394 3 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS4 1.4090 34.1 28.4 395 RED BLOOD CELL DISORDERS AGE >17 0.9050 26.8 22.3 396 8 RED BLOOD CELL DISORDERS AGE 0-17 0.5711 20.8 17.3 397 COAGULATION DISORDERS 1.0816 25.2 21.0 398 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC 0.9248 23.0 19.1 399 1 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC 0.5711 20.8 17.3 401 5 LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 1.9873 41.3 34.4 402 3 LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC 0.9785 27.4 22.8 403 LYMPHOMA & NON-ACUTE LEUKEMIA W CC 0.9099 22.7 18.9 404 LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC 0.7410 17.9 14.9 405 8 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 0.7347 23.1 19.2 406 5 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC 1.9873 41.3 34.4 407 8 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC 0.9785 27.4 22.8 408 3 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC 0.9785 27.4 22.8 409 RADIOTHERAPY 0.8961 25.1 20.9 410 3 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS 0.9785 27.4 22.8 411 3 HISTORY OF MALIGNANCY W/O ENDOSCOPY 0.9785 27.4 22.8 412 5 HISTORY OF MALIGNANCY W ENDOSCOPY 1.9873 41.3 34.4 413 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC 0.9603 25.2 21.0 414 2 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC 0.7347 23.1 19.2 415 O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES 1.7239 40.9 34.0 416 SEPTICEMIA AGE >17 0.9553 25.2 21.0 417 8 SEPTICEMIA AGE 0-17 0.9785 27.4 22.8 418 POSTOPERATIVE & POST-TRAUMATIC INFECTIONS 0.8612 25.3 21.0 419 3 FEVER OF UNKNOWN ORIGIN AGE >17 W CC 0.9785 27.4 22.8 420 1 FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC 0.5711 20.8 17.3 421 2 VIRAL ILLNESS AGE >17 0.7347 23.1 19.2 422 8 VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 0.5711 20.8 17.3 423 OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES 0.9930 25.9 21.5 424 O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS 1.2281 44.2 36.8 425 ACUTE ADJUSTMENT REACTION & PSYCHOLOGICAL DYSFUNCTION 0.6040 26.9 22.4 426 DEPRESSIVE NEUROSES 0.5583 23.3 19.4 427 4 NEUROSES EXCEPT DEPRESSIVE 1.4090 34.1 28.4 428 1 DISORDERS OF PERSONALITY & IMPULSE CONTROL 0.5711 20.8 17.3 429 ORGANIC DISTURBANCES & MENTAL RETARDATION 0.6562 27.4 22.8 430 PSYCHOSES 0.4808 22.6 18.8 431 1 CHILDHOOD MENTAL DISORDERS 0.5711 20.8 17.3 432 1 OTHER MENTAL DISORDER DIAGNOSES 0.5711 20.8 17.3 433 ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA 0.3416 14.6 12.1 439 SKIN GRAFTS FOR INJURIES 1.4429 41.2 34.3 440 WOUND DEBRIDEMENTS FOR INJURIES 1.6794 39.4 32.8 441 5 HAND PROCEDURES FOR INJURIES 1.9873 41.3 34.4 442 OTHER O.R. PROCEDURES FOR INJURIES W CC 1.6280 46.4 38.6 443 3 OTHER O.R. PROCEDURES FOR INJURIES W/O CC 0.9785 27.4 22.8 444 TRAUMATIC INJURY AGE >17 W CC 0.9311 30.7 25.5 445 TRAUMATIC INJURY AGE >17 W/O CC 0.8278 27.3 22.7 446 8 TRAUMATIC INJURY AGE 0-17 0.7347 23.1 19.2 447 3 ALLERGIC REACTIONS AGE >17 0.9785 27.4 22.8 448 8 ALLERGIC REACTIONS AGE 0-17 0.5711 20.8 17.3 449 3 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC 0.9785 27.4 22.8 450 3 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC 0.9785 27.4 22.8 451 8 POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 0.5711 20.8 17.3 452 COMPLICATIONS OF TREATMENT W CC 0.9830 25.5 21.2 453 COMPLICATIONS OF TREATMENT W/O CC 0.8894 25.5 21.2 454 2 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC 0.7347 23.1 19.2 455 1 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC 0.5711 20.8 17.3 461 O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES 1.4214 36.6 30.5 462 REHABILITATION 0.6528 22.7 18.9 463 SIGNS & SYMPTOMS W CC 0.7824 26.4 22.0 464 SIGNS & SYMPTOMS W/O CC 0.6259 25.2 21.0 465 1 AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS 0.5711 20.8 17.3 466 AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS 0.7783 22.6 18.8 467 OTHER FACTORS INFLUENCING HEALTH STATUS 1.4773 32.6 27.1 468 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2.0716 43.7 36.4 469 6 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 0.0000 0.0 0.0 470 6 UNGROUPABLE 0.0000 0.0 0.0 471 5 BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY 1.9873 41.3 34.4 473 2 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 0.7347 23.1 19.2 475 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT 2.0241 33.0 27.5 476 PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.0056 32.9 27.4 477 NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1.8688 40.7 33.9 478 7 OTHER VASCULAR PROCEDURES W CC 1.3238 34.9 29.0 479 7 OTHER VASCULAR PROCEDURES W/O CC 1.3238 34.9 29.0 480 6 LIVER TRANSPLANT 0.0000 0.0 0.0 481 8 BONE MARROW TRANSPLANT 0.5711 20.8 17.3 482 5 TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES 1.9873 41.3 34.4 483 TRACH W MECH VENT 96+ HRS OR PDX EXCEPT FACE,MOUTH & NECK DIAG 3.1562 54.9 45.7 484 8 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1.9873 41.3 34.4 485 8 LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR 1.9873 41.3 34.4 486 4 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1.4090 34.1 28.4 487 OTHER MULTIPLE SIGNIFICANT TRAUMA 1.2653 33.2 27.6 488 5 HIV W EXTENSIVE O.R. PROCEDURE 1.9873 41.3 34.4 489 HIV W MAJOR RELATED CONDITION 0.9656 22.1 18.4 490 HIV W OR W/O OTHER RELATED CONDITION 0.7956 20.5 17.0 491 8 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY 1.9873 41.3 34.4 492 8 CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR W USE HIGH DOSE CHEMOTHERAPY AGENT 0.9785 27.4 22.8 493 4 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 1.4090 34.1 28.4 494 4 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC 1.4090 34.1 28.4 495 6 LUNG TRANSPLANT 0.0000 0.0 0.0 496 8 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 1.4090 34.1 28.4 497 3 SPINAL FUSION W CC 0.9785 27.4 22.8 498 3 SPINAL FUSION W/O CC 0.9785 27.4 22.8 499 5 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 1.9873 41.3 34.4 500 4 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC 1.4090 34.1 28.4 501 5 KNEE PROCEDURES W PDX OF INFECTION W CC 1.9873 41.3 34.4 502 2 KNEE PROCEDURES W PDX OF INFECTION W/O CC 0.7347 23.1 19.2 503 3 KNEE PROCEDURES W/O PDX OF INFECTION 0.9785 27.4 22.8 504 8 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1.9873 41.3 34.4 505 3 EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT 0.9785 27.4 22.8 506 2 FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA 0.7347 23.1 19.2 507 2 FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 0.7347 23.1 19.2 508 2 FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA 0.7347 23.1 19.2 509 1 FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA 0.5711 20.8 17.3 510 2 NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA 0.7347 23.1 19.2 511 1 NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA 0.5711 20.8 17.3 512 6 SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT 0.0000 0.0 0.0 513 6 PANCREAS TRANSPLANT 0.0000 0.0 0.0 515 5 CARDIAC DEFIBRILATOR IMPLANT W/O CARDIAC CATH 1.9873 41.3 34.4 516 8 PERCUTANEOUS CARDIVASCULAR PROCEDURE W AMI 0.9785 27.4 22.8 517 4 PERCUTANEOUS CARDIVASCULAR PROC W NON-DRUG ELUTING STENT W/O AMI 1.4090 34.1 28.4 518 3 PERCUTANEOUS CARDIVASCULAR PROC W/O CORONARY ARTERY STENT OR AMI 0.9785 27.4 22.8 519 4 CERVICAL SPINAL FUSION W CC 1.4090 34.1 28.4 520 8 CERVICAL SPINAL FUSION W/O CC 0.9785 27.4 22.8 521 ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC 0.5064 20.9 17.4 522 ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY W/O CC 0.4221 19.5 16.2 523 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O CC 0.4366 21.9 18.2 524 TRANSIENT ISCHEMIA 0.6178 23.4 19.5 525 8 HEART ASSIST SYSTEM IMPLANT 1.9873 41.3 34.4 526 8 PERCUTANEOUS CARVIOVASCULAR PROC W DRUG-ELUTING STENT W AMI 1.4090 34.1 28.4 527 8 PERCUTANEOUS CARVIOVASCULAR PROC W DRUG-ELUTING STENT W/O AMI 1.4090 34.1 28.4 528 8 INTRACRANIAL VASCLUAR PROCEDURES WITH PDX HEMORRHAGE 1.9873 41.3 34.4 529 2 VENTRICULAR SHUNT PROCEDURES WITH CC 0.7347 23.1 19.2 530 8 VENTRICULAR SHUNT PROCEDURES WITHOUT CC 0.7347 23.1 19.2 531 8 SPINAL PROCEDURES WITH CC 1.4090 34.1 28.4 532 4 SPINAL PROCEDURES WITHOUT CC 1.4090 34.1 28.4 533 8 EXTRACRANIAL VASCULAR PROCEDURES WITH CC 1.9873 41.3 34.4 534 5 EXTRACRANIAL VASCULAR PROCEDURES WITHOUT CC 1.9873 41.3 34.4 535 8 CARDIAC DEFIB IMPLANT WITH CARDIAC CATH WITH AMI/HF/SHOCK 1.9873 41.3 34.4 536 5 CARDIAC DEFIB IMPLANT WITH CARDIAC CATH WITHOUT AMI/HF/SHOCK 1.9873 41.3 34.4 537 8 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC 0.7347 23.1 19.2 538 4 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC 1.4090 34.1 28.4 539 8 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC 1.9873 41.3 34.4 540 1 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC 0.5711 20.8 17.3 1 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low volume quintile 1. 2 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low volume quintile 2. 3 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low volume quintile 3. 4 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low volume quintile 4. 5 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low volume quintile 5. 6 Proposed relative weights for these proposed LTC-DRGs were assigned a value of 0.0000. 7 Proposed relative weights for these proposed LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 5 above). 8 Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to the appropriate proposed low volume quintile because they had no LTCH cases in the FY 2002 MedPAR. Appendix A—Regulatory Analysis of Impacts I. Background and Summary We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act
(RFA)(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. Executive Order 12866 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). Based on the overall percentage change in payments per case estimated using our payment simulation model (a 2.5 percent increase), we estimate that the total impact of these proposed changes for FY 2004 payments compared to FY 2003 payments to be approximately a $2.1 billion increase. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes. The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and 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 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the acute care hospital inpatient prospective payment systems, we classify these hospitals as urban hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any 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 would 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. The following analysis, in conjunction with the remainder of this document, demonstrates that this proposed rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. The proposed rule would affect payments to a substantial number of small rural hospitals as well as other classes of hospitals, and the effects on some hospitals may be significant. II. Objectives The primary objective of the IPPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of preserving the Medicare Trust Fund. We believe the changes in this proposed rule would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences. III. Limitations of Our Analysis The following quantitative analysis presents the projected effects of our proposed policy changes, as well as statutory changes effective for FY 2004, on various hospital groups. We estimate the effects of individual proposed policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but we do not attempt to predict behavioral responses to our proposed policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. As we have done in previous proposed rules, we are soliciting comments and information about the anticipated effects of these proposed changes on hospitals and our methodology for estimating them. IV. Hospitals Included In and Excluded From the IPPS The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general short-term, acute care hospitals that participate in the Medicare program. There were 45 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 48 such hospitals in Maryland remain excluded from the IPPS under the waiver at section 1814(b)(3) of the Act. There are approximately 729 critical access hospitals (CAHs). These small, limited service hospitals are paid on the basis of reasonable costs rather than under the IPPS. The remaining 20 percent are specialty hospitals that are excluded from the IPPS. These specialty hospitals include psychiatric hospitals and units, rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals. The impacts of our proposed policy changes on these hospitals are discussed below. Thus, as of April 2003, we have included 4,087 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 April 2003, there were 1,085 specialty hospitals excluded from the IPPS that were paid instead on a reasonable cost basis subject to the rate-of-increase ceiling under § 413.40. Broken down by specialty, there were 484 psychiatric, 214 rehabilitation, 296 long-term care, 80 children's, and 11 cancer hospitals. In addition, there were 1,410 psychiatric units and 979 rehabilitation units in hospitals otherwise subject to the IPPS. Under § 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 48 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 IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid based on their reasonable costs are subject to TEFRA limits for FY 2004. For these hospitals, the proposed update is the percentage increase in the excluded hospital market basket (currently estimated at 3.5 percent). Inpatient rehabilitation facilities
(IRFs)are paid under a prospective payment system (IRF PPS) for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2004, the IRF PPS is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. Therefore, these hospitals would not be impacted by this proposed rule. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs are paid under a LTCH PPS, based on the adjusted Federal prospective payment amount, updated annually. LTCHs will receive a blended payment (Federal prospective payment and a reasonable cost-based payment) over a 5-year transition period. However, under the LTCH PPS, a LTCH 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 LTCH PPS transition blend payment based on reasonable costs for inpatient operating services would be determined by updating the LTCH's TEFRA limit by the estimate of the excluded hospital market basket (or 3.5 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 would 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 would 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 IPPS for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing policy changes and payment rate updates for the IPPS for operating and capital-related costs. Based on the overall percentage change in payments per case estimated using our payment simulation model (a 2.5 percent increase), we estimate the total impact of these changes for FY 2004 payments compared to FY 2003 payments to be approximately a $2.1 billion increase. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes. We have prepared separate impact analyses of the proposed changes to each system. This section deals with changes to the operating prospective payment system. Our payment simulation model relies on available data to enable us to estimate the impacts on payments per case of certain changes we are proposing in this proposed rule. However, there are other changes we are proposing for which we do not have data available that would allow us to estimate the payment impacts using this model. For those proposals, we have attempted to predict the payment impacts of those proposed changes based upon our experience and other more limited data. The data used in developing the quantitative analyses of changes in payments per case presented below are taken from the FY 2002 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Although the analyses of the changes to the operating PPS do not incorporate cost data, data from the most recently available hospital cost report were used to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to these proposed policy changes, and we do not adjust for future changes in such variables as admissions, lengths of stay, or case-mix. Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we 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. However, for individual hospitals, some miscategorizations are possible. Using cases in the FY 2002 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the IPPSs (Indian Health Service hospitals and hospitals in Maryland) were excluded from the simulations. The impact of payments under the capital IPPS, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of proposed FY 2004 changes to the capital IPPS are discussed in section IX. of this Appendix. The proposed changes discussed separately below are the following: • The effects of expanding the postacute care transfer policy to 19 additional DRGs. • The effects of the proposed annual reclassification of diagnoses and procedures and the recalibration of the DRG relative weights required by section 1886(d)(4)(C) of the Act. • The effects of the proposed changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 2000, compared to the FY 1999 wage data, including the effects of removing wage data for Part B costs of RCHs and FQHCs. • The effects of geographic reclassifications by the MGCRB that will be effective in FY 2004. • The total change in payments based on proposed FY 2004 policies relative to payments based on FY 2003 policies. To illustrate the impacts of the proposed FY 2004 changes, our analysis begins with a FY 2004 baseline simulation model using: the FY 2003 DRG GROUPER (version 20.0); the current postacute care transfer policy for 10 DRGs; the FY 2003 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating DRG and outlier payments. Each proposed and statutory policy change is then added incrementally to this baseline model, finally arriving at an FY 2004 model incorporating all of the proposed changes. This allows us to isolate the effects of each proposed change. Our final comparison illustrates the percent change in payments per case from FY 2003 to FY 2004. Five factors have significant impacts here. The first is the update to the standardized amounts. In accordance with section 1886(b)(3)(B)(i) of the Act, we are proposing to update the large urban and the other areas average standardized amounts for FY 2004 using the most recently forecasted hospital market basket increase for FY 2004 of 3.5 percent. Under section 1886(b)(3)(B)(iv) of the Act, the updates to the hospital-specific amounts for sole community hospitals
(SCHs)and for Medicare-dependent small rural hospitals
(MDHs)are also equal to the market basket increase, or 3.5 percent. A second significant factor that impacts changes in hospitals' payments per case from FY 2003 to FY 2004 is the change in MGCRB status from one year to the next. That is, hospitals reclassified in FY 2003 that are no longer reclassified in FY 2004 may have a negative payment impact going from FY 2003 to FY 2004; conversely, hospitals not reclassified in FY 2003 that are reclassified in FY 2004 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. However, this effect is alleviated by section 1886(d)(10)(D)(v) of the Act, which provides 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 2003 will be 5.5 percent of total DRG payments. When the FY 2003 final rule was published, we projected FY 2003 outlier payments would be 5.1 percent of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the higher than expected outlier payments during FY 2003 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2003 payments per case to estimated FY 2004 payments per case. Fourth, we are proposing to expand the postacute care transfer policy to 19 additional DRGs. This proposed expansion would result in Medicare savings of $160 million because we would no longer pay a full DRG payment for these cases. As a result, there would be a lower total increase in Medicare spending for FY 2004. Fifth, section 402(b) of Pub. L. 108-7 provided that the large urban standardized amount of the Federal rate is applicable for all IPPS hospitals for discharges occurring on or after April 1, 2003, and before October 1, 2003. For discharges occurring on or after October 1, 2003, the Federal rate will again be based on separate average standardized amounts for hospitals in large urban areas and for hospitals in other areas. The effect is to reduce the percent increase in FY 2004 payments compared to those made in FY 2003. B. Analysis of Table I 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 4,087 hospitals included in the analysis. This number is 143 fewer hospitals than were included in the impact analysis in the FY 2003 final rule (67 FR 50279). There are 98 new CAHs that were excluded from last year's 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 2,582 hospitals located in urban areas (MSAs or NECMAs) included in our analysis. Among these, there are 1,493 hospitals located in large urban areas (populations over 1 million), and 1,089 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 1,505 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 2004 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 2,591, 1,572, 1,019, and 1,496, respectively. The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have GME residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 2,976 nonteaching hospitals in our analysis, 873 teaching hospitals with fewer than 100 residents, and 238 teaching hospitals with 100 or more residents. In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural after MGCRB reclassifications. Therefore, hospitals in the rural DSH categories represent hospitals that were not reclassified for purposes of the standardized amount or for purposes of the DSH adjustment. (However, they may 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 (149), SCHs (494), MDHs (254), and hospitals that are both SCH and RRC
(78)shown here were not reclassified for purposes of the standardized amount. 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 2000 Medicare cost report files, if available (otherwise FY 1999 data are used). Data needed to determine ownership status were unavailable for 120 hospitals. Similarly, the data needed to determine Medicare utilization were unavailable for 104 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 2004. 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 Proposed Changes for FY 2004 Operating Prospective Payment System [Percent changes in payments per case] Number of hosps. 1 Transfer changes 2004 base 2 DRG changes 3 New wage data 4 New wage index without nonphys. part B 5 DRG & wage index changes 6 MCGRB reclassi- fication 7 ALL FY 2004 changes 8
(8)By Geographic Location: All hospitals 4,087 −0.2 0.0 −0.4 0.1 0.0 0.0 2.5 Urban hospitals 2,582 −0.2 0.0 −0.5 0.1 0.0 −0.4 2.5 Large urban areas (populations over 1 million) 1,493 −0.2 0.0 −0.4 0.0 −0.1 −0.4 2.6 Other urban areas (populations of 1 million of fewer) 1,089 −0.2 −0.1 −0.5 0.3 0.1 −0.2 2.2 Rural hospitals 1,505 −0.2 0.0 −0.2 0.0 0.5 2.6 3.1 Bed Size (Urban): 0-99 beds 626 −0.3 0.0 −0.1 0.3 0.6 −0.7 2.7 100-199 beds 916 −0.2 0.0 −0.4 0.2 0.1 −0.4 2.6 200-299 beds 507 −0.2 0.0 −0.5 0.1 −0.1 −0.3 2.3 300-499 beds 377 −0.2 0.0 −0.3 0.1 0.1 −0.3 2.5 500 or more beds 156 −0.1 −0.1 −0.8 0.1 −0.5 −0.4 2.3 Bed Size (Rural): 0-49 beds 690 −0.2 0.2 −0.3 0.0 0.7 0.6 3.4 50-99 beds 477 −0.2 0.0 −0.2 0.0 0.5 1.0 3.3 100-149 beds 202 −0.2 0.0 −0.3 0.0 0.3 2.9 2.8 150-199 beds 70 −0.2 −0.1 0.0 0.0 0.7 4.6 2.7 200 or more beds 66 −0.1 −0.1 −0.1 0.0 0.4 4.8 3.0 Urban by Region: New England 134 −0.4 0.0 −1.0 0.8 1.1 −0.1 2.7 Middle Atlantic 394 −0.2 0.0 −1.0 0.1 −0.7 0.1 1.7 South Atlantic 372 −0.2 0.0 −0.4 0.1 −0.1 −0.5 2.5 East North Central 429 −0.2 0.0 −0.5 0.1 −0.1 −0.4 2.5 East South Central 155 −0.1 −0.1 0.3 0.1 0.6 −0.6 3.1 West North Central 176 −0.2 −0.1 0.1 0.1 0.3 −0.7 2.8 West South Central 329 −0.1 0.0 −0.4 0.0 −0.2 −0.6 2.5 Mountain 131 −0.2 −0.2 0.5 0.1 0.7 −0.5 3.5 Pacific 416 −0.2 −0.1 −0.4 0.1 −0.1 −0.4 2.5 Puerto Rico 46 0.0 −0.1 −0.1 0.0 −0.1 −0.7 2.9 Rural by Region: New England 38 −0.2 −0.1 0.3 0.0 0.8 2.6 3.3 Middle Atlantic 67 −0.2 0.1 −0.1 0.0 0.3 2.4 2.6 South Atlantic 221 −0.2 0.0 −0.3 0.0 0.2 2.9 2.3 East North Central 199 −0.2 −0.1 0.2 0.0 0.8 2.1 3.1 East South Central 232 −0.2 0.1 −0.2 0.0 0.4 2.8 3.0 West North Central 254 −0.1 −0.1 −0.2 0.1 1.0 1.9 3.8 West South Central 273 −0.1 0.1 −0.4 0.1 0.2 3.7 3.5 Mountain 127 −0.1 −0.1 −0.2 0.0 0.3 1.5 3.2 Pacific 89 −0.2 −0.1 −0.5 0.1 0.5 2.5 3.5 Puerto Rico 5 0.0 −0.1 −4.1 0.0 −4.1 0.4 −0.2 By Payment Classification: Urban hospitals 2,591 −0.2 0.0 −0.5 0.1 0.0 −0.3 2.5 Large urban areas (populations over 1 million) 1,572 −0.2 0.0 −0.4 0.1 −0.1 −0.2 2.7 Other urban areas (populations of 1 million of fewer) 1,019 −0.2 −0.1 −0.5 0.3 0.1 −0.4 2.2 Rural areas 1,496 −0.2 0.0 −0.2 0.0 0.5 2.2 3.0 Teaching Status: Non-teaching 2,976 −0.2 0.0 −0.3 0.1 0.2 0.4 2.6 Fewer than 100 Residents 873 −0.2 −0.1 −0.2 0.1 0.2 −0.2 2.6 100 or more Residents 238 −0.2 −0.1 −0.9 0.1 −0.5 −0.1 2.3 Urban DSH: Non-DSH 1,381 −0.2 −0.1 −0.2 0.1 0.2 0.0 2.7 100 or more beds 1,398 −0.2 0.0 −0.6 0.1 −0.1 −0.3 2.4 Less than 100 beds 276 −0.3 0.0 −0.2 0.3 0.5 −0.5 2.4 Rural DSH: Sole Community
(SCH)484 −0.1 0.1 −0.2 0.0 0.5 0.4 3.7 Referral Center
(RRC)161 −0.1 −0.1 −0.1 0.0 0.4 4.6 2.8 Other Rural: 100 or more beds 75 −0.3 0.1 −0.5 0.0 0.1 1.0 1.9 Less than 100 beds 312 −0.3 0.2 −0.4 0.0 0.3 1.0 2.5 Urban teaching and DSH: DSH 771 −0.2 0.0 −0.6 0.1 −0.1 −0.3 2.5 Teaching and no DSH 273 −0.2 −0.1 −0.3 0.1 0.0 −0.2 2.6 No teaching and DSH 903 −0.2 0.0 −0.5 0.2 0.0 −0.2 2.3 No teaching and no DSH 644 −0.2 0.0 −0.2 0.1 0.3 −0.3 2.7 Rural Hospital Types: Non special status hospitals 521 −0.3 0.1 −0.4 0.0 0.3 1.0 2.2 RRC 149 −0.2 −0.1 −0.1 0.0 0.6 5.9 2.6 SCH 494 −0.1 0.0 −0.1 0.0 0.5 0.3 3.9 Medicare-dependent hospitals
(MDH)254 −0.3 0.2 −0.2 0.0 0.8 0.7 3.3 SCH and RRC 78 0.0 −0.1 −0.1 0.0 0.3 1.4 3.3 Type of Ownership: Voluntary 2,435 −0.2 0.0 −0.5 0.1 0.0 0.0 2.5 Proprietary 699 −0.2 0.0 −0.2 0.1 0.2 0.0 2.6 Government 833 −0.2 0.0 −0.4 0.1 0.0 0.3 2.7 Unknown 120 −0.1 0.0 −1.1 0.0 −0.8 −0.4 1.8 Medicare Utilization as a Percent of Inpatient Days: 0-25 304 −0.2 −0.1 0.0 0.0 0.1 −0.3 3.0 25-50 1,557 −0.2 0.0 −0.5 0.1 −0.1 −0.2 2.5 50-65 1,663 −0.2 0.0 −0.4 0.2 0.2 0.3 2.5 Over 65 459 −0.2 0.0 −0.1 0.1 0.4 0.7 2.7 Unknown 104 −0.2 −0.1 0.0 0.0 0.2 −0.6 3.0 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2004 Reclassifications: All Reclassified Hospitals 639 −0.2 0.0 −0.3 0.1 0.3 4.3 3.0 Standardized Amount Only 22 −0.2 0.0 −0.7 0.5 0.0 3.9 5.8 Wage Index Only 556 −0.2 0.0 −0.4 0.2 0.3 4.3 2.4 Both 33 −0.2 −0.1 −0.4 0.2 0.2 6.0 3.1 Nonreclassified Hospitals 3,442 −0.2 0.0 −0.4 0.1 0.0 −0.62.5 All Reclassified Urban Hospitals 136 −0.2 0.0 −0.5 0.3 0.1 4.0 2.7 Standardized Amount Only 13 −0.2 −0.1 −1.4 0.2 −1.2 0.9 2.4 Wage Index Only 82 −0.2 0.0 −0.7 0.3 0.1 3.9 2.3 Both 41 −0.3 0.0 0.1 0.2 0.6 5.4 3.8 Urban Nonreclassified Hospitals 2,415 −0.2 0.0 −0.5 0.1 −0.1 −0.6 2.4 All Reclassified Rural Hospitals 503 −0.2 −0.1 −0.1 0.0 0.5 4.6 3.2 Standardized Amount Only 15 −0.2 0.1 −0.4 0.1 0.4 4.8 2.1 Wage Index Only 464 −0.1 −0.1 −0.1 0.0 0.5 4.2 3.2 Both 24 −0.2 0.0 −0.1 0.0 0.5 8.7 3.8 Rural Nonreclassified Hospitals 999 −0.2 0.1 −0.3 0.0 0.5 −0.5 2.8 Other Reclassified Hospitals (Section 1886(D)(8)(B)) 34 −0.2 0.1 0.0 0.0 0.4 −2.0 1.8 1 Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 2002, and hospital cost report data are from reporting periods beginning in FY 2000 and FY 1999. 2 This column displays the payment impact of the expanded postacute care transfer policy. 3 This column displays the payment impact of the recalibration of the DRG weights based on FY 2002 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 2000 cost reports. 5 This column displays the impact of removing nonphysician Part B costs and hours from cost report data (Worksheet S-3, Part II, Line 5.01). 6 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 removal of nonphysician Part B 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 3, 4, and 5, and the proposed FY 2004 budget neutrality factor of 1.003133. 7 Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2004 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2004. Reclassification for prior years has no bearing on the payment impacts shown here. 8 This column shows changes in payments from FY 2003 to FY 2004. It incorporates all of the changes displayed in columns 2, 6, and 7 (the changes displayed in columns 3, 4, and 5 are included in column 6). It also reflects the impact of the FY 2004 update, changes in hospitals' reclassification status in FY 2004 compared to FY 2003, and the difference in outlier payments from FY 2003 to FY 2004. The sum of these impacts may be different from the percentage changes shown here due to rounding and interactive effect. C. Impact of the Proposed Changes to the Postacute Care Transfer Policy (Column 2) In column 2 of Table I, we present the effects of the postacute care transfer policy expansion, as discussed in section IV.A. of the preamble to this proposed rule. We compared aggregate payments using the FY 2003 DRG relative weights (GROUPER version 21.0) with the expanded postacute care transfer policy to aggregate payments using the proposed expanded postacute care transfer policy (with the additional 19 DRGs). The changes we are proposing to make would result in 0.2 percent lower payments to hospitals overall. We estimate the total savings at approximately $160 million. To simulate the impact of this proposed policy, we calculated hospitals' transfer-adjusted discharges and case-mix index values, including the proposed additional 19 DRGs. The transfer-adjusted discharge fraction is calculated in one of two ways, depending on the transfer payment methodology. Under our current transfer payment methodology, for all but the three DRGs receiving special payment consideration (DRGs 209, 210, and 211), this adjustment is made by adding 1 to the length of stay and dividing that amount by the geometric mean length of stay for the DRG (with the resulting fraction not to exceed 1.0). For example, a transfer after 3 days from a DRG with a geometric mean length of stay of 6 days would have a transfer-adjusted discharge fraction of 0.667 ((3+1)/6). For transfers from any one of the three DRGs receiving the alternative payment methodology, the transfer-adjusted discharge fraction is 0.5 (to reflect that these cases receive half the full DRG amount the first day), plus one half of the result of dividing 1 plus the length of stay prior to transfer by the geometric mean length of stay for the DRG. None of the proposed 19 additional DRGs would receive the alternative payment methodology. As with the above adjustment, the result is equal to the lesser of the transfer-adjusted discharge fraction or 1. The transfer-adjusted case-mix index values are calculated by summing the transfer-adjusted DRG weights and dividing by the transfer-adjusted discharges. The transfer-adjusted DRG weights are calculated by multiplying the DRG weight by the lesser of 1 or the transfer-adjusted discharge fraction for the case, divided by the geometric mean length of stay for the DRG. In this way, simulated payments per case can be compared before and after the proposed change to the transfer policy. This proposed expansion of the policy has a negative 0.2 percent payment impact overall among both urban and rural hospitals. There is very small variation among all of the hospital categories from this negative 0.2 percent impact. This outcome is different than the impacts exhibited when we implemented the postacute care transfer policy for the current 10 DRGs in the July 31, 1998 **Federal Register** (63 FR 41108). At that time, the impact of going from no postacute transfer policy to a postacute care transfer policy applicable to 10 DRGs was a 0.6 percent decrease in payments per case. In addition, at that time, the impact was greatest among urban hospitals (0.7 percent payment decrease, compared to 0.4 percent among rural hospitals). The less dramatic impact observed for this proposed expansion to additional DRGs is not surprising. The movement to transfer more and more patients for postacute care sooner appears to have abated in recent years. While it does appear that many patients continue to be transferred for postacute care early in the course of their acute care treatment, the rapid expansion of this trend that was apparent during the mid-90s appears to have subsided. To a large extent, this decline probably stems from the decreased payment incentives to transfer patients to postacute care settings as a result of the implementation of prospective payment systems for IRFs, SNFs, LTCHs, and HHAs. D. 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 annually to 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 2003 DRG relative weights (GROUPER version 20.0) to aggregate payments using the proposed FY 2004 DRG relative weights (GROUPER version 21.0). Both simulations reflected the proposed expansion of the postacute care transfer policy. 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 proposed budget neutrality factor of 1.003133 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 major DRG classification changes we are proposing are: Creating additional DRGs that are split based on the presence or absence of CCs; creating a new DRG for cases with ruptured brain aneurysms; and creating a new DRG for cases involving the implantation of a cardiac defibrillator where the patient experiences acute myocardial infarction, heart failure, or shock. In the aggregate, these proposed changes would result in 0.0 percent change in overall payments to hospitals. The overall level of the DRG weights are determined by the normalization factor intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS. Because we count transfer cases as a fraction of a case in the recalibration process, expanding the postacute care transfer policy to 19 additional DRGs would affect the proposed relative weights for those DRGs. Therefore, we calculated the proposed FY 2004 normalization factor comparing the case-mix using the proposed FY 2004 DRG relative weights in which we treated postacute care transfer cases in the 19 additional DRGs being proposed for FY 2004 as a fraction of a case with the case-mix using the FY 2003 DRG relative weights without treating cases in these 19 additional DRGs as transfer cases. As noted above, the proposed expansion of the postacute care transfer policy impacts the overall level of the DRG weights, contributing to the impacts seen in this column. Rural hospitals with fewer than 50 beds would experience a 0.2 percent increase due to these changes, while rural hospitals with more than 150 beds will experience a 0.1 percent decrease. Also, RRCs and hospitals classified with both SCH and RRC would experience a 0.1 percent decrease. MDHs would experience a 0.2 percent increase. Hospitals in the urban Mountain census division would experience the largest change, with a 0.2 percent decrease. Again, these impacts are ultimately offset by the budget neutrality factor of 1.003133. E. Impact of Proposed Wage Index Changes (Columns 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 2004 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 1999 and before October 1, 2000. As with column 3, the impact of the new data on hospital payments is isolated in column 4 by holding the other payment parameters constant in this simulation. That is, column 4 shows the percentage changes in payments when going from a model using the FY 2003 wage index (based on FY 1999 wage data to a model using the FY 2004 pre-reclassification wage index based on FY 2000 wage data). The wage data collected on the FY 2000 cost reports are similar to the data used in the calculation of the FY 2003 wage index. Also, as described in section III.B of this preamble, the proposed FY 2004 wage index is calculated by removing the nonphysician Part B costs and hours of RHCs and FQHCs, shown in column 5. Column 4 shows the impacts of updating the wage data using FY 2000 cost reports. Overall, the new wage data would lead to a 0.4 percent reduction, but this reduction is offset by the budget neutrality factor. Urban hospitals' wage indexes would decline by 0.5 percent, and rural hospitals' wage indexes would decline by 0.2 percent. Among regions, the largest impact of updating the wage data is seen in rural Puerto Rico (a 4.1 percent decrease). Rural hospitals in the Pacific and West South Central regions would experience the next largest impact, a 0.5 percent and 0.4 percent decrease, respectively. Rural New England and East North Central regions would experience an increase of 0.3 percent and 0.2 percent, respectively. Among urban hospitals, New England and the Middle Atlantic regions would experience 1.0 percent decreases, respectively. These impacts result, respectively, from a 9.0 percent decrease in the proposed FY 2004 wage index for Springfield, Massachusetts, and a 6.1 percent decrease in the Pittsburgh, Pennsylvania wage index. The East South Central, West North Central, and Mountain regions would experience increases of 0.3 percent, 0.1 percent, and 0.5 percent, respectively. The next column shows the impacts on the calculation of the proposed FY 2004 wage index of removing nonphysician Part B data for RHCs and FQHCs. Column 5 shows the impacts of removing nonphysician Part B costs for RHCs and FQHCs. The effects of this proposed change are relatively small with the exception of New England, which would experience a 0.8 percent decrease. We note that the wage data used for the proposed wage index are based upon the data available as of March 2003 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 2004 relative to FY 2003. This chart demonstrates the impact of the changes for the proposed FY 2004 wage index, including updating to FY 2000 wage data. The majority of labor market areas
(331)would experience less than a 5-percent change. A total of 13 labor market areas would experience an increase of more than 5 percent and less than 10 percent. Two areas would experience an increase greater than 10 percent. A total of 24 areas would experience decreases of more than 5 percent and less than 10 percent. Finally, 3 areas would experience declines of 10 percent or more. Percentage change in area wage index values Number of labor market areas FY 2003 FY 2004 Increase more than 10 percent 3 2 Increase more than 5 percent and less than 10 percent 11 13 Increase or decrease less than 5 percent 343 331 Decrease more than 5 percent and less than 10 percent 15 24 Decrease more than 10 percent 1 3 Among urban hospitals, 45 would experience an increase of between 5 and 10 percent and 8 more than 10 percent. A total of 64 rural hospitals would experience increases greater than 5 percent, but none would experience greater than 10-percent increases. On the negative side, 109 urban hospitals would experience decreases in their wage index values of at least 5 percent but less than 10 percent. Nine urban hospitals and one rural hospital would experience decreases in their wage index values greater than 10 percent. There are 25 rural hospitals that would experience decreases in their wage index values of greater than 5 percent but less 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 8 0 Increase more than 5 percent and less than 10 percent 45 64 Increase or decrease less than 5 percent 2,436 1,714 Decrease more than 5 percent and less than 10 percent 109 25 Decrease more than 10 percent 9 1 F. Combined Impact of Proposed DRG and Wage Index Changes, Including Budget Neutrality Adjustment (Column 6) The impact of the 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 2003 DRG relative weights and wage index to simulated aggregate payments using the proposed FY 2004 DRG relative weights and blended wage index. In addition, we are required to ensure that any add-on payments for new technology under section 1886(d)(5)(K) of the Act are budget neutral. As discussed in section II.E. of the preamble of this proposed rule, we are proposing to maintain the new technology status of Xigris TM (approved in last year's final rule at 67 FR 50013). We estimate the proposed total add-on payments for this new technology for FY 2004 would be $50 million. We computed a proposed wage and recalibration budget neutrality factor of 1.003133. The 0.0 percent impact for all hospitals demonstrates that these proposed changes, in combination with the proposed budget neutrality factor, are budget neutral. In Table I, the combined overall impacts of the effects of both the proposed DRG reclassifications and recalibration and the proposed updated wage index are shown in column 6. The proposed changes in this column are the sum of the proposed changes in columns 3, 4, and 5, combined with the budget neutrality factor and the wage index floor for urban areas required by section 4410 of Pub. L. 105-33 to be budget neutral. There also may be some variation of plus or minus 0.1 percentage point due to rounding. G. 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 7 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2004. 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 2004 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2004. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process as of February 28, 2003. 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 2004. 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 1.003133 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 would rise 2.6 percent in column 7. Payments to urban hospitals would decline 0.4 percent. Hospitals in other urban areas would experience an overall decrease in payments of 0.2 percent, while large urban hospitals would lose 0.4 percent. Among urban hospital groups (that is, bed size, census division, and special payment status), payments generally would decline. A positive impact is evident among most of the rural hospital groups. The smallest increases among the rural census divisions are 0.4 and 1.5 percent for the Puerto Rico and Mountain regions, respectively. The largest increases are in the rural South Atlantic and West South Central regions. These regions would experience increases of 2.9 and 3.7 percent, respectively. Among all the hospitals that were reclassified for FY 2004 (including hospitals that received wage index reclassifications in FY 2002 or FY 2003 that extend for 3 years), the MGCRB changes are estimated to provide a 4.3 percent increase in payments. Urban hospitals reclassified for FY 2004 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 3.9 percent is expected, while those reclassified for purposes of the wage index only show a 4.3 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 0.6 percent for urban hospitals and 0.5 percent for rural hospitals. H. All Changes (Column 8) Column 8 compares our estimate of payments per case, incorporating all changes reflected in this proposed rule for FY 2004 (including statutory changes), to our estimate of payments per case in FY 2003. This column includes all of the proposed policy changes. Because the reclassifications shown in column 7 do not reflect FY 2003 reclassifications, the impacts of FY 2004 reclassifications only affect the impacts from FY 2003 to FY 2004 if the reclassification impacts for any group of hospitals are different in FY 2004 compared to FY 2003. Column 8 includes the effects of the 3.5 percent update to the standardized amounts and the hospital-specific rates for MDHs and SCHs. It also reflects the 0.4 percentage point difference between the projected outlier payments in FY 2003 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2003 (5.5 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.4 percent higher in FY 2003 than originally estimated, resulting in a 0.4 percent smaller increase than would otherwise occur. Section 213 of Public Law 106-554 provides 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 2004, eligible SCHs receive 100 percent of their 1996 hospital-specific rate. The impact of this provision is modeled in column 8 as well. The proposed expansion of the postacute care transfer policy also reduces payments by paying for discharges to postacute care in 19 additional DRGs as transfers. Because FY 2003 payments reflect full DRG payments for all cases in these 19 DRGs, there is a negative impact due to the proposed expansion of this policy compared to FY 2003. The net effect of this proposed policy, as displayed in column 2, is also seen in the lower overall percent change shown in column 8 comparing FY 2004 simulated payments per case to FY 2003 payments. Another influence on the overall change reflected in this column is the requirement of section 402(b) of Public Law 108-7 that all hospitals receive the large urban standardized amount for all discharges occurring on or after April 1, 2003, and before October 1, 2003. For discharges occurring on or after October 1, 2003, the Federal rate will again be calculated based on separate average standardized amounts for hospitals in large urban areas and for hospitals in other areas. The effect is to reduce the percent increase reflected in the “all changes” column. 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 described above. The overall change in payments per case for hospitals in FY 2004 would increases by 2.5 percent. Hospitals in urban areas would experience a 2.5 percent increase in payments per case compared to FY 2003. Hospitals in rural areas, meanwhile, would experience a 3.1 percent payment increase. Hospitals in large urban areas would experience a 2.6 percent increase in payments. Among urban census divisions, the largest payment increase was 3.5 percent in the Mountain region. Hospitals in the urban East South Central region and in Puerto Rico would experience an overall increase of 3.1 percent and 2.9 percent, respectively. The smallest increase would occur in the Middle Atlantic, with an increase of 1.7 percent. These below average increases are primarily due to the inflated outlier payments for some of these hospitals during FY 2003 compared to FY 2004. Among rural regions, the only hospital category that would experience overall payment decreases is Puerto Rico, where payments would decrease by 0.2 percent, largely due to the updated wage data. In the West North Central region, payments are projected to increase by 3.8 percent. West South Central and Pacific regions also would benefit, both with 3.5 percent increases. Among special categories of rural hospitals, those hospitals receiving payment under the hospital-specific methodology (SCHs, MDHs, and SCH/RRCs) would experience payment increases of 3.9 percent, 3.3 percent, and 3.3 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 would not experience negative payment impacts from the decline in outlier payments from FY 2003 to FY 2004 as would hospitals paid based on the national standardized amounts. Hospitals that were reclassified for FY 2004 are estimated to receive a 3.0 percent increase in payments. Urban hospitals reclassified for FY 2004 are anticipated to receive an increase of 2.7 percent, while rural reclassified hospitals are expected to benefit from reclassification with a 3.2 percent increase in payments. Overall, among hospitals reclassified for purposes of the standardized amount, a payment increase of 5.8 percent is expected, while those hospitals reclassified for purposes of the wage index only would show an expected 2.4 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 1.8 percent. Table II.—Impact Analysis of Proposed Changes for FY 2004 Operating Prospective Payment System [Payments per case] Number of hospitals Average FY 2003 payment per case 1 Average FY 2004 payment per case 1 All FY 2004 changes
(4)By Geographic Location: All hospitals 4,087 7,423 7,612 2.5 Urban hospitals 2,582 7,890 8,084 2.5 Large urban areas (populations over 1 million) 1,493 8,368 8,586 2.6 Other urban areas (populations of 1 million or fewer) 1,089 7,257 7,418 2.2 Rural hospitals 1,505 5,393 5,558 3.1 Bed Size (Urban): 0-99 beds 626 5,479 5,625 2.7 100-199 beds 916 6,658 6,829 2.6 200-299 beds 507 7,610 7,788 2.3 300-499 beds 377 8,445 8,660 2.5 500 or more beds 156 10,027 10,261 2.3 Bed Size (Rural): 0-49 beds 690 4,468 4,620 3.4 50-99 beds 477 5,037 5,204 3.3 100-149 beds 202 5,430 5,582 2.8 150-199 beds 70 5,780 5,937 2.7 200 or more beds 66 6,792 6,993 3.0 Urban by Region: New England 134 8,326 8,555 2.7 Middle Atlantic 394 8,916 9,064 1.7 South Atlantic 372 7,454 7,640 2.5 East North Central 429 7,416 7,604 2.5 East South Central 155 7,156 7,376 3.1 West North Central 176 7,659 7,875 2.8 West South Central 329 7,343 7,523 2.5 Mountain 131 7,697 7,967 3.5 Pacific 416 9,598 9,840 2.5 Puerto Rico 46 3,329 3,426 2.9 Rural by Region: New England 38 6,841 7,067 3.3 Middle Atlantic 67 5,426 5,565 2.6 South Atlantic 221 5,486 5,614 2.3 East North Central 199 5,451 5,622 3.1 East South Central 232 4,922 5,071 3.0 West North Central 254 5,294 5,497 3.8 West South Central 273 4,711 4,875 3.5 Mountain 127 6,235 6,436 3.2 Pacific 89 7,151 7,399 3.5 Puerto Rico 5 2,553 2,548 −0.2 By Payment Classification: Urban hospitals 2,591 7,886 8,080 2.5 Large urban areas (populations over 1 million) 1,572 8,283 8,502 2.7 Other urban areas (populations of 1 million of fewer) 1,019 7,302 7,460 2.2 Rural areas 1,496 5,355 5,516 3.0 Teaching Status: Non-teaching 2,976 6,132 6,293 2.6 Fewer than 100 Residents 873 7,666 7,867 2.6 100 or more Residents 238 11,347 11,603 2.3 Urban DSH: Non-DSH 1,381 6,624 6,803 2.7 100 or more beds 1,398 8,502 8,706 2.4 Less than 100 beds 276 5,447 5,579 2.4 Rural DSH: Sole Community
(SCH)484 5,239 5,434 3.7 Referral Center
(RRC)161 6,159 6,331 2.8 Other Rural: 100 or more beds 75 4,696 4,785 1.9 Less than 100 beds 312 4,278 4,386 2.5 Urban teaching and DSH: Both teaching and DSH 771 9,333 9,562 2.5 Teaching and no DSH 273 7,618 7,814 2.6 No teaching and DSH 903 6,852 7,009 2.3 No teaching and no DSH 644 6,174 6,341 2.7 Rural Hospital Types: Non special status hospitals 521 4,445 4,544 2.2 RRC 149 5,851 6,003 2.6 SCH 494 5,630 5,849 3.9 Medicare-dependent hospitals
(MDH)254 4,168 4,305 3.3 SCH and RRC 78 6,757 6,982 3.3 Type of Ownership: Voluntary 2,435 7,532 7,722 2.5 Proprietary 699 7,087 7,272 2.6 Government 833 7,164 7,356 2.7 Unknown 120 7,431 7,565 1.8 Medicare Utilization as a Percent of Inpatient Days: 0-25 304 9,997 10,294 3.0 25-50 1,557 8,448 8,657 2.5 50-65 1,663 6,450 6,613 2.5 Over 65 459 5,764 5,916 2.7 Unknown 104 6,720 6,921 3.0 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2004 Reclassifications: All Reclassified Hospitals 639 6,883 7,088 3.0 Standardized Amount Only 22 5,590 5,912 5.8 Wage Index Only 556 6,914 7,077 2.4 Both 33 6,081 6,269 3.1 All Nonreclassified Hospitals 3,442 7,542 7,734 2.5 All Urban Reclassified Hospitals 136 8,787 9,020 2.7 Urban Nonreclassified Hospitals 13 6,211 6,358 2.4 Standardized Amount Only 82 9,866 10,098 2.3 Wage Index Only 41 6,934 7,200 3.8 Both 2,415 7,853 8,045 2.4 All Reclassified Rural Hospitals 503 6,006 6,199 3.2 Standardized Amount Only 15 4,743 4,843 2.1 Wage Index Only 464 6,014 6,205 3.2 Both 24 6,242 6,482 3.8 Rural Nonreclassified Hospitals 999 4,624 4,756 2.8 Other Reclassified Hospitals (Section 1886(d)(8)(B)) 34 4,950 5,039 1.8 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 2004 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 2003 with the average estimated per case payments for FY 2004, 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 Other Policy Changes In addition to those proposed changes discussed above that we are able to model using our IPPS payment simulation model, we are proposing various other changes in this proposed rule. Generally, we have limited or no specific data available with which to estimate the impacts of these proposed changes. Our estimates of the likely impacts associated with these other proposed changes are discussed below. A. Changes to Bed and Patient Day Counting Policies 1. Background Under IPPS, both the IME and the DSH adjustments utilize statistics regarding the number of beds and patient days of a hospital to determine the level of the respective payment adjustment. For IME, hospitals receiving this adjustment want to minimize their numbers of beds in order to maximize their resident-to-bed ratio. For DSH, urban hospitals with 100 or more beds qualify for a higher payment adjustment, so some hospitals have an incentive to maximize their bed count to qualify for higher payments. Existing regulations specify that the number of beds 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. 2. Unoccupied Beds Over the years, questions have arisen 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. In section IV.C. of the preamble of this proposed rule, we are proposing to base the determination of whether a bed is available upon whether the unit where the bed is located is staffed for patient care. If the bed is located in a unit that was staffed by nurses to provide patient care at any time during the 3 preceding months, all of the beds in the unit would be counted for purposes of determining available bed days during the current month. If no patient care were provided in that unit during the 3 preceding months, the beds in the unit would be excluded from the determination of available bed days during the current month. This proposal is primarily intended to establish clear and consistent guidelines for hospitals and fiscal intermediaries to use when determining whether beds should be counted. We do not anticipate this proposal would have a significant impact on payments. In some cases, previously uncounted beds would now be counted, such as when a hospital is undertaking to remodel a unit and that unit is temporarily unavailable for patient occupancy. Under the proposed policy, if the remodeling is completed in less than 3 months and patients are again being treated in the unit, all of the beds in the unit would be counted as available for the entire year. 3. Nonacute Care Beds and Days The proposed rule would clarify that days attributable to a nonacute care unit or ward, regardless of whether the unit or ward is separately certified by Medicare or is adjacent to a unit or ward used to provide an acute level of care, would not be included in the count of bed or patient days. In a recent decision by the Ninth Circuit Court of Appeals ( *Alhambra Hosp.* v. *Thompson* , 259 F.3d 1017 (9th Cir. 2001)), the court found that our policy for counting patient days did not preclude a hospital from counting the patient days attributable to a nonacute care unit adjacent to an area of the hospital subject to the IPPS. Under this ruling, hospitals within the jurisdiction of the Ninth Circuit would be able to count those patient days. Because the *Alhambra* decision was based on a regulatory interpretation, this proposed rule, when finalized, would supersede the *Alhambra* decision in the Ninth Circuit. We estimate that if all hospitals in the Ninth Circuit that could take advantage of this ruling were currently doing so, the impact of this provision of the proposed rule would be $184 million in reduced Medicare program payments to the affected hospitals in FY 2004 for DSH. This estimate reflects the impact of adding all days of non-Medicare certified nursing facilities to the count of inpatient days for hospitals in the nine States under the jurisdiction of the Ninth Circuit. For example, in Alaska, nursing facility days constitute 11 percent of total Medicaid inpatient days. If all of these nursing facility days are currently included in the Medicaid inpatient days count, we estimate this proposed provision would reduce Medicare DSH payments to Alaska's hospitals by $662,097. We are unable to estimate the effect of this proposed provision on specific hospitals because we are not aware of specific hospitals that are presently including those inpatient days in their calculation of Medicaid days for purposes of determining their Medicare DSH percentage. However, we expect the impact on any particular hospital would be minimal (with no impact on the level of beneficiary services), because the days attributable to patients receiving these limited benefit programs should be only a small portion of the overall Medicaid days at any particular hospital. No other provider types would be affected. However, because our policy is to count patient days and beds consistently, inclusion of the days of postacute care units in the DSH calculation would lead to an offsetting negative payment impact for teaching hospitals. The inclusion of additional beds decreases the resident-to-bed ratios used to calculate the IME adjustments. Therefore, the actual potential impact on hospitals of this policy clarification is likely to be significantly less than $184 million. 4. Observation and Swing-Beds We are proposing to revise our regulations to clarify that swing-bed and observation bed days are to be excluded from the count of bed and patient days. Because this certification reflects our current policy, despite the fact that there has been some confusion and we have had adverse court decisions, we do not anticipate this clarification would have a significant impact on payments. We do not have data available that would enable us to identify those hospitals that have not been applying this policy and, therefore, would be required to change their policy. Consequently, we are unable to quantify the impacts of this clarification. 5. Labor, Delivery, Recovery, and Postpartum Beds and Days Similarly, in the case of labor, delivery, recovery, and postpartum rooms, we would clarify that it is necessary to apportion the days and costs of a patient stay between the labor/delivery ancillary cost centers and the routine adults and pediatrics cost center on the basis of the percentage of time during the entire stay associated with these various services. Because this is a clarification of existing policy, we do not anticipate this proposed change would have a significant payment impact. However, we do not have data available that would enable us to identify those hospitals that have not been applying this policy and, therefore, would be required to change their policy. Consequently, we are unable to quantify the impacts of this clarification. 6. Days Associated With Demonstration Projects Under Section 1115 of the Act Some States have demonstration projects that provide family planning or outpatient drug benefits that are limited benefits that do not include Medicaid coverage for inpatient services. In this proposed rule, we also would clarify that any hospital inpatient days attributed to a patient who is not eligible for Medicaid inpatient hospital benefits either under the approved State plan or through a section 1115 waiver must not be counted in the calculation of Medicaid days for purposes of determining a hospital's DSH percentage. We estimated the potential impact of the proposed clarification to our policy of excluding days associated with inpatients who are eligible only for Medicaid outpatient benefits. We identified the percentage of individuals receiving only outpatient family planning benefits under Medicaid compared to all Medicaid-eligible beneficiaries (this is currently the only outpatient-only category for which we have numbers of eligible beneficiaries). These percentages were calculated on a statewide basis for each State with a family planning benefit. Based on these percentages, assuming family planning beneficiaries use inpatient services at the same rate as all other Medicaid beneficiaries, we estimated the amount of total Medicare DSH payments for each State that may be attributable to family planning beneficiaries' use of inpatient services. For example, in Alabama, total Medicare DSH payments in 1999 (the latest year for which a complete database of cost reports from all hospitals is available) were $97.1 million. Because the percentage of family planning beneficiaries to total Medicaid eligible beneficiaries is 11.24 percent, we estimated 11.24 percent of $97.1 million in Medicare DSH payments, or $10.9 million, is the maximum amount of Medicare DSH that may currently be attributable to the inclusion of inpatient days for individuals who are only eligible for outpatient family planning Medicaid benefits. Based on this analysis, we have identified the potential impact upon hospitals to be as much as $290 million in reduced DSH payments from the Medicare program to those hospitals in FY 2004. Of this amount, $170 million is attributable to California. This amount is not an impact on State programs nor does it require States to spend any additional money. We also note that we are not aware of any specific hospitals that are including inpatient days attributable to individuals with no inpatient Medicaid benefits. Therefore, this estimate reflects the maximum potential impact, but the actual impact is very likely to be much less. We are unable to estimate the effect of this clarification on specific hospitals because we are not aware of specific hospitals that are presently including those inpatient days in their calculation of Medicaid days for purposes of determining their Medicare DSH percentage. However, we expect the impact on any particular hospital would be minimal (with no impact on the level of beneficiary services), because the days attributable to patients receiving these limited benefit programs should be only a small portion of the overall Medicaid days at any particular hospital. No other provider types would be affected. 7. Dual-Eligible Patient Days We are proposing to change our policy for counting days for patients who are Medicare beneficiaries and also eligible for Medicaid, to begin to count in the Medicaid fraction of the DSH patient percentage the patient days of these dual-eligible Medicare beneficiaries whose Medicare coverage has expired. Our current policy regarding dual-eligible patient days is they are counted in the Medicare fraction and excluded from the Medicaid fraction, even if the patient has no Medicare Part A coverage or coverage has been exhausted. However, we recognize it is often difficult for fiscal intermediaries to differentiate the days for dual-eligible patients whose Part A coverage has been exhausted. We believe the impact of this proposed change would be minimal, both because situations where dual-eligible patients exhaust their Medicare benefits occur infrequently, and because, due to the administrative difficulty separately identifying these days, in many cases they are already included in the hospital's Medicaid fraction. Accordingly, we do not have data available to allow us to quantify the impact of this proposed change precisely. 8. Medicare+Choice (M+C) Days We have received questions whether patients enrolled in a Medicare+Choice (M+C) Plan should be counted in the Medicare fraction or the Medicaid fraction of the DSH patient percentage calculation. The questions stem from whether M+C plan enrollees are entitled to Medicare Part A because M+C plans are administered through Medicare Part C. We are proposing to clarify that once a beneficiary elects Medicare Part C, those patient days attributable to the beneficiary should not be included in the Medicare fraction of the DSH patient percentage. These patient days should be included in the count of total patient days in the Medicaid fraction (the denominator), and the patient's days for an M+C beneficiary who is also eligible for Medicaid would be included in the numerator of the Medicaid fraction. We do not have data readily available to assess the impacts of this proposed change. In particular, it appears likely that there is some variation in how these days are currently being handled from one hospital and fiscal intermediary to the next. Nonetheless, we believe there should not be a major impact associated with this proposed change. B. Costs of Approved Nursing and Allied Health Education Activities 1. Continuing Education In section IV.E. of the preamble of this proposed rule, we are proposing to clarify further the distinction between continuing education, which is not eligible for pass-through payment, and approved educational programs, which are eligible for pass-through payment. An approved program that qualifies for pass-through payment is generally a program of long duration designed to develop trained practitioners in a nursing or allied health discipline, such as professional nursing, in which the individual learns “value-added” skills that enable him or her to work in a particular capacity upon completion of the program. Such a program is in contrast to a continuing education program in which a practitioner, such as a registered nurse, receives training in a specialized skill or a new technology. While such training is undoubtedly valuable in enabling the nurse to treat patients with special needs, the nurse, upon completion of the program, continues to function as a registered nurse, albeit one with an additional skill. We are proposing to clarify our policy concerning not allowing pass-through payment for continuing education because it has come to our attention that certain programs, which in our view constitute continuing education, such as pharmacy or clinical pastoral education, are inappropriately receiving pass-through payment. To the extent that Medicare would no longer pay for such programs as pharmacy and clinical pastoral education, Medicare payments would be reduced. We believe that these two programs comprise a small fraction of the approximately $230 million that are paid for all nursing and allied health education programs under Medicare. 2. Nonprovider-Operated Nursing and Allied Health Education Programs With Wholly Owned Subsidiary Educational Institutions As discussed in section IV.E.3. of this proposed rule, we are proposing that Medicare would not recoup reasonable cost payment from hospitals that have received pass-through payment for portions of cost reporting periods occurring on or before October 1, 2003 (the effective date of finalizing this proposed rule) for costs of nursing or allied health education program(s) where the program(s) had originally been operated by the hospital, and then operation of program(s) had been transferred by the hospital to a wholly owned subsidiary educational institution in order to meet accreditation standards prior to October 1, 2003, and where the hospital had continued to incur the costs of both the classroom and clinical training portions of the programs while the program(s) were operated by the educational institution. We estimate that the costs to the Medicare program of this proposal would be approximately $10 to $20 million. We do not believe many hospitals fit the criteria described above of previously receiving Medicare payment for direct operation of nursing or allied health education program(s) and then transferring operation of the program(s) to a wholly owned subsidiary educational institution, all the while incurring the classroom and clinical training costs of the program(s). In addition, we are also proposing that, for portions of cost reporting periods beginning on or after October 1, 2003, a hospital that meets the criteria described above may continue to receive reasonable cost payments for clinical training costs incurred by the hospital for the nursing and allied health education program(s) that were operated by the hospital prior to the date the hospital transferred operation of the program(s) to its wholly owned subsidiary educational institution (and ceased to be a provider-operated program). We are further proposing that, with respect to classroom costs, only those classroom costs incurred by the hospital for the courses that were paid by Medicare on a reasonable cost basis and included in the hospital's provider-operated program(s) could continue to be reimbursed on a reasonable cost basis. We estimate the costs to the Medicare program for this proposal would be $1 to $2 million per year. C. Prohibition Against Counting Residents Where Other Entities Have Previously Incurred the Training Costs As we explain in section IV.F.2. of the preamble of this proposed rule, under section 1886(h) of the Act, hospitals may count the time that residents spend training in nonhospital sites if they meet certain conditions, including incurring “all or substantially all” of the costs of training at the nonhospital site. Legislative history indicates that the purpose of this provision is to encourage hospitals to provide more training outside the traditional hospital environment. It has come to our attention that hospitals have been incurring the costs of and receiving direct GME and IME payment for residency training that had previously been occurring in nonhospital settings, without the financial support of the hospitals. We believe that where no new or additional training is provided in these nonhospital settings, the receipt of Medicare payment in such cases is contrary to Congressional intent and is, therefore, inappropriate. In addition, it violates Medicare's anti-redistribution principle, which states that Medicare will not share in the costs of educational activities of a hospital that represent a redistribution of costs from the community to the hospital. Accordingly, we are proposing to revise our policy concerning counting residents to ensure that Medicare IME and direct GME payments are not made to hospitals for training that had already been in place in the absence of the hospital's financial support. We are proposing that effective October 1, 2003, in order for a hospital to receive IME and direct GME payment, the hospital must have been continuously incurring the direct GME costs of residents training in a particular program since the date the resident first began training in the program in order for the hospital to count the FTE residents. By prohibiting payment for residency training that had been previously supported by nonhospital institutions, this proposal would reduce the amount of direct GME and IME payments received by hospitals. Although we cannot estimate the impact on programs nationally, we are aware that two hospitals in New York were receiving over $10 million annually for payments for dental residents training in nonhospital sites (including a site in Hawaii). Another hospital in Boston was receiving over $2 million annually for dental residents training at a dental school. D. Rural Track GME Training Programs 1. Reduction in the Time Required for Training Residents in a Rural Area As explained in section IV.F.3 of the preamble of this proposed rule, under existing regulations, if an urban hospital rotates residents to a separately accredited rural track program in a rural area for two-thirds of the duration of the training program, the urban hospital may receive an increase in its FTE cap to reflect the time those residents train at the urban hospital. When we first implemented these regulations, we did so based on our understanding that the Accreditation Council for Graduate Medical Education (ACGME) requires that at least two-thirds of the duration of the program be spent in a rural area. However, it has come to our attention that, while the ACGME generally follows a one-third/two-thirds model for accreditation, the rural training requirement is actually somewhat less than two-thirds of the duration of the program. Therefore, we are proposing to revise the regulations to state that if an urban hospital rotates residents to a separately accredited rural track program in a rural area for more than 50 percent of the duration of the training program, the urban hospital may receive an increase in its FTE cap to reflect the time those residents train at the urban hospital. We estimate that this proposal would only slightly increase Medicare payments for IME and direct GME costs. 2. Inclusion of Rural Track FTE Residents in the Rolling Average Calculation As explained in section IV.F.4 of the preamble of this proposed rule, when we first issued the regulations concerning residents training in a rural track program, we inadvertently did not specify in regulations that these residents would be included in the hospital's rolling average count of FTE residents used for computing GME payment. We are proposing to make this technical clarification to the regulations. We believe that this proposed provision would not have a budget impact because it is a clarification of existing policy. VIII. Impact of Proposed Changes in the Capital PPS A. General Considerations Fiscal year 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital capital-related costs. During the transition period, hospitals were paid under one of two payment methodologies: Fully prospective or hold harmless. Under the fully prospective methodology, hospitals were paid a blend of the 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 V. of the preamble of this proposed rule, with the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), beginning in FY 2004 capital prospective payment system payments for most hospitals are based solely on the Federal rate. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis. In accordance with § 412.312, the basic methodology for determining a capital 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 threshold established for each fiscal year. The data used in developing the impact analysis presented below are taken from the December 2002 update of the FY 2002 MedPAR file and the December 2002 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 2002 update of the most recently available hospital cost report data (FY 2000) 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 2002 update of the FY 2002 MedPAR file, we simulated payments under the capital prospective payment system for FY 2003 and FY 2004 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 would increase by 1.01505 percent in FY 2003 and would increase by 1.02010 percent in FY 2004. • We estimate that the Medicare discharges will be 14,288,000 in FY 2003 and 14,507,000 in FY 2004 for a 1.5 percent increase from FY 2003 to FY 2004. • 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 2004 update is 0.7 percent ( *see* section III.A.1.a. of the Addendum to this proposed rule). • In addition to the proposed FY 2004 update factor, the proposed FY 2004 Federal rate was calculated based on a GAF/DRG budget neutrality factor of 1.0038, an outlier adjustment factor of 0.9455, and a (special) exceptions adjustment factor of 0.9995. 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 § 412.304(c)(2)) are paid 100 percent of the Federal rate in FY 2004. We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2004 on total capital payments per case, using a universe of 3,922 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2002 update of the FY 2002 MedPAR file, the December 2002 update to the Provider-Specific File, and the most recent cost report data from the December 2002 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2003 compared to FY 2004 based on the proposed FY 2004 payment policies. Column 2 shows estimates of payments per case under our model for FY 2003. Column 3 shows estimates of payments per case under our model for FY 2004. Column 4 shows the total percentage change in payments from FY 2003 to FY 2004. The change represented in Column 4 includes the 0.7 percent update to the Federal rate, a 1.02010 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 1.0 percent in FY 2004. 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 different rates of increase in capital payments per case (0.9 percent and 1.5 percent, respectively). This difference is due to a projection that rural hospitals will experience a larger increase in the GAF due to reclassifications from rural to urban and a slightly larger increase in DSH and IME payments from FY 2003 to FY 2004 compared to urban hospitals. All regions are estimated to receive an increase in total capital payments per case. Changes by region vary from a minimum increase of 0.4 percent (Middle Atlantic urban region) to a maximum increase of 2.1 percent (New England rural region). Hospitals located in Puerto Rico are expected to experience an increase in total capital payments per case of 1.3 percent. By type of ownership, government hospitals are projected to have the largest rate of increase of total payment changes (1.2 percent). Similarly, payments to voluntary hospitals will increase 1.0 percent, while payments to proprietary hospitals will increase 0.9 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 2004 compared to the effects of reclassification for FY 2003, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. The reclassified groups are compared to all other nonreclassified hospitals. These categories are further identified by urban and rural designation. Hospitals reclassified for FY 2004 as a whole are projected to experience a 1.7 percent increase in payments. Payments to nonreclassified hospitals would increase almost half as much (0.9 percent) as reclassified hospitals, overall. Hospitals reclassified during both FY 2003 and FY 2004 are projected to receive an increase in payments of 1.4 percent. Hospitals reclassified during FY 2004 only are projected to receive an increase in payments of 4.9 percent. This increase is primarily due to changes in the GAF (wage index). Table III.—Comparison of Total Payments Per Case [FY 2003 payments compared to proposed FY 2004 payments] Number of hospitals Average FY 2003 payments/case Average FY 2004 payments/case Change By Geographic Location: All hospitals 3,922 706 713 1.0 Large urban areas (populations over 1 million) 1,420 808 815 0.9 Other urban areas (populations of 1 million of fewer) 1,041 693 700 1.0 Rural areas 1,461 476 483 1.5 Urban hospitals 2,461 758 765 0.9 0-99 beds 549 529 535 1.0 100-199 beds 884 643 649 1.0 200-299 beds 501 728 735 0.9 300-499 beds 373 809 817 1.1 500 or more beds 154 959 967 0.8 Rural hospitals 1,461 476 483 1.5 0-49 beds 659 390 396 1.6 50-99 beds 469 440 446 1.4 100-149 beds 198 483 488 1.2 150-199 beds 70 524 530 1.3 200 or more beds 65 594 606 2.0 By Region: Urban by Region 2,461 758 765 0.9 New England 131 808 820 1.5 Middle Atlantic 386 851 854 0.4 South Atlantic 356 724 729 0.8 East North Central 409 726 734 1.0 East South Central 152 684 695 1.6 West North Central 168 732 741 1.3 West South Central 303 711 715 0.6 Mountain 119 732 744 1.6 Pacific 393 893 904 1.2 Puerto Rico 44 317 322 1.3 Rural by Region 1,461 476 483 1.5 New England 38 591 603 2.1 Middle Atlantic 66 500 506 1.0 South Atlantic 218 490 496 1.2 East North Central 195 490 497 1.6 East South Central 229 435 443 1.6 West North Central 248 468 477 1.9 West South Central 263 426 432 1.5 Mountain 117 506 511 0.9 Pacific 82 564 574 1.7 By Payment Classification: All hospitals 3,922 706 713 1.0 Large urban areas (populations over 1 million) 1,497 799 807 1.0 Other urban areas (populations of 1 million of fewer) 972 697 703 0.9 Rural areas 1,453 474 479 1.2 Teaching Status: Non-teaching 2,829 580 586 1.0 Fewer than 100 Residents 857 733 741 1.1 100 or more Residents 236 1,074 1,083 0.8 Urban DSH: 100 or more beds 1,373 798 806 1.0 Less than 100 beds 258 528 531 0.7 Rural DSH: Sole Community (SCH/EACH) 476 417 423 1.5 Referral Center (RRC/EACH) 161 546 553 1.2 Other Rural: 100 or more beds 72 447 448 0.3 Less than 100 beds 301 405 410 1.3 Urban teaching and DSH: Both teaching and DSH 762 876 885 1.0 Teaching and no DSH 264 766 774 1.0 No teaching and DSH 869 644 650 0.8 No teaching and no DSH 574 627 634 1.1 Rural Hospital Types: Non special status hospitals 495 426 430 0.8 RRC/EACH 148 554 561 1.2 SCH/EACH 482 437 444 1.4 Medicare-dependent hospitals
(MDH)250 394 400 1.6 SCH, RRC and EACH 78 540 546 1.2 Hospitals Reclassified by the Medicare Geographic Classification Review Board: Reclassification Status During FY2003 and FY2004: Reclassified During Both FY2003 and FY2004 562 621 629 1.4 Reclassified During FY2004 Only 68 600 630 4.9 Reclassified During FY2003 Only 43 601 575 −4.2 FY2004 Reclassifications: All Reclassified Hospitals 630 619 630 1.7 All Nonreclassified Hospitals 3,258 723 729 0.9 All Urban Reclassified Hospitals 131 815 828 1.6 Urban Nonreclassified Hospitals 2,299 756 763 0.9 All Reclassified Rural Hospitals 499 528 537 1.8 Rural Nonreclassified Hospitals 959 410 414 0.9 Other Reclassified Hospitals (Section 1886(D)(8)(B)) 34 486 472 −2.8 Type of Ownership: Voluntary 2,404 719 726 1.0 Proprietary 674 691 697 0.9 Government 813 645 652 1.2 Medicare Utilization as a Percent of Inpatient Days: 0-25 291 901 914 1.4 25-50 1,529 804 812 0.9 50-65 1,645 615 621 1.0 Over 65 446 556 561 1.0 Appendix B: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the 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 proposed update factors recommended under section 1886(e)(4) of the Act in this proposed rule, and the final update factors recommended by the Secretary in the final rule. Accordingly, this Appendix provides the recommendations of appropriate update factors for the IPPS standardized amounts, the hospital-specific rates for SCHs and MDHs, and the rate-of-increase limits for hospitals and hospitals units excluded from the IPPS. We also discuss our update framework and respond to MedPAC's recommendations concerning the update factors. II. Secretary's Recommendations Section 1886(b)(3)(B)(i)(XIX) of the Act sets the FY 2004 percentage increase in the operating cost standardized amounts equal to the rate of increase in the hospital market basket for IPPS hospitals in all areas. Based on the Office of the Actuary's first quarter 2003 forecast of the FY 2004 market basket increase, the proposed update to the standardized amounts is 3.5 percent (that is, the market basket rate of increase) for hospitals in both large urban and other areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2004 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 IPPS, or the rate of increase in the market basket). Therefore, the proposed update to the hospital-specific rate applicable to SCHs and MDHs is also 3.5 percent. Under section 1886(b)(3)(B)(ii) of the Act, the FY 2004 percentage increase in the rate-of-increase limits for hospitals and hospital units excluded from the IPPS (psychiatric hospitals and units, rehabilitation hospitals and units (now referred to as IRFs), LTCHs, cancer hospitals, and children's hospitals) is the market basket percentage increase. In the past, hospitals and hospital units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). However, some of these categories of excluded hospitals and units have begun to be paid under prospective payment systems. Hospitals and units that receive any hospital-specific payments will have those payments subject to TEFRA limits for FY 2004. For these hospitals, the proposed update is the percentage increase in the excluded hospital market basket (currently estimated at 3.5 percent). IRFs are paid under the IRF PPS for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2004, the Federal prospective payment for IRFs is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. Effective for cost reporting periods beginning during FY 2003, LTCHs are paid under the LTCH PPS under which they receive payment based on a 5-year transition period (see the August 30, 2002 final rule (67 FR 55954)). An LTCH may elect to be paid on 100 percent of the Federal prospective rate at the start of any of its cost reporting periods during the 5-year transition period. For purposes of the update factor, the portion of the LTCH PPS transition blend payment based on reasonable costs for inpatient operating services is determined by updating the LTCH's TEFRA limit by the current estimate of the excluded hospital market basket (or 3.5 percent). III. Update Framework Consistent with current law, we are proposing an update recommendation equal to the full market basket percentage increase for the IPPS operating cost standardized amounts for FY 2004. We also have analyzed 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 discussion of this analysis is below. 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 0.30 to 0.35 percent of the change in output (that is, a 1.0 percent increase in output would be correlated with a 0.30 percent to a 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 during which output growth is relatively low and larger in years during which 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. Normally, the expected FY 2004 hospital output growth would be simply the sum of the expected change in intensity (1.0 percent), projected admissions change (1.6 percent), and projected real case-mix growth (1.0 percent—a definition of real case mix growth appears below), or 3.6 percent. However, as discussed below and in relation to the proposed capital update, we believe our intensity estimate is skewed by hospitals' charge data. Therefore, we are including only the projected changes in admissions and real case-mix in our calculation of productivity gains. This results in an estimate of 2.6 percent. The share of direct labor services in the market basket (consisting of wages, salaries, and employee benefits) is 61.6 percent. Multiplying the expected change in total hospital service output (2.6 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 of 61.6 provides our productivity standard of -0.6 to -0.5 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 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 non-cost-effective services. Under the capital IPPS framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that are used in the framework for the operating IPPS. We calculate case-mix constant intensity as the change in total Medicare charges per admission, adjusted for price level changes (the Consumer Price Index
(CPI)for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor, that is, charges for capital services are already built into the calculation of the factor. However, as discussed above in relation to the proposed capital update, because our intensity calculation relies heavily upon charge data and we believe that this charge data may be inappropriately inflated due to manipulation of charges to maximize outlier payments, we are proposing a 0.0 percent adjustment for intensity in FY 2004. In past fiscal years (1996 through 2000) when we found intensity to be declining, we believed a zero (rather then negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to propose a zero intensity adjustment for FY 2004 until we determine that any increase in charges can be tied to intensity, rather than to attempts to maximize outlier payments. C. Change in Case-Mix Our analysis takes into account projected changes in real case-mix, less the changes attributable to improved coding practices. 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. For our FY 2004 update recommendation, we are projecting a 1.0 percent increase in the case-mix index. We do not believe changes in coding behavior will impact the overall case-mix in FY 2004. As such, for FY 2004, 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 2002 DRG Reclassification and Recalibration We estimate that DRG reclassification and recalibration for FY 2002 (GROUPER version 19.0) resulted in a 0 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 (version 18.0). Therefore, we are recommending a 0 percent adjustment for the effect of FY 2002 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 2002 payment rates was 3.3 percent. Our most recent data indicates the actual FY 2002 increase was 2.9 percent. The resulting forecast error in the FY 2002 market basket rate of increase is (-0.4) percentage points. This overestimate was due largely to a lower-than-expected increase in energy costs that impacted natural gas and chemical prices. This follows consecutive years where the market basket was under-forecast by 0.7 percentage points each year. The following is a summary of the update range supported by our analyses: HHS's FY 2004 Update Recommendation Market basket MB Policy Adjustment Factors: Productivity −0.6 to −0.5 Intensity 0.0 Subtotal −0.6 to −0.5 Case-Mix Adjustment Factors: Projected Case-Mix Change 1.0 Real Across DRG Change −1.0 Subtotal 0.0 Effect of FY 2002 DRG Reclassification and Recalibration 0.0 Forecast Error Correction −0.4 Total Recommendation Update −1.0 to −0.9 IV. MedPAC Recommendations for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In the past, MedPAC recommended specific adjustments to its update recommendation for each of the factors discussed under section III. of this Appendix. In its March 2003 Report to Congress, MedPAC assesses the adequacy of current payments and costs and the relationship between payments and an appropriate cost base. MedPAC stresses that the issue at hand is whether payments are too high or too low, and not how they became such. In the first portion of MedPAC's analysis on the assessment of payment adequacy, the Commission reviews the relationship between costs and payments (typically represented as a margin). Based on the latest cost report data available, MedPAC estimated an inpatient Medicare operating margin for FY 2000 of 10.8 percent (down from 12.3 percent for FY 1999). MedPAC also projects margins through FY 2003, making certain assumptions about changes in payments and costs. On the payment side, MedPAC applied the annual payment updates (as specified by law for FYs 2001 through 2003) 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 cost per unit of output over the same time period at the rate of inflation as measured by the applicable market basket index generated by CMS adjusted downward, anticipating improvements in productivity. While no specific Medicare inpatient margin is identified for a calendar year beyond 2000, MedPAC projected an overall Medicare margin for FY 2003 of 3.9 percent (page 41). The FY 2000 overall Medicare margin, as estimated by MedPAC, was 5.0 percent. 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 42): • Changes in access to or quality of care; • Changes in the volume of services or number of providers; and • Change in providers' access to capital. MedPAC's assessment of aggregate Medicare payments finds that payments were at least adequate as of FY 2003. MedPAC's recommendation related to updating payments under the IPPS is that the Congress should increase the payment rates for the IPPS by the rate of increase in the hospital market basket, less 0.4 percent, for FY 2004. MedPAC focuses on the operating update exclusively because operating costs account for about 92 percent of total hospital costs and because the operating update is of most interest to Congress. Based on the current market basket estimate for FY 2003 of 3.5 percent, this update would increase Medicare inpatient payments to hospitals covered by IPPS by 3.1 percent. *Response:* As described above, we are recommending a full market basket update for FY 2004 consistent with current law. We believe this will appropriately balance incentives for hospitals to operate efficiently with the need to provide sufficient payments to maintain access to quality care for Medicare beneficiaries. 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 to this proposed rule. [FR Doc. 03-11966 Filed 5-9-03; 3:51 pm]
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  • Pub. L. 99-272
  • Pub. L. 104-191
  • Pub. L. 97-248
  • 42 CFR 412.308
  • 42 CFR 412
  • Pub. L. 105-33
  • Pub. L. 106-113
  • Pub. L. 106-554
  • 42 CFR 413
  • Pub. L. 107-105
  • 45 CFR 162.1002
  • 45 CFR 162.1102
  • Pub. L. 90-248
  • Pub. L. 92-603
  • 165 F.3d 1162
  • 905 F. Supp. 460
  • 314 F.3d 241
  • 259 F.3d 1071
  • 42 CFR 413.86
  • 42 CFR 412.105
  • 42 CFR 413.85
  • Pub. L. 101-239
  • Pub. L. 101-508
  • 42 CFR 413.85(f)
  • Pub. L. 99-509
  • Pub. L. 89-97
  • 42 CFR 413.85(c)
  • Pub. L. 15-1
  • 512 U.S. 504
  • 42 CFR 485
  • 42 CFR 410.2
  • Pub. L. 108-7
  • Pub. L. 100-203
  • Pub. L. 96-354
  • Pub. L. 104-4
  • Pub. L. 98-21
  • 259 F.3d 1017
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F. App'x165 F.3d 1162
F. Supp.905 F. Supp. 460
F. App'x314 F.3d 241
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SCOTUS512 U.S. 504
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